Judy DeanManaging Director

Tips in Addressing Carrier Medical Directors

What Causes Payers to Expand Coverage Policies?

Additional new data is available (internal and external)A code changeCustomer requests (employers, patients, etc)Provider requestsIncrease in overturned denials

Stakeholders, (providers, KOLs, patients, employers and Societies) can create noise in the network asking for change, therefore, as Physicians and Professional Society, you can drive change to payer coverage policies

How Can You Be Heard?

Contact the Decision Makers - Make Noise in the NetworkTalk to the Provider rep assigned to you by the payerWrite a letter to the payer medical director

Appeal your DenialsTake Denials to the highest level of appeal possibleAsk for a meeting or a conference call with the medical policy

decision makerEducate your patients on appealing denials

Denial Appeals ResourcesKaiser Family Foundation and Consumers Union

Sitehttp://www.kff.org/consumerguide/7350.cfm

Insurance CarriersAetna Appeals Guide

http://www.aetna.com/provider/data/PhysicianInternalAppealRefGuide.pdf

Anthem/WellPoint Appeals Guidehttp://www.anthem.com/provider/in/f3/s4/t1/pw_ad089352.p

df

Cigna Appeals Policyhttp://www.cigna.com/health/provider/medical/procedural/cl

aim_appeals/appeal_policies_procedures.html

How Can you Be Most Effective?How Can you Be Most Effective?

Be available to the payer for questions or phone calls. (they are not very flexible on scheduling meetings or calls)

Be clear and concise regarding your position Follow up – the payer has hundreds of policies to review. Establish a relationship with the medical director who can

impact the policy, if possible. Ask for a policy change and be specific on what your

state needs Be familiar with the policy—with its benefits and its

drawbacks.

Preparation

Read the payer’s coverage policy and note the areas where you disagree or feel it can be improved—all policies are different

Ask your provider rep for the name, address and phone number of the medical director

Understand the high points of the key clinical studiesFeel comfortable with the PowerPoint presentation

How to Get the MeetingObtain the medical director contact information

through your existing contact baseHospital administrationYour carrier provider repYour denial management efforts

Request the meeting either through a phone call or through a brief but well written letter

Be persistent—the payer medical director has a many policies to manage and fewer people now on staff to help

Offer your help in developing criteria on patient selection

Form a relationship with the medical director. Be available to help his group write a fair policy for their members

Once you get the meeting—Words are Important

What you say What they Hear

Needs longer term data Investigational

Studies are sufficient Coverage now

Specialty Society Support Technology is wide spread enough for physician group to agree

High risk patient Inclusion limitations – i.e. High BMI

What is Most Helpful in Communicating with Medical Directors

Guidance on which patients are appropriate Clear Statements Outcomes Statement on evidence Statement on validity of evidence How to limit risk Clarification of coding if confusion exists in the field

Stay on Message

Ask for a policy changeData is sufficient nowData is long termFollow NIH guidelines without BMI limitationsDo not limit to 2 step procedureOther payers now cover SG, including UHC

Key points for the letterKey points for the letter

State your credentials and expertise Be specific regarding your support and any State Society

Support Reference key data and studies Specifically ask for a policy change and for the payer to follow

NIH guidelines for sleeve gastrectomy. Set a time to follow up. “ I will contact you in 2 weeks….” Indicate the procedure is not investigational and is widely

accepted within the physician community State that studies and data are sufficient to support payer policy Point out parts of the policy that need to be change Tell them how it impacts your patients and your practice of

medicine

Conclusion Be persistent to be heard Follow up with information The Manager of the Medical policy area may be responsive to

you, or help you get the ear of the Medical Director Noise in the provider network can have great impact on payer

policy Key opinion leaders help the payer by having clear input

regarding technology Specialty Societies and the physician network must get

involved to change policy. There has to be a reason for policy to change: a coding

change, additional evidence, a new society statement, letters from the state specialty societies

Payers are updating policies now and you can impact those policies.