Paying for Quality
ACHD Care
How to get insurance companies to work with you
Christy Sillman, RN, MSN
ACHD nurse coordinator
Inpatient ACHD Nurse Educator The Adult Congenital Heart Program Stanford
Lucile Packard Children’s Hospital Stanford Hospital and Clinics
Susan Fernandes, LP.D., P.A.-C
Program Director
The Adult Congenital Heart Program Stanford
Lucile Packard Children’s Hospital Stanford Hospital and Clinics
What we’ll discuss:
The AHA/ACC 2008 guidelines
Upcoming changes in ACHD care
Using the guidelines to advocate for care
Navigating insurance
RAF’s, TAR’s, and appeals – oh my!
Simple Congenital Heart Disease
Unrepaired conditions:
• Isolated small atrial septal defects (ASD)
• Isolated small ventricular septal defects (VSD)
• Mild pulmonic stenosis
• Isolated detrocardia with no other CHD
Repaired conditions:
• Patent Ductus Arteriosis (PDA) • Secundum atrial septal defect
(ASD)
• Isolated ventricular septal defect (VSD)
Repaired or unrepaired conditions:
• Isolated aortic valve disease • Isolated mitral valve disease • Isolated patent foramen ovale
(PFO
Moderate Complex Congenital Heart Disease • Anomalous Left Coronary Artery
from Pulmonary Artery (ALCAPA) • Anomalous Pulmonary Venous
Drainage (partial or total)
• Atrioventricular (AV) canal/septal defects (partial or complete • Ostium primum or sinus venosus
ASDs
• Coarctation of the aorta • Ebstein’s anomaly
• Infundibular right ventricular
outflow obstruction (mild to severe) • Pulmonary valve regurgitation
(moderate to severe)
• Pulmonic valve stenosis (moderate to severe
• Sinus of Valsalva fistula/aneurysm • Subvalvular or supravalvuar aortic
stenosis
• Tetralogy of Fallot
• Ventricular septal defect (VSD) with any valve problems or obstructions
Highly Complex Congenital Heart Disease
Repaired or unrepaired conditions:
• ccTGA or L-TGA • Double Outlet Ventricle • Mitral Atresia
• Pulmonary atresia (all forms) • Pulmonary arterial hypertension • Shone’s syndrome
• Single Ventricle – all forms
• Transposition of the great arteries (d-TGA)
• Tricuspid atresia
• Truncus arteriosis/hemitruncus • Other abnormalities of the AV
connections
All patients who have undergone any of the following procedures:
• Arterial switch procedure • Blalock-Taussig Shunt
• Any Conduit(s), valved or non valved
• Double-switch procedure
• Fontan procedure (all types) • Mustard procedure
• Norwood procedure • Rastelli procedure • Senning procedure
All patients with Eisenmenger syndrome
All patients who are cyanotic (“blue”)
AHA/ACC 2008 Guidelines
Simple CHD’s
: General cardiologist can usually
oversee care. One visit to an ACHD program to
verify diagnosis and health status is
recommended.
Moderately complex CHD’s
: These patients should
be seen every two years or more frequently at an
ACHD program
Highly Complex CHD’s: These patients should be
seen every year or more frequently at an ACHD
program.
What makes an ACHD program?
Regional ACHD Centers should provide: Patient counseling;
Operating rooms—specially equipped with personnel familiar with CHD surgery, fully trained congenital cardiac perfusionists, as well as a full array of diagnostic equipment;
Cardiac surgery—at least two congenital heart surgeons to provide 24-hour-a-day coverage;
Cardiac anesthesia; Intensive Care;
In-patient service; Transplantation;
Catheterization laboratory with staff specifically trained in the needs of ACHD patients;
Noninvasive imaging service 24 hours a day, 7 days a week; Electrophysiology service;
High-risk obstetrics; Cardiac pathology.
Updated Standards
Board certification in adult congenital heart disease – cardiology subspecialty.
First exam will be in fall 2015 for practicing physicians. Fellowships in ACHD starting 2014
Program accreditation: ACHA accreditation standards for regional ACHD programs
The road to ACHD care
Primary Care
Physician
In-network/Local
cardiologist
ACHD regional
center
Navigating Insurance
Establish a contact person with your insurance
Case worker
Nurse
Authorization specialist
Medical director
Get their direct number
Navigating Insurance
Establish a contact person at the ACHD center
Nurse coordinator
Authorization and referral coordinator
Medical Billing
Social worker
Ask about the necessity of tests Case study #1 - MRI
Navigating Insurance
Get any approvals or denials in writing
Keep all insurance related documents
Before signing up for coverage
Check with the ACHD center to see if they accept the insurance for all aspects of care – Case Study #2
Understand the plan premiums, deductibles, and yearly out-of-pocket maximum
RAF’s, TAR’s, and Appeals (oh my!)
RAF (Risk Adjustment Factor) – insurance approval for higher than expected coverage
TAR (Treatment Authorization Request) – request for treatments/studies outside of expected coverage
Don’t hesitate to appeal any denial you receive. Escalate, advocate, and use the guidelines. Insurance companies don’t understand CHD.
Know
your
rights
Can not be denied on the basis of “pre-existing condition”
Can stay on parents insurance up to 26yrs old
Guaranteed right to appeal – both internal review and independent external review. Access to consumer assistance program.
Ends life-time limits on coverage
Emergency care at any emergency room – they will treat without proof of insurance.
Case Study #3 – Tying it all together
Patient moved from out of state – changed insurance
Transferring care from one ACHD program to another ACHD program
Rural area with limited PMD options – urgent primary care visit – submitted a RAF
RAF automatically denied
Patient getting sicker and sicker – Emergency Department
Appeal process
Template Letter
To whom it may concern:
I was born with _[severity level of CHD]______ congenital heart disease: ___[your
diagnosis]____________________. According to the ACC/AHA 2008 guidelines,
adults with congenital heart disease in this category should be seen every
___[guideline frequency]________or more frequently with active issues at an adult
congenital heart program. According to the same guidelines an adult congenital heart center consists of a set number of recommended services – please see attached guidelines. For continuity of care I am requesting my cardiac care at
____[name of ACHD program/facility]_____, a program that fulfills the ACC/AHA
Template letter example
To whom it may concern:
I was born with complex congenital heart disease: tetralogy of Fallot with pulmonary atresia. According to the ACC/AHA 2008 guidelines, adults with congenital heart
disease in this category should be seen every _year_ or more frequently with active issues at an adult congenital heart program. According to the same guidelines an adult congenital heart center consists of a set number of recommended services – please see attached guidelines. For continuity of care I am requesting my cardiac care at The Adult Congenital Heart Program at Stanford, a program that fulfills the
Resources
Your insurance handbook or website
US department of Health and Human services
http://www.hhs.gov/healthcare/
State website - managed care division
ACHA for guidelines and advocacy
