Tips in Addressing Carrier Medical Directors

1. Tips in Addressing Carrier Medical Directors Judy Dean Managing Director

2. What Causes Payers to Expand Coverage Policies? Additional new data is available (internal and external) A code change Customer requests (employers, patients, etc) Provider requests Increase in overturned denials Stakeholders, (providers, KOLs, patients, employers and Societies) can create noise in the network asking for change, therefore, as Physicians and Professional Society, you can drive change to payer coverage policies

3. How Can You Be Heard? • Contact the Decision Makers - Make Noise in the Network • Talk to the Provider rep assigned to you by the payer • Write a letter to the payer medical director • Appeal your Denials • Take Denials to the highest level of appeal possible • Ask for a meeting or a conference call with the medical policy decision maker • Educate your patients on appealing denials

4. Denial Appeals Resources • Kaiser Family Foundation and Consumers Union Site • http://www.kff.org/consumerguide/7350.cfm • Insurance Carriers • Aetna Appeals Guide • http://www.aetna.com/provider/data/PhysicianInternalAppealRefGuide.pdf • Anthem/WellPoint Appeals Guide • http://www.anthem.com/provider/in/f3/s4/t1/pw_ad089352.pdf • Cigna Appeals Policy • http://www.cigna.com/health/provider/medical/procedural/claim_appeals/appeal_policies_procedures.html

5. How Can you Be Most Effective? Be available to the payer for questions or phone calls. (they are not very flexible on scheduling meetings or calls) Be clear and concise regarding your position Follow up – the payer has hundreds of policies to review. Establish a relationship with the medical director who can impact the policy, if possible. Ask for a policy change and be specific on what your state needs Be familiar with the policy—with its benefits and its drawbacks.

6. Preparation Read the payer’s coverage policy and note the areas where you disagree or feel it can be improved—all policies are different Ask your provider rep for the name, address and phone number of the medical director Understand the high points of the key clinical studies Feel comfortable with the PowerPoint presentation

7. How to Get the Meeting • Obtain the medical director contact information through your existing contact base • Hospital administration • Your carrier provider rep • Your denial management efforts • Request the meeting either through a phone call or through a brief but well written letter • Be persistent—the payer medical director has a many policies to manage and fewer people now on staff to help • Offer your help in developing criteria on patient selection • Form a relationship with the medical director. Be available to help his group write a fair policy for their members

8. Once you get the meeting—Words are Important

9. What is Most Helpful in Communicating with Medical Directors Guidance on which patients are appropriate Clear Statements Outcomes Statement on evidence Statement on validity of evidence How to limit risk Clarification of coding if confusion exists in the field

10. Stay on Message Ask for a policy change Data is sufficient now Data is long term Follow NIH guidelines without BMI limitations Do not limit to 2 step procedure Other payers now cover SG, including UHC

11. Key points for the letter State your credentials and expertise Be specific regarding your support and any State Society Support Reference key data and studies Specifically ask for a policy change and for the payer to follow NIH guidelines for sleeve gastrectomy. Set a time to follow up. “ I will contact you in 2 weeks….” Indicate the procedure is not investigational and is widely accepted within the physician community State that studies and data are sufficient to support payer policy Point out parts of the policy that need to be change Tell them how it impacts your patients and your practice of medicine

12. Conclusion Be persistent to be heard Follow up with information The Manager of the Medical policy area may be responsive to you, or help you get the ear of the Medical Director Noise in the provider network can have great impact on payer policy Key opinion leaders help the payer by having clear input regarding technology Specialty Societies and the physician network must get involved to change policy. There has to be a reason for policy to change: a coding change, additional evidence, a new society statement, letters from the state specialty societies Payers are updating policies now and you can impact those policies.