Tips in addressing carrier medical directors
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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

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What causes payers to expand coverage policies
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

How can you be heard
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

Denial appeals resources
Denial Appeals Resources

  • Kaiser Family Foundation and Consumers Union Site


  • Insurance Carriers

    • Aetna Appeals Guide


    • Anthem/WellPoint Appeals Guide


    • Cigna Appeals Policy


How can you be most effective
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.


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

How to get the meeting
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

Once you get the meeting words are important
Once you get the meeting—Words are Important

What is most helpful in communicating with medical directors
What is Most Helpful in Communicating with Medical Directors

Guidance on which patients are appropriate

Clear Statements


Statement on evidence

Statement on validity of evidence

How to limit risk

Clarification of coding if confusion exists in the field

Stay on message
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

Key points for the letter
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


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.