Tips in Addressing Carrier Medical Directors. Judy Dean Managing Director. 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
Additional new data is available (internal and external)
A code change
Customer requests (employers, patients, etc)
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
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.
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
Guidance on which patients are appropriate
Statement on evidence
Statement on validity of evidence
How to limit risk
Clarification of coding if confusion exists in the field
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
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
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.