provider relations doug moats [email protected] april 2015 [email protected]

Provider Relations

Doug Moats

[email protected]

April 2015

mailto:[email protected]

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

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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

http://www.unitedhealthcareonline.com/

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UnitedHealthcare Provider Relations and Service Team

Your Partner for Claims and Service Needs:

[email protected]

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


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


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


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


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.



Sample of “Questionnaire”

Here are some questions a provider may be asked when submitting a request for vein surgery:

Additional Online Training


• 1st Wednesday of the month (1:00 pm central)

• www.unitedhealthcareonline.com > Tools & Resources > Training & Education


https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=ee09c7958f5fa010VgnVCM100000c520720a____

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=8c6592752e071110VgnVCM100000c520720a____

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

http://frontier.uhg.com/Corporate/Brand/Photography%20%20Clinical/42-21636590.jpg

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

http://frontier.uhg.com/Corporate/Brand/Photography%20%20Clinical/FAN9003173.JPG

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


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


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


Assessment Key Features - Quality


• 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


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.


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


UnitedHealthcare Tiered Benefit Plan Example Member ID Card


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


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


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.



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


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



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


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


UnitedHealthcare Provider Relations and Service Team

• Your Partner for • Claims and Service Needs:

[email protected]

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

provider relations doug moats [email protected] april 2015 [email protected]

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