WHAT IS MEDICAL
MANAGEMENT?
How health plans make decisions to approve
payment for medical treatment is a poorly
under-stood part of the healthcare system. One part of
the process, known as medical management, is
often viewed as a mysterious “black box” in the
insurance process.
Our goal at Health Republic is to shine the light
on the process so that our members and providers
WHAT IS THE PURPOSE OF
MEDICAL MANAGEMENT?
All insurance companies, including Health Republic, review certain medical services that members receive before, during, or after care is delivered. This medical management process (also known as utilization review) helps ensure that the treatment you receive meets certain standards of medical practice.
WHAT GETS
REVIEWED?
A request for service can be reviewed:
WHO MAKES
MEDICAL MANAGEMENT
DECISIONS?
Initially, a nurse reviews clinical records sent from your doctor (or the practitioner requesting the treatment) and compares those to the request. This is known as “medical necessity” review. In order to decide if something is medically necessary for a particular individual, the health plan staff reviews the information using evidence-based clinical guidelines (we’ll cover more about these in a minute). The majority of the requests are approved at the first review.
When a requested service is not approved (not meeting clinical criteria), that final decision is made by a physician. A nurse can approve a treatment decision, but only a physician can deny a request for service.
There are NEVER any financial incentives to our employees or reviewers if they determine services are not medically necessary. It is their job as professionals to make sure the care you receive is medically necessary, and clinical guidelines and protocols have been developed to assist them in this process.
Before the service is performed
(pre-authorization)
– this is typically done for elective (non-emergency)
tests or procedures
While the service is being performed
(concurrent review)
– this is usually done during the course of a treatment,
such as a hospital stay
After the service is performed
(retrospective review)
– this can be for elective or emergency services that
Physician DENIES authorization. Nurse notifies all parties
Physician Assessment: Request DOES NOT MEET
clinical guidelines Physician Assessment: Request MEETS clinical guidelines HEALTH REPUBLIC PHYSICIAN REVIEWS CASE Request AUTHORIZED Nurse notifies all parties Nurse Assessment: Request MEETS clinical guidelines Nurse Assessment: Request DOES NOT MEET
clinical guidelines Nurse Assessment:
ADDITIONAL CLINICAL INFORMATION is needed from your doctor
CASE PENDED
for information
HEALTH REPUBLIC NURSE RECEIVES: - Request for test/treatment
- Clinical information about your condition
NURSE Reviews: - Test/Treatment request - Your clinical information
- Evidence-based clinical guidelines
WHAT FACTORS INTO
THE DECISION?
Is the requested service being delivered consistent with established evidence-based clinical guidelines for the condition?
Making decisions based upon the latest and best evidence that is available is important. What we know about medical facts, treatment and how successful they are, changes as new technologies, practices and research emerge. (As you may know, years ago the idea that healthcare workers should wash their hands before touching a patient was scoffed at by leading clinicians.)
To guide their decisions, our staff uses evidence-based clinical guidelines that are re-searched, updated and published by nationally recognized authorities. These type of guidelines (also known as clinical criteria) incorporates outcomes research to evaluate the effectiveness and safety of various treatments for multiple conditions. So when we make a decision based on evidence-based medicine, you know it comes from a fact-based back-ground. Some of the criteria we use are:
■ Centers for Medicare & Medicaid Services (CMS) ■ MCG™ Criteria
■ Medicare Benefit Policy Manual
But, these are only guidelines, not rules. We also consider your specific condition and clinical situation and how those compare with the guidelines.
Your doctor can request to see the criteria used in making any decision about your case by contacting us via e-mail at ProviderRelations@healthrepublicny.org
What is the setting requested for the delivery of service (also known as the “level of care”)? We want you to receive the care you need in the appropriate place and at the appropriate time. The evidence-based clinical criteria are tools to help us determine the level of care that meets your condition and the treatment requested.
WHAT IS
TIMING OF THE AUTHORIZATION PROCESS?
For prospective reviews, if we have all the information we need to authorize a request, we will provide a notice to you and your doctor, by telephone and in writing, within 3 business days after we receive the request. The infographic below shows the timeframes and responses in the event that we cannot approve a request on the first review.
Health Republic Insurance of New York
TIMELINE OF
AUTHORIZATION
PROCESS
Within THREE BUSINESS DAYS after receiving the request, we will provide a notice to you and your doctor, by telephone and in writing.
*BUSINESS DAYS (Monday - Friday)
3
Within THREE BUSINESS DAYS we will let you and your doctor know we need additional information.
This is usually a request for more clinical information about your specific condition or clarification about what
treatment has already been tried.
3
Within THREE BUSINESS DAYS of when we receive the additional information we’ll notify you and your doctor of the decision, by telephone and in writing.
3
15
WE HAVE ALL INFORMATION WE NEED TO AUTHORIZE REQUEST
WE NEED ADDITIONAL INFORMATION
DAYS
WE DID NOT RECEIVE NECESSARY INFORMATION WITHIN FORTY-FIVE CALENDAR DAYS
45
YOU AND YOUR DOCTOR HAVE FORTY-FIVE CALENDAR DAYS TO SUBMIT REQUESTED ADDITIONAL INFORMATIONIF YOU DISAGREE WITH A DECISION.
If you want to appeal a medical necessity decision, you (or your designee or your provider) have up to 180 calendar days to request an internal appeal either by phone or in writing. You can appeal out-of-network service denials or out-of-network referral denials. There are first and second level appeals, and the process is explained in more detail in the Utilization Management document on the Health Republic website.
WHAT
ELSE?
When you need a procedure or to be admitted to a hospital, we can assist you to safely transition back home or to the next level of care, such as rehabilitation, and then to remain as healthy as possible. We can help you in a number of ways:
■ Case Management: A Case Manager is a nurse or social worker who assists many of our members with complex or chronic care needs to navigate through the health care system. If you think you might benefit from having a Case Manager work with you and your healthcare providers, feel to complete and submit a referral and send it to us or call us at 888-990-5702.
■ Home Health, Outpatient Therapies, Equipment or Supplies: Part of your transition in care may include getting therapy in your home or another setting, or you may need some equipment or supplies. Some of these items may require prior authorization as well. Check your Certificate of Coverage to review the covered benefits within your plan or you can contact us at Member Services at 888-990-5702 for assistance. ■ Medications: For more information about prescription medications coverage and
access, please visit our pharmacy page.
■ Next Steps in Your Care: Make and keep a follow-up appointment with your doctor after any visit to the hospital. This is one of the key actions you can take to keep from having complications and having to be readmitted. Make sure you know when you are scheduled for follow-up and keep that appointment.
■ But, if you should need to talk to a doctor when yours is not available (and it’s not an emergency), you can contact our telemedicine service and consult with a
board-certified emergency room physician through Stat Doctors, by phone or video, on a 24/7 basis. Click this site StatDoctors.com to learn more.
