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2Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Agenda
• Physician Advocates & Network Management
• View 360
• Notifications/Prior Authorizations
• Premium Designation Program
3
Advocates &Network Management
4
What is a Physician Advocate?
A UnitedHealthcare navigational specialist
Product expert, represents all
Externally focused – interacts with the physicians and has a direct line
of sight to the challenges experienced by local practices.
Relationship manager – builds collaborative working relationships
and communicates changes to physicians in a timely way
United Healthcare
Physician Advocate
PhysiciansOffice Staff
Responsive, Proactive, Reliable and Simplistic!
5
Network Account Management
Your Partner for Contract Needs
To find your Network Account Manager
www.unitedhealthcareonline.com > Contact Us > Select “Nebraska”
Contract negotiations and management
Contract interpretation questions
Fee schedule inquiries
Product offerings and amendments
6
UnitedHealthcare Provider Relations and Service Team
Your Partner for Claims and Service Needs:
Navigational specialist
One contact for all UnitedHealth Group companies
Assistance with education; self-service tools
Help with service issues
Works to maximize the ability of practices to interact with UnitedHealthcare
7Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
View 360 to be Discontinued as of April 22
As of April 22, 2015, View360 will no longer be available.
View360 will be replaced by new program tools specific to each of our health plans
and their plan membership populations.
• Monthly member data updates on View360 online will
continue through March 2015.
• Care providers who use View360 online will continue
to have access through April 22, 2015.
Over the last five years, View360 provided care opportunity information about UnitedHealthcare members who may be due or overdue for preventive screenings or other health services. Our other quality and preventive care programs –
such as UnitedHealth Premium® designation program – will continue and we will introduce new programs to meet members’ and providers’ evolving needs.
For more information, please contact us at
[email protected] or 866-270-5588.
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Prior Authorization/Notification Enhancements
Confidential & Proprietary. Not for Distribution to Third Parties
Addition of Orthopedic Procedures
As previously communicated in the JanuaryNetwork Bulletin, orthopedic procedures is anew category that will be added to the advancenotification or prior authorization requirements forthe UnitedHealthcare and UnitedHealthcare WestCommercial and Medicare Advantage Plans,effective April 6, 2015.These three new codes will become effective forUnitedHealthcare Community Plans on June 1, 2015.
• 29914• 29915• 29916
Confidential & Proprietary. Not for Distribution to Third Parties
Enhanced Automated Decision Functionality
• During Q3 2014, UnitedHealthcare is enhancing the functionality of the submission process by expanding and evolving the existing automated capabilities to include additional services.
Date of Deployment: • October 1, 2014
Deployed to the following products in our Market:• UHC Employer & Individual Business (Fully Insured & ASO)• UHC Medicare & Retirement
Confidential & Proprietary. Not for Distribution to Third Parties
Specialty Categories
The following specialty categories are being added to the auto decisioning logic:• Bariatric Surgery • Cosmetic & Reconstructive • Spinal Stimulator for Pain Management • BRAC Genetic Testing • Orthognathic Surgery • Breast Reconstruction – Non Mastectomy• Spinal Surgery • Sleep Studies • Vein Procedures • Durable Medical Equipment (DME) - greater than $1000• Joint Replacement
Confidential & Proprietary. Not for Distribution to Third Parties
Automatic Decisioning Process
• When a provider submits a prior authorization request for a service within the specialty category, the provider has an option to access a questionnaire.
• Based on the information provided while completing the questionnaire, the provider will either receive an automated approval or will be informed that additional clinical information is needed to review.
Confidential & Proprietary. Not for Distribution to Third Parties
Confidential & Proprietary. Not for Distribution to Third Parties
Sample of “Questionnaire”
Here are some questions a provider may be asked when submitting a request for vein surgery:
Additional Online Training
Confidential & Proprietary. Not for Distribution to Third Parties
• 1st Wednesday of the month (1:00 pm central)
• www.unitedhealthcareonline.com > Tools & Resources > Training & Education
UnitedHealth Premium®
Designation ProgramPower to transform heath care delivery
2015 Program Overview: Doug MoatsProprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Welcome to UnitedHealth Premium Designation
Today we will review: • UnitedHealth Premium Designation Program• Premium Methodology Overview• Physician Communication• Premium Designation Reports• Reconsideration • Group Methodology• UnitedHealthcareonline.com resources
This presentation will provide an overview of the UnitedHealth Premium Designation program and resources available on UnitedHealthcareonline.com
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Premium Designation Physician Specialties
Primary Care
Family Medicine
Pediatrics
Obstetrics & Gynecology
Internal Medicine
Specialists
AllergyCardiologyCardiology-ElectrophysiologyCardiology-InterventionalEar, Nose, & Throat *EndocrinologyGastroenterology*General SurgeryGeneral Surgery-Colon/RectalNephrologyNeurologyNeurosurgery-Spine
OphthalmologyOrthopedics-GeneralOrthopedics-Foot/AnkleOrthopedics-HandOrthopedics-Hip/KneeOrthopedics-Shoulder/ElbowOrthopedics-SpineOrthopedics-Sports MedicinePulmonologyRheumatologyUrology
* New specialties for 2015
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
UnitedHealth Premium® Deployment map
HI
CT
RI
MA
DEMD
NJ
AL
ARAZ
FL
IA
ILMO
LA
MI
MS
TN
KY
SC
PA
NE
NY
TX
UT
WI
VACO
MN
NC
OHIN
WV
NV
NM
ND
OK
OR
WA
GA
SD
VT NH
ID
KS
DC
MEAK
CA
WY
MT
Not available
AvailableMichigan: Not available in Upper Michigan
Missouri & Illinois: Not available in St. Louis, (including SW Illinois)
Upper Michigan
St. Louis area
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Program and Eligibility Standards
• Physician’s performance compared to benchmark results• Performance differences are statistically significant• Group assessment at specialty level• Minimum 45-day interval to review • Reconsideration opportunities
Program Standards
• Active commercial contract with UnitedHealthcare• Primary place of service in a Premium program market• Primary specialty in the Premium program
Eligibility Standards
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Assessment Key Features - Quality
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
• Measures may be attributed to multiple physicians involved in the patient’s care
• Measures are compared to national benchmarks, at the 50th percentile performance level
• Commercial and Medicare data each with separate benchmarks are included
• Minimum sample size: 20 measures among five patients is required for measurement
• Quality is assessed first. If quality criteria is not met, the physician is not eligible for the Cost Efficiency designation
Quality Standards
Assessment Key Features – Cost Efficiency
• Minimum sample size is 10 episodes • Case-mix and risk-adjustment • Patients are attributed to no more than one physician within each
specialty category
Population Cost Standards
• Minimum sample size is 10 patients• Case-mix and severity-adjustment• Medical episode attributed to one physician who generated the
highest cost• Surgical episode attributed to the physician who performed the
procedure
Episode Cost Standards
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Benchmark performance is at the 75th percentile. Must be statistically significantly lower cost than benchmark to be designated for cost efficiency
Data used for Assessment
• Commercial fee-for-service claims
• For the quality only, UnitedHealthcare Medicare and Retiree claims
• Claims incurred and paid from January 1, 2011 through February 28, 2014.
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Premium Designation Results
Premium Designations• Quality & Cost Efficiency• Cost Efficiency & Not Enough Data to Assess Quality• Quality & Not Enough Data to Assess Cost Efficiency• Quality & Did Not Meet Cost Efficiency• Not Enough Data to Assess Quality & Did Not Meet Cost Efficiency• Not Enough Data to Assess• Not Evaluated• Did Not Meet Quality & Cost Efficiency
Members in health plans that offer tiered benefits may pay lower copays and coinsurance amounts for services provided by UnitedHealth Premium Tier 1 physicians.
UnitedHealth Premium Tier 1 physicians have received the Premium designation for:• Quality & Cost Efficiency • Cost Efficiency & Not Enough Data to Assess Quality
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
UnitedHealthcare Tiered Benefit Plan Example Member ID Card
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Bottom of card • Name of network
(i.e., Choice/Choice Plus) • Type of business:
“Underwritten by” = Fully-Insured Business “Administered by” = Self-Funded Business
STANDARD FAMILY CARD
Only plans with physician tiering utilizing Premium will be identified by the
“UnitedHealth Premium” in the Customer field
If member in Tiered Plan uses a Tier 1 physician, the office will collect a flat dollar
copay.
If member visits a physician that does not have Tier 1 designation, they will be
responsible for a % of the allowed charges.
Myuhc.com designation display
Premium Designation and UnitedHealth Premium Tier 1 on “Find a Physician” search tool
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Physician CommunicationThe Annual Assessment Notification Includes:
• Designation results • The personal identification number
(PIN) if the physician has not previously validated their PIN
• Instructions on how to access the Premium designation assessment reports through UnitedHealthcareOnline.com
• The date in which reconsideration is due in order to be reviewed prior to public display
• Annual Assessment Notifications are mailed out each year
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
ReconsiderationPremium reconsideration is an opportunity to request a change to the patient-level information used in the Premium assessment. Additional patient-level information is submitted that may impact the Premium assessment.
When can physicians submit a reconsideration?• Physicians have 30 days prior to initial assessment display to submit a
reconsideration in time to affect the designation displayed.• Physicians can submit a reconsideration at any time up to the reconsideration end
date.• Physicians are notified at least 30 days prior to reconsideration end date.
How do physicians submit a reconsideration? • Reconsiderations are submitted via our online reconsideration tool located on the
physician portal at www.unitedhealthcareonline.com . • The Reconsideration tool provides a step by step process indicating the items that
can be reconsidered.
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Group MethodologyEach specialty within a medical group is assessed for quality and cost efficiency using the same methodology applied to individual physicians.
• Quality and cost efficiency measures are aggregated by specialty • Physicians who do not meet data sufficiency requirements may meet the quality
and cost efficiency criteria based on the group results• Results are communicated to practice administrator’s only and are not publicly
displayed
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
UnitedHealthcareOnline Physician Portal
UnitedHealthcareOnline.com > UnitedHealth Premium
Resources are available on UnitedHealthcareOnline
• Detailed program methodology
• Premium FAQ’s• Reconsideration How-to
guide• Evidence-based Medicine
guidelines• Premium Profile and
Preferences• Contact Premium Program
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group
Premium Designation
Letters were mailed 11/3/2014Reconsideration/Review period runs through 12/3/2014 Public display of results January 2015
To learn more, please visit UnitedHealthcareonline.com > UnitedHealth Premium
31Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Premium Designation
Training now Available forUnitedHealth PremiumDesignation® Program
We are pleased to announce the availability ofthe UnitedHealth Premium Overview training
course. This online course will help you understandthe Premium program’s key features and explain the
resources available on UnitedHealthcareOnline.com. Italso includes an introduction to the methodology used
to determine quality and cost efficiency.The self-paced course is available to you
on-demand at UnitedHealthcareOnline.com> UnitedHealth Premium > Premium Helpful
32Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
UnitedHealthcare Provider Relations and Service Team
• Your Partner for • Claims and Service Needs:
Navigational specialist
One contact for all UnitedHealth Group companies
Assistance with education; self-service tools
Help with service issues
Works to maximize the ability of practices to interact with UnitedHealthcare