from approval to implementation...understand and come prepared to discuss roi bring data if you...

From Approval to

Implementation – The Payor

Perspective

By: Brian Stamm, MBA

Disclaimer

The views expressed during this presentation are solely those of the

presenter; they do not necessarily reflect the views of the Department of

Employee Trust Funds.

I am not receiving any sort of compensation for this presentation.

About

Work Experience

Current:

Deputy Director of the Office of

Strategic Health Policy for Wisconsin’s

Department of Employee Trust Funds

Previous:

4 years as Operations and Quality

Manager with a regional health insurer

4 years as Manager of Operations and

Business Analytics with a university

health center

8 years in pharmacy retail

Education

• Current:

• Master of Public Health – Infectious Disease and Epidemiology

• Johns Hopkins Bloomberg School of Public Health

• Previous:

• Master of Business Administration –Health Sector Management | Leadership & Organizational Transformation

• Boston University’s Questrom School of Management

• BS – Consumer Science – Retail Management

• University of Wisconsin-Madison

Picture Source: https://microbewiki.kenyon.edu/images/6/6c/3D_Yersinia_pestis_model.jpeg

Thomas Vicary

Picture Source: https://en.wikipedia.org/wiki/Thomas_Vicary

Picture Source: https://www.npr.org/sections/goatsandsoda/2017/08/18/542435991/those-iconic-

images-of-the-plague-thats-not-the-plague

Vicary Method

Picture Source: https://www.npr.org/sections/goatsandsoda/2017/08/18/542435991/those-iconic-

images-of-the-plague-thats-not-the-plague

Vicary Method

Medical Practice Constantly

Evolves

Medical Practitioners Continuously Improve

Medical Insurance Consistently Lags Behind

…and so do payments

Welcome to Health

Insurance

The land that logic and reason

forgot

Medical Policy

Medical Policy Committee

Sets the criteria for making medical coverage determinations

Sets the documentation requirements to be considered

Medically Necessary

Defines the scope of services

Medical Policy is typically set well in advance (18

months) of coverage changes – so plan ahead

Tip: Make sure that coverage for Athletic Trainers is not a

Direct Exclusion

Tip: Make sure that coverage for Athletic Trainers is

directly included

Product Configuration

The interpretation of Medical Policy into computer

programing

Claims systems are fragile

Thousands of inter-connected configurations

Thousands of variations by plan

System updates or connected configurations can have ripple

effects

Test, test, and re-test… then audit

Tips & Tricks

Find a champion

Develop a simple explanation of who Athletic Trainers

are

Understand and come prepared to discuss ROI

Bring data

If you don’t understand ROI, then find someone that does

ROI Numerator – more than just earnings

Increased throughput

Increased access & availability

Drive home the “working at the top of licensure” idea

Tips & Tricks (continued)

Understand, train and communicate the documentation

requirements, medical coding requirements, and proper

billing practices needed for a claim to process correctly!

Audit frequently

Needed: more data on the utilization of Athletic Trainers

in ER/Urgent Care settings and ROI

Please Don’t

Don’t add new costs to an already burdened system

Football player at a state university received treatments from

Athletic Trainers over the course of a year

3rd party biller charged over $250,000 in claims

Start small and stick to your scope of services

Poor documentation, bad medical coding, and sloppy

billing practices will ruin progress for yourself and all

others

Don’t scope creep

Contact

Brian.Stamm@etf.wi.gov

https://www.linkedin.com/in/brian-stamm-mba-ab208063/

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