Hello and welcome. My name is Dr. Mary Russell and I'm an assistant professor at the University of Texas McGovern Medical School at Houston in the Department of Physical Medicine Rehabilitation. I have an appointment as medical director of Tier Memorial Hermann in the Woodlands and also have an outpatient practice and provide inpatient coverage as well. So I'm on the Speakers Bureau for MERS and Allergan. I do not intend to talk about any promotional or commercial uses of any specific products that would demonstrate any conflicts of interest. So from the U.S. Census Bureau report in September 2020, there are several types of health insurances. There's private coverage and public coverage. Under the private coverage, there's employer provided and where the employer subsidizes along with members. There's direct purchase where a member gets policy directly from the insurance company and then there's TRICARE, which is generally for military members and their family. There's also public coverage that includes Medicare and Medicaid and these can be managed by insurers or direct from the government. There's also civilian health, VA and military coverage. In 2019, there was 8% of the population that was uninsured and 92% of Americans had health insurance. Private insurers made up 68% of the population with the majority of those through employers. This is also according to the U.S. Census Bureau. 34% of the population received health insurance via public plans. This is a very small slide, but this is another graphic showing the same thing and also breaks it down a little bit by demographic. So working with insurance companies can be a frustrating part of physician's practice and can seem like it is difficult to get recommended freedoms. Per this article in 2017, paperwork burden and administrative cost was about $471 billion annually. And per this article in 2014, from 1993 to 2010, there was an increase in healthcare workforce due to administrative needs, which was a 40% increase since 1968. Administrative cost doubled from 1980 to 2010 and private insurers overhead had risen 117% from 2001 to 2010. We all know that there's a lot of administrative burdens and the upcoming speakers will educate us on how to understand and make the process easier to improve the odds of success. Here's my references. And I hope you enjoy the future speakers. Thank you for having me today. Very excited to present at APM&R 2020 and to talk a little bit about my experience with dealing with the insurance world as a physician who very much wants to be a big advocate for her patient. I am a professor and chair of rehab medicine at UT Health in San Antonio at the Long School of Medicine and very excited to be talking about this topic today. As far as disclosures, I have been also a consultant with some of the toxin companies. COVID is owning all our lives right now. I won't talk about either of those things today. And really the objectives of what I'm going to be talking about today is, you know, the number one thing that you do as a physician is try to advocate for your patients and make sure that they get the best treatment possible. And we have to work through certain systems to get that outcome. And so it's just here to talk to you a little bit about doing the right thing for your patients and get what they need, which may also be what you need, which is also getting paid for what you're doing. And then always reminding you that kindness counts a lot. So not getting frustrated by the system, not getting angry, not yelling at anyone, but being kind when trying to navigate this system. I can't stress that enough. So what's my why? Why do I care so much about doing this? And it's really the people, the people that I work with, the people that I work for, which is our patients, and just having a passion for doing what I do in PM&R. And, you know, my day job, other than being the chair when I get to take care of patients for that part of the time is brain injury medicine, interventional spasticity management. So if a lot of my experience is going to be either working on the inpatient side or working on the outpatient side and doing interventional spasticity management. So you might hear a little bit more about my experiences and how to navigate the insurance world in those experiences, including getting patients from acute care to inpatient rehab, and then patients or outpatients getting them the treatments that they need when they need management for their spasticity or cervical dystonia or headaches, etc. Persons with disabilities, they have a lot of barriers just to start with. And there are multiple barriers that can make access to healthcare more difficult. So this is a big conversation that we're having now with healthcare disparities. And patients with disabilities are disproportionately affected, especially ones who also have an intersectional identity, meaning they're Black, Hispanic, Native American, and these are some of the barriers that they have to deal with. Infrastructure and access barriers, regulatory barriers, operational and system challenges, communication barriers, etc. And so how do we help our patients navigate these barriers is something that we have to consider when we are doing healthcare for them. And also, outcomes are not just based on what we do for them in healthcare. Other things matter, such as social determinants of health, their type of insurance that they have, the ability for them to afford medications or treatments. So I know even though we have the best intentions to treat our patients, there are other circumstances, other types of external forces that are affecting the outcome that they're going to have. And we have to consider this and work within the system that they have. That's kind of the system-based practice that we talk about all the time to help our patients have the best outcome. And so these are a little bit about my tips of working with insurance companies and with different payers to get your patients what they need. At least this is one little aspect of it. So I'm going to talk about five main rules. That's it, to work to get the outcome that you need when you're working with payers and with the health insurance world. And they really all come from the all I really need to know I learned in kindergarten roles. And so that's kind of a famous poem. You can't read it all there, but you can look it up online to know that all you need to know that all you need to know to work with insurers is the rules. And they're very regulated by rules. So first, know who the payer is for your patient. And I hate to say that matters, but it does. And we know that matters on outcomes and we know that that matters on disposition. And so it's important to know, you know, Dr. Russell talked about the different payers that people have also when they don't have insurance because in Texas, the highest rate in the whole country of uninsured population. So I like to know what I'm dealing with when I'm going in to treat a patient and what options there are for them. Know the guidelines, whatever guidelines that may be. So if you are taking care of patients and you're trying to get them in inpatient rehab and your unit or the unit follows Medicare guidelines or the patient has Medicare or Medicare HMO, then know what those guidelines are to getting a patient into inpatient rehab. Do the private health insurance may not use the Medicare rules. They may have their own set of guidelines. There's Milliman guidelines and there's other guidelines. So they may not follow exactly what Medicare has, the 13 diagnosis or the 60% rule because they have their own guidelines. And that includes some Medicare HMOs don't follow the strict Medicare criteria guidelines. So know what the guidelines are. The same thing, know the coverage. So what kind of coverage is offered? What are the benefits there in Texas? Some Medicaid doesn't cover inpatient rehab in a freestanding rehab. So no matter what I may want to do for an adult patient that has a Medicaid HMO, I am not going to be able to get them in a freestanding rehab. So you have to know the coverage that's offered by their insurance. Know what the FDA says. So this is a lot of times there are certain medications that may be given and it has to be FDA approved. And a lot of the payers and the insurance companies will go by what's on label by the FDA. So if you know what that is for whatever treatment you're going to do, then it's going to be easier to get it approved because we know that there's at least been trials that have proven that that's safe for the FDA. And then that's usually what's accepted by the payer. And then know what the literature says, because sometimes the literature may contradict, may not truly contradict what the FDA says, but may give us a little bit more leeway. So though the FDA says for botulinum toxins, if you're using on a botulinum toxin or incobotulinum toxin that on labels 400 units, but you feel like you have a patient that needs more, then you may be able to go to the literature that shows in certain studies, like the Tower study, that it's been safely used in doses up to 800 units for patients who have two limbs spasticity. And maybe you're able to argue your case for getting more units for a patient based on what the literature says. So again, it's all about knowing the rules and knowing the literature. Okay. So what happens if you make an ask and you want your patient to have a certain treatment and then you get a big fat no. So they deny what you want. And so the number two rule of, you know, all I need to know I learned in kindergarten was being nice to people and that kindness matters. So remember, going back, rules are rules. They have rules to follow. They have guidelines to follow. They're, you know, checking off boxes and they want to follow those. So don't yell at them. Don't be mean to them. It gets you nowhere. The phone call is recorded. Don't try to tell them that you're going to sue them. You know, just try to be kind and figure out what the next steps are. They don't care if you cry either. You know, as frustrated as you may be and as much as you want to do something for your patient, it doesn't matter because you have to go through the right steps to get them what they need. So again, ask how to appeal. Ask what the timeline it is for appeal. Who has to do the appeal? Can it be done by the physician? Does it have to be done by the patient? And then there's sometimes options for specialty specific appeals. So can you do a peer-to-peer? So peer-to-peer is talking to a physician who may be able to talk you through the process. The other thing, if you have an opportunity to do a peer-to-peer, look at the timeline for it. Because they're sometimes working with workers' comp. They'll be like, you have to do the peer-to-peer and it has to be done by 2 p.m. today and you get it at 1 p.m. And so you have one hour to do it. Or they tell you it has to be done by 2 p.m. but you don't get the facts in your inbox until 2 o'clock. And so then you have to know, well, what's the next step? And I will tell you, this happens very, very frequently. And then you call the peer-to-peer and they're like, sorry, it's closed because you didn't call. You were supposed to call seven minutes ago. So yes, things can be unfair and you're going to want to be like anger there. But just ask for what's the next step in the process to help your patient. And then you can ask for a specialty specific appeal. So sometimes, you know, the person on the other line may not likely or not a PM&R doctor. They may be a medical director for the insurance company that was a pediatrician before, that was internal medicine, that was family medicine, that has no idea what brain injury medicine is about, who has no idea what interventional spasticity is about, but they just know what, they're very good at knowing what the guidelines are for their insurance company is. So again, asking for maybe a specialty specific appeal. So what happens? You know, you get a no, you don't want to be angry. What's the next rule? Then rule number three is, you know, this is from Frozen 2, you do the next right thing, which is clean up your own mess. So again, knowing the situation, you have to look at your documentation and see. A lot of times, that's just what they want. For example, I'm just giving an example of patients who have chronic migraine. One of the treatments for chronic migraine, prophylaxis of chronic migraine is onabotulinum toxin A, or tox that a patient could get for chronic migraine. In order to get that, they just write a note that says, needs Botox for migraine. That's not something that's going to be acceptable. With an insurance company, you have to make sure that they've gone through, that they first, that they meet the criteria for a chronic migraine, which is, you know, that they have headaches at least 15 days per month, and that they last a certain amount of duration when they get the headaches, and that they do fall into the definition of migraine. And then they are supposed to at least fail a medication from three classes that they've been on for two months. So have they been on an SNRI, have they been on an antiepileptic agent, have they been on a beta blocker antihypertensive, and have been on those for two months and have failed that? Or if there is a contraindication to those medications, to one of those medications, what is the contraindication that they have? And only with that and documentation of all of that, then they will approve that medication. So was it all documented in your paperwork? If it was not, then you may have to see the patient again, or make sure that they've gone through all the right steps to get them the treatment that they want. And so look at your documentation, look at what you've documented, look at what they are expecting for you to document. Sometimes there's a form that Blue Cross Blue Shield has, and there's checkboxes whenever you're ordering a botulinum toxin. And they'll show you exactly what their guidelines are. Do the appeal if you can do the appeal. Have a standardized letter ready. I have a standardized letter for different toxins that I want to be able to inject for patients. And then I provide the data, including sometimes I will have links to PubMed articles, or I will actually print out articles that I will send with my appeal, just so that it's, again, they just want to see data, it's data driven. So that's doing the next right thing. So a tale of two cities, I like saying it's a tale of two outcomes. What can happen to your patients? Again, what's going to lead to health care disparities if you're not following the rules and trying to get the best thing that you can for your patients. So did your patient, did you get a big fat no, and then you did nothing about it or felt that there was nothing else to do about it, then that patient may not get the best treatment that you think they need. They may have a worse outcome. They may, in the case of, my spasticity patients have worse spasticity, have less function and more caregiver and societal burden. So you have to think if you're not able to work through these processes and getting the patient what they want, then the outcome may not be as good. And we should strive for the best outcomes for our patients. And then what happens if you do the next right thing, just like Anna said in Frozen 2, so the next right thing is going to be, you know, you see your patients again. You document, you find out what needs to be documented. You document what needs to be in the appeal. You send the appeal. You look at other options within their insurance. So maybe in the insurance, they are limiting the toxin use to another toxin. They're saying everyone must start a ABO botulinum toxin first. And so you have to say, okay, well then let's go through the rules. We'll start with that toxin and move on to another one. That's just an example for interventional spasticity management. So what are the other options? The other thing, an example is, you know, sometimes for patients who might have Medicare HMOs and you're trying to get them to inpatient rehab or insurances where you're trying to get them to inpatient rehab. I used to see patients in the outpatient setting. Sometimes we would admit patients from home for more intense inpatient rehab, especially if a new medical need came up. Again, you have to follow the rules. Do they have a medical need that needs to be followed by a rehabilitation physician daily? Do they need and they can participate in three hours of therapy daily? Yes. Yes. You know, do they need to rehab nursing 24 seven? Yes. Yes. Okay. And then let's make the referral. Maybe an insurance or a Medicaid HMO will not be as receptive to sending up to inpatient rehab. What are the other options within their insurance? And sometimes it was like, well, we will be willing to send them to a skilled nursing level of care. They do think about pricing. They do think about value-based. And so sometimes that was an option. I had to tell my patients, you know, this at least will give the family a little respite. The patient will get therapy in that setting. There is still a physician that can come see them, maybe not every single day. And I think that some families were happy to at least have that option for their families to get some therapy. The other thing is changing insurances. And sometimes if it's that time of the year where you can change the type of insurance that you have, or your patient can go change from their Medicare HMO and maybe switch to traditional Medicare. Again, I've seen that before where someone maybe had a Medicare HMO, they had a stroke and we said, okay, strokes, you know, part of the 60% rule stroke is a 13 diagnoses, but sometimes Medicare HMOs will not allow strokes still to go to inpatient rehab because they're there. Some of the thoughts are, okay, they can be served still in skilled nursing. And that's one reason why we need to have more data in PM&R of why inpatient rehab provides the best level of care. So I've had some patients when, if the time was up and that was the right time of the year, that they would get off of the HMO and get onto Medicare because with Medicare, traditional Medicare, they would be able to go to inpatient rehab. And then the other thing, the next right thing may be, is the patient really in need of the treatment? And is there a way that you can get the samples? So can they be treated with samples that you may be able to get from a drug company? The other thing is we used to, there are RSVP clinics in different parts of the country. That means there are clinics that have ability to do some of these procedures or see patients at no cost. And so maybe a referral to one of the free clinics to be able to take care of the patient. So again, doing the right thing for your patient in different situations. Next rule is be aware of wonder. And so what really that means, it goes back to, don't make the other person on the other side of the table who has your documentation, wonder what's going on. Don't leave things to the imagination for them. So you always want, again, going back to documenting, going back to rule number one about knowing the rules, you have to document those things. Don't leave things to the imagination. So I tell residents when I work with them and they write assessments and plans and the plans like needs, toxin, that's not a plan. Someone's going to say, no, I need to have the, you know, what's their condition? Where is it affecting them? What have they failed? Why do they need this treatment? What are the goals of treatment? What do we know about why, you know, that they need this treatment for spasticity and document the reasoning and the assessment and plan, you know, what did they fail before? Why did they fail it? What's changed? How did they do with previous interventions? So if they've had it once and they're coming back again, that doesn't mean that it's going to get approved a second time. Again, documenting why they need it, how they responded, if it's helpful to them. And the same thing goes about knowing the rules. Again, if someone is a chronic migraine patient and they need, they got it once and they had a good response, we know the rules, the chronic migraine rules for them to get repeat injection is it has to have been decreased by 50%, either in hours or numbers of days. And so that has to be documented. If it's not again, they're going to say no. And so don't leave any of these rules to the imagination. Rule number five, I don't have it there, but I will tell you and you can, you know, email me or tweet me any kind of questions. Rule number five is because we're in COVID, wash your hands and flush the toilet. So that's just my take home message from COVID and these times. So thank you for having me. So hello, my name is Monica Crump Baldrige, and I will be giving the next part of this lecture series on navigating the chasm between clinical work and the insurance world. So just to give a little bit of background about myself, I am a board certified physiatrist. I was in clinical practice for a little over 10 years, focusing primarily on stroke, brain injury, and spasticity management. And I spent the last few years of clinical practice as a medical director for an inpatient rehabilitation unit. More recently, I served as a medical director in inpatient case management for an insurance company. And I'm currently a medical director manager for post acute care management for Optum Enterprise Clinical Services, which is part of UnitedHealth Group. So moving along, I have no disclosures. And these are the objectives. I'll be talking about the insurance process, some of the reasons for denials, challenges that providers face, and then kind of where we move forward from here. In this talk, you'll hear me piggyback a lot on what you've already heard Dr. Gutierrez say, and then I'll also add in some additional information. All right. So starting with utilization management. So just the insurance world, the insurance companies are really large entities. They're multiple facets. They do lots of different things. I work for one, and I really have not been able to grasp even a large portion of what they do. But when we think about the insurance world and our relationship, this is what we're usually thinking about, utilization management. It is a prominent fixture in the healthcare system. It has evolved a lot over time, and it does continue to evolve. So just to give a brief definition, it is a process that is externally imposed upon the physician patient and is directed at containing healthcare costs for payers. It evaluates the efficiency, appropriateness, and medical necessity of treatments, services, procedures, and facilities provided to patients on a case-by-case basis. There are three types of review usually, prospective, concurrent, and retrospective, and I will talk about those a little bit more in a minute. So utilization management. Over time, there's been significant progress in the diagnosis and treatment of illness, as well as where healthcare services are delivered. With this came an increase in utilization of healthcare services, the type of services offered, and an increased cost of that care. Utilization management has been a way to address this issue. So just to take you back in history a little bit, in the early 1900s, healthcare was not considered insurable. Despite that, many individuals did begin a movement to organize and promote third-party financing for healthcare. So basically, they took a little bit of money out of their paychecks, set it aside, and when someone became ill, they had that money to compensate for those lost wages. It started out kind of like we view our disability insurance today, but this continued to evolve, and this concept of a prepaid health plan grew during the Great Depression. And in the 1950s, when employers had caps on how much they could pay employees, which made competing for employees difficult, they used healthcare benefits as an incentive to get employees. This private insurance quickly became regarded as a necessity. But after 50 years of growth, the reach of private insurance reached a peak and started to decline, and actually, the number of people without public or private insurance increased. Now, of course, there were several contributing factors to this, but the continuous rise in healthcare costs was certainly one of those factors. So utilization review or utilization management is really nothing new. It's been around. It's been something that providers have tried to manage for an extended period of time. So the first utilization review began in the 1950s. At that time, it consisted of a committee in the hospital looking at appropriateness of admissions and length of stay. And from there, they did use various tools and use various tools were created to control the costs, but these tools were often not rigorously applied or evaluated. And controlling costs was overshadowed by this desire to develop and implement advances in medical care. Then you also had Medicare and Medicaid programs developed in 1965. Medicare was for those over the age of 65, and Medicaid was for your poor population. This increased access to healthcare for the high-risk individuals, they used, I'm sorry, as an initial strategy to manage healthcare costs. Medicare and Medicaid programs tried to expand and strengthen the provider-based utilization review by having committees to ensure medical necessity. These took the forms of peer-reviewed organizations. But despite this, there was still a continued rise in cost. Then the private sector really started to step in and respond to this rise in cost. Not only at that time was there a rise in healthcare costs, but there was also increased oil prices, taxes were going up. And so they really started to notice and acknowledge their contribution to the rise in costs with their previously passive approach. So they began meeting, and with this came a shift in the 80s from provider utilization review to utilization management by third parties. Multiple factors played a role. So at this time, now you start to have this growing body of research highlighting medically unnecessary services that could be eliminated. Some of this was noticed by the wide variations in care. And also now there's more information resources, assessment tools, and organizations that make case-by-case review of proposed services feasible. Practice guidelines and protocols were starting to be implemented as a way for cost-effective use of specific medical services. And I see this as when there really starts to be more linking of quality and cost. And also you could say it's kind of the beginning of the triple aim, which is improving the patient experience, improving population health while reducing cost. So circling back to that definition of utilization management, once again, with some additions, as I mentioned, it's a process that evaluates the efficiency, appropriateness, and medical necessity of treatments, services, procedures, and facilities provided to patients on a case-by-case basis. And often it's run by or on the behalf of insurance providers rather than doctors now. So the goal is to reduce costs while improving patient outcomes, that whole linking cost and quality that I mentioned. And this is done by using objective evidence-based criteria to make fair determinations about the medical necessity services requested. And then, as I mentioned before, there are three types of reviews. So going into those three types of reviews. Let me go back one. The first type, prospective. It's when prospective reviews are performed before or at the onset of treatment. Usually you have information about an individual and you're making a determination for a proposed service prior to that service being rendered. This is done to eliminate unneeded, ineffective, or duplicate treatments. Then there's concurrent reviews. Reviews during the course of treatment, it tracks progress and resource consumption. During this time, you're looking at care coordination and discharge planning. You're looking at has this person met milestones to transition to another level of care. So an example might be a person's in acute inpatient rehabilitation. They have done very well functionally, but maybe they still need a week of IV antibiotics for say a complicated urinary tract infection. The insurer may say, hey, this person has benefits for home health that can help assist in providing those IV antibiotic administrations, or they are able to go to an infusion center. So maybe you can coordinate a discharge for that patient at a more appropriate time because those services can be done at a lower level of care. Then retrospective reviews are conducted after treatment is done, usually in issues with reimbursement or in response to a grievance or if a denial is being challenged, but it also provides data for future patients. And then I mentioned medical necessity as a part of the utilization management and how the determinations are made. So let's talk about that definition. What I have here is the CMS definition of medical necessity. Services or supplies that are proper and needed for the diagnosis or treatment of a medical condition are provided for the diagnosis, direct care, and treatment of a medical condition, meet the standards of good medical practice in the local area, and are not mainly for the convenience of the patient or the doctor. Basically, it determines if a service is appropriate, justifiable, and reimbursable. So another way to look at this is, could this service have been provided in a lower cost setting? This patient with the hip fracture and no complications after their ORIF, do they need to go in acute inpatient rehab where their PT and OT needs, or can they go to a skilled nursing facility or an outpatient setting to get those therapy services that they need? Does the evaluation and management exceed what is considered medically necessary and reasonable? You have a patient with some spasticity, do they need to have botulinum toxin injections, or can this be managed with physical therapy and oral antispasmodic medications? Are there symptoms or a documented condition that calls for the screening tests, exams, or therapies? This person that you're evaluating for back pain for the first time, do they need an X-ray or do they need an MRI for those exam findings? And is the service necessary for the diagnosis? So those are some of the questions that you can ask yourself in helping to determine medical necessity. And then we have guidelines to help determine the medical necessity. These are some of the larger often used guidelines that I have here, Milliman Care Guidelines, or MCG, InterQOL, and then of course we all know the Center for Medicare and Medicaid Services, or CMS. So these are evidence-based decision supporting tools. They focus on all aspects of care, whether it be inpatient, post-acute, behavioral health, outpatient, et cetera. When giving an adverse determination, these are not used in isolation. They are used along with clinical judgment. Here I just have an example of criteria. These are the CMS criteria for acute inpatient rehabilitation, which I'm sure many of you probably know, like the back of your hand if you do inpatient rehabilitation. And then also it highlights that actually the Milliman criteria and InterQOL are very similar to the CMS criteria for this particular service. So then I want to move toward mentioning the process, kind of the basic structure that is used when reviewing a case. Usually starts out with a physician or provider determining that a service is needed or a service that they want to provide to a patient. They then notify the insurance company with that request for that particular service. Records are requested by the insurer. Records are received and reviewed, usually first by a nurse who reviews those records against whatever guidelines they're using. If they determine that that particular service meets the guidelines based on the records that they have reviewed, then they may simply approve the service if they have the authority or they may send it to a medical director to approve those services. But if they review those records and feel that the guidelines have not been met or it's a gray area, then those records, then that request will go on to a medical director to review because nurses do not deliver adverse determinations. Those are done by a physician. So that physician can then review or medical director can review those records. They may determine that they need more information. They may elect to do a peer-to-peer before rendering a decision or they may go ahead and render a decision and then the provider is notified of whether that determination is agreed upon or if it's a denial of services. So I'm highlight, this is a basic structure. I mean, different insurers, different companies will have their own processes that they follow, but this is kind of the basic backbone that is used with additional things mixed in by whatever provider or organization that is reviewing those records. But I also wanna highlight that there are many other things that do occur maybe prior to this process happening or maybe after that will determine whether a service is denied or approved. So it doesn't always come down to just medical necessity. There are several other reasons that a service could be denied. One example will be the health plan benefits. A patient may not have benefits for the service that you're proposing with the insurance that they have. And in that case, they may not be able to get that service. So you may have two patients with similar issues. One patient has approval of those services, another patient does not, and it may come down to what their benefits are within their health plan. Another one would be in-network versus out-of-network. So if a person does not have out-of-network benefits and the facility or service that you're proposing is not contracted with their insurer, then that may be another reason that those services are denied. Say this patient's in an acute care setting, you want to send them right down to the hall, to the next floor, to the inpatient rehabilitation unit there, but it turns out they don't have benefits for that. They don't have in-network benefits for that facility. So that service may be denied. It may be that actually they have to go to the inpatient rehabilitation center that's 30 minutes away because that's who their insurer is contracted with. So that's another example. And then another thing may be benefit exhaustion. Maybe they have limits on what is available. Some people have maybe 30 or 60 days for a particular level of care. An example may be that you have a brain injury patient who required a craniectomy. After their acute care stay, they go to acute inpatient rehab for their care. They're stabilized. They make some progress. And then 30 days later, they discharge to a lower level of care or to home. Then a month later, they're back to the hospital to get a cranioplasty done. And you think, okay, now they have a cranioplasty. This is a good time to resume rehabilitation once again in the acute inpatient rehab setting. But they only have a 30-day benefit. So now they exhausted that benefit already for that calendar year, no longer have that benefit available. So that service is not available to them. But that also highlights that knowing those benefits upfront is very helpful because then you could maybe coordinate maybe we need to discharge this person a little bit sooner to make sure those services are available to them. So those are some reasons. Another thing may be lack of documentation. If you request a service, but then don't also provide an adequate diagnosis or reason for that services, the documentation is not there. Then again, that service may be denied because of lack of information available to say that that service is necessary. So these are all things to keep in mind as reasons for denial of services other than just medical necessity. So moving on to some of the challenges that we all have. Of course, I know there are provider frustrations. Going through this utilization management process may feel like there's a limit on clinical autonomy as well as an increased administrative burden. There takes more time, it takes more money because you may have to have staff to manage things that related to utilization review. Then of course, as providers, a lot of times we're not thinking about medical necessity guidelines when we're delivering patient care. We're just trying to get the care to the patient that we think they need. But I will say that we do have to think about if that care that we want to give is necessary. And then not understanding why coverage is denied, that can be a frustrating factor and something that's often missed. I just gave you several examples of some reasons why services are denied that you may not always know up front, and it may not be communicated easily and quickly, but may be reasons why you can't get the services that you are proposing for a patient. Then reviews are rising, denials in coverage seem to be rising, and this can be a frustrating factor or a challenge. There could be many reasons for that. The more the population is growing, more people need that service, so there are more reviews. Another reason could be insurers see other opportunities for utilization management of services, and so they're reviewing more cases. And then also thinking about kind of this shift that we see in healthcare toward treatment in the home, more services are available to patients within their home safely. And so there may be this trend toward trying to get those services in the home versus in an inpatient setting. And then there sometimes seems to be this, may possibly this difference between best practice and most cost-effective treatment. I think providers think in terms of best practice and insurers may think in terms of cost-effective treatment. In my opinion, yes, those should be one in the same, but I don't know if they always are. And then process by insurers may feel unnecessary, like there's red tape. I just sent you through the process that is often used to review services. Guidelines are vague. There's no well-defined criteria for most appropriate post-acute level of care for a lot of specific diagnosis. Both MCG and CMS guidelines are subject to variable interpretation with few quantitative thresholds. And then we know what we do is valuable as physiatrists. We know what impact we have on patients. But honestly, the value of post-acute care is not always clear. And then there can be a lack of standardization on both ends, lack of standardization among insurance organizations on how things are determined, but also a lack of standardization in the post-acute, among post-acute care settings, the different levels of care. There are some benefits for utilization management. There is an increasing focus on quality and coming up with guidelines that focus on quality, lowering cost, and then also better data. With better data, we can evaluate effectiveness of treatments and protocols. And with this, you have better use of resources, unnecessary treatments decrease, and effective treatments become more available. Lower costs and better outcomes do prevent an individual's health problems from negatively impacting resources available for others. That I think goes toward that triple A concept once again. So moving forward, so moving forward, we do need to acknowledge the value of post-acute care is not always clear, and there are variations in care and outcomes. There's limited evidence on the best setting and what mix of services will achieve outcomes lots of times in post-acute care. So we do need clear evidence-based guidelines demonstrating the effectiveness and the need for different forms of care and the services that we provide. We need to understand where the healthcare industry is going and how to best provide care in that environment. Two things to think about in ways to do that, value-based care and that triple aim. Although here I want to point out, we really need to think about the quadruple aim versus the triple aim, but that fourth aim being provider experience. You know, the work life of the provider is very important and essential to providing care for patients. You know, doctors certainly need to be advocating for themselves and saying what they need to be able to provide care for patients, and providers need to be given the resources they need to be able to do that, in addition to incentives for those who are really taking a proactive approach to achieving the triple aim and managing cost and quality. So we really need to think about value-based care as well. You know, that's where the insurance world is, I'm sorry, that's where the healthcare system is really going, looking at providing care more efficiently and looking at an episode of care. So we have to define our place within that value-based care payment system. And part of doing that is developing the evidence-based practice guidelines that can select the most appropriate post-acute care setting for the patient. And predict the clinical course of individual patients. That's looking at research opportunities that look at not only outcome, but looking at quality, I'm sorry, looking at cost is very important as well in determining that value. Ultimately, we have to understand that the needs, there is a need to deliver care to more people with limited dollars. And we have to play a proactive role in doing that. So in conclusion, I made an attempt to give you just kind of a basic overview of the utilization management process, understanding of medical necessity, and understanding that utilization management is this forever evolving process. It isn't perfect, no doubt about that. We always have ways that we can make improvements in the processes that we use. But also understand where we as a specialty need to grow and make our impact on the healthcare system and the way things are evaluated. Healthcare will continue to evolve in an effort to provide needed care while controlling cost. And we can play a role in that. There has to be a collaborative relationship between community insurers and providers in order to achieve goals, achieving that quadruple aim in particular. So adapt, evolve, and thrive. And that brings us to the end to hear some of the references that I have used for today's lecture. Thank you.

insurance world

healthcare

health insurance coverage

private coverage

public coverage

administrative burden

insurance companies

treatments

evidence-based practice guidelines