Physical Medicine Benefits Management Program Overview Dean Health Plan PT/OT Providers

1. Physical Medicine Benefits Management Program Overview Dean Health Plan PT/OT Providers June 19 & 28, 2012

2. Agenda New Requirements for Physical Medicine Services Utilization Management Program Rapid Response Preauthorization System Measuring Outcomes Provider Reconsiderations and Appeals Additional Tools for Providers If you have questions during the presentation, please e-mail them to provider.communication@healthways.com

3. New Requirements Physical Medicine Services

4. New Requirements Effective July 2, 2012, Dean Health Plan (DHP) will implement a program to manage utilization of outpatient physical medicine services. Healthways will administer a Utilization Management Program on behalf of DHP. Preauthorization is required only for members who utilize > 8 PT/OT visits per year. DHP will continue to process claims and manage its network of participating providers.

5. What You Will Use • User Information and Access Code for Healthways Provider Portal www.wholehealthpro.com • A link to Healthways portal is included on DeanCare and Dean ASO website • Healthways Online Submission Form and Input Guidelines • Healthways UM Department Request Form(used to request peer-to-peer discussions or appeals) • Access to additional information is available at www.DeanCare.com

6. HMO Considerations • The count of services (visits) will be based on member plan year • Count will start at 0 in July and then will start at 0 upon the start of each contract year • The count of combined PT & OT services will be set at 0 on July 2, 2012 • Visits after 8 for PT/OT services will require authorization • A referral request will still be required and managed by DHP UM staff for requests for PT or OT out-of-network services. • If a PT visit and an OT visit occur on the same day, they will count as 2 separate visits

7. POS and PPO Considerations The count of services (visits) will be based on member plan year Visits after the first 8 will require authorization

8. ASO Considerations ASO members will continue to have the same authorization requirements and will be required to submit authorization requests to Healthways

9. Medicaid Considerations • Visits after the first 8 require authorization • The Birth-3 program will be managed by DHP. If a provider does submit an auth for one of these members, Healthways will send back to DHP for processing • All other benefit limits will be maintained

10. Exceptions Members with autism diagnoses will be excluded from the Healthways UM Program. Providers will not be required to submit an authorization request for PT/OT services for patients with a primary autism diagnosis If an authorization request is received, Healthways will notify the provider that an authorization is not required and will send DHP the member information CCHP members are excluded entirely from the program

11. Utilization Management Program

12. Utilization Management Program Summary Healthways UM Program is URAC accredited and meets Wisconsin DOI requirements. Quick turnaround of reviews (1-2 business days) once all information is received Authorization System is accessible 24/7 to provider offices Written notifications of review determinations are faxed to providers within 20 minutes of decision Care plan authorizations will be matched by DHP to submitted claims. Utilization review of outlier cases and reconsiderations are evaluated on a like-specialty peer review basis

13. Care Authorization If the member’s care is anticipated to exceed 8 visits in a calendar year, additional treatment requires preauthorization through Healthways. Prior to the ninth (9th) visit, the treating provider will need to obtain a care authorization from Healthways for any evaluation visit or future manipulation or physical medicine services by submitting information about the patient’s treatment plan. Authorization requests should be submitted as soon as possible; should be within +/- 7 days of patient visit Authorization for subsequent treatments will be based upon specific clinical criteria, evidence based guidelines, and DHP standards for medical necessity, and is a requirement for reimbursement. If a provider performs services without an authorization, the claim will deny.

14. Rapid Response System Authorizations

15. Rapid Response System (RRS) • Following evaluation of the member, providers prepare a treatment plan and complete the Treatment Authorization Template. • Providers (or designees) submit (+/- 7 days) the authorization request and question responses via Healthways Rapid Response System (RRS). • RRS is accessed via Healthways provider portal www.wholehealthpro.com • Proposed treatment plan is benchmarked against clinical algorithms for provider consideration and member’s case history is assessed for potential clinical red flags and cross referenced with treatment protocols for specific conditions. • Provider is immediately aware of pre-screening outcome. • Prescreening approval, or • Pend for peer clinical review • Written notification is faxed to provider’s office within 20 minutes.

16. RRS Access via WholeHealthPro

17. RRS AuthorizationInsurance Section

18. RRS Authorization Condition

19. RRS Authorization Treatment Plan

20. RRS Authorization History

21. RRS Authorization Summary and Review

22. RRS Authorization Prescreening

23. RRS Authorization Prescreening Outcome

24. RRS Authorization Approval Outcome

25. RRS Authorization Pended Outcome

26. Authorization Process ~ Level I Data Input and Interface with Algorithms & Clinical Criteria for Prescreening via Rapid Response System

27. Bar Code TechnologySecurely Links Member Medical Records To Electronic File

28. Medical Records SubmittedWhen Requested • Patient’s case history. • Findings of all examinations performed. • Findings of special studies, including but not limited to x-ray studies taken or reviewed. • Clinical impression (including rationale for changes in diagnosis). • Treatment plan (including rationale for changes in duration or frequency). • Informed consent or terms of acceptance. • Progress notes for each patient encounter in a Problem Oriented Medical Record (POMR), or similar charting format — dated and signed by the provider who rendered the services. • Details of (and rationale for) supportive procedures or therapies, when administered, dispensed or prescribed. • Specific description of anatomical sites or regions of all treatment services.

29. Level II ~ Peer Clinical Review Clinical reviews are managed by nurses, clinical peers, and physicians; completed within 1–2 business days

30. Measuring Patient ResponsePatient Specific Functional Scale • Patient-Specific Functional Scale • This questionnaire can be used to quantify activity limitation and measure functional outcome for patients with orthopaedic and other conditions. • Clinician completes at the end of the history and prior to physical examination. • Initial assessment • I am going to ask you to identify up to three important activities that you are unable to do or are having difficulty with as a result of your problem. Today, are there any activities that you are unable to do or having difficulty with because of your problem? (Clinician: show scale to patient and have the patient rate each activity). • Follow-up assessments • When I assessed you on (state previous assessment date), you told me that you had difficulty with (read all activities from list). Today, do you still have difficulty with (read and have patient score each item in the list)? • Patient-specific activity scoring scheme (Point to one number): • 0 1 2 3 4 5 6 7 8 9 10 • Unable to Able to perform activity at the same activity level as before injury or problem

31. Patient Specific Functional Scale

32. Application of Clinical Criteria When considering an initial or continuation of care request for manipulation and physical medicine services, the following data elements are evaluated to ensure correlation to the presenting diagnosis and proposed care plan: • Chief complaint • Past medical history • Mechanism of onset • Duration of symptoms (acute or chronic) • Severity of condition (mild, moderate or severe) • Examination findings • Results of diagnostic testing • Diagnostic impression • Co-morbidities or complicating factors (conditions or circumstances that may affect the patient’s response to care) • Prior and/or concurrent history of treatment • Prognosis and provider comments • Changes in Outcome Assessment Tools

33. Assessment of Patient Response Clinically significant improvement measured by: • Clinical and functional improvement in a patient’s net health outcome as reflected by a decrease in symptoms, positive correlation in reduction of objective findings, and an increase in function. • Outcome Assessment Questionnaire scores indicate qualitative and/or quantifiable improvement in the patient’s ability to perform functional tasks and/or activities of daily living. • Expected level of improvement, rate of change, and required duration and frequency of care vary by diagnosis in concert with the age of the patient, mechanism of onset, duration of condition, contributing past history, and the presence or absence of complicating factors.

34. Non-Covered Care • Coverage may not be provided for those categories of services commonly described as “maintenance care,” “wellness care, or “preventive care.” • For instance, when the status of a patient has remained stable for a given illness/condition/injury over approximately four (4) weeks, without functional improvement in a patient’s net health outcome or expectation of additional objectively measurable clinical improvement, further treatment is considered non-covered care. • Ongoing care after a patient’s condition has stabilized or reached a clinical plateau, called Maximum Medical Improvement (MMI), does not qualify for coverage.

35. Provider Reconsiderations & Appeals

36. Reconsiderations and Appeals Provider peer to peer discussions for adverse determinations and provider appeals (standard & expedited) are administered by Healthways with communication of outcome to both the provider and member. Healthways UM Department Request Form is utilized for requesting peer to peer discussions or appeals. Member appeals (standard & expedited) of adverse determinations are administered by DHP. Healthways coordinates with DHP in administering the External Appeals process as required by state and federal regulations.

37. Provider Relations - Customer Care DHP Customer Care • Eligibility and Benefits • Claims • Member Appeals Healthways Provider Relations/Customer Service • Dedicated line for DHP providers: 800-500-0997 • Assistance with preauthorization process • Assistance with provider appeal process

38. Thank you for attending!If you have additional questions, please email them to… provider.communication@healthways.com

39. Appendix

41. Clinical Leadership Kevin Basile, PT, MS, OCS – Director, Clinical Services, PT/OT • APTA advanced certified orthopedic specialist and advanced certification in manual therapy with15 years clinical experience including 8 years as a physical therapy peer reviewer; lectured nationally on various topics pertaining to physical rehabilitation and treatment interventions • Member of 2008 & 2010 APTA task force to review and revise the APTA Guidelines William Dorney, DC, CHCQM – Director, Clinical Operations & UM • Certified in Peer Review & Health Care Quality Management with 30 years experience in Clinical Services, Managed Care Operations, UM Accreditation, Quality, and Compliance • Former President and CEO of Alignis, Inc., a chiropractic & physical therapy MCO Roger Nelson, PhD, PT., FAPTA - Director, Expert Clinical Benchmarks • Professor of Physical Therapy and internationally recognized educator and expert in the field of physical medicine; 52 peer reviewed publications and more than 100 professional presentations and two published books (one in the 3rd edition) in the area of Electrotherapy • Represented the Physical Therapy profession on the Agency for Health Care Policy and Research (AHCPR) Low Back Guideline Panel; Chair of the National Institute for Occupational Safety and Health's (NIOSH) Low Back Atlas Study

42. Clinical Leadership (continued) Mark H. Nolting, ND, L.Ac, Dipl.Ac., Medical Director, CAM Services • Board Certified, National Certification Commission Acupuncture & OM; former chair and faculty of acupuncture and Oriental medicine at Bastyr University • 25 years clinical experience as naturopathic physician and acupuncturist; 12 years experience as CAM IME examiner Richard Olson, DC – Director, Clinical Services • 25 years as consultant in the Chiropractic profession and insurance industry including former National Chiropractic Consultant for The Travelers Insurance Company • Author of Procedural Utilization Facts, Chiropractic Care Standards along with Chiropractic Care Plans, Best Practice Guidelines Andy Perez, MD – Director, Medical Integrity & Science • Functions as research clinical advisor and supports domestic and international Business Development and Strategic Development initiatives • Former Associate Medical Director for Medical Policy Development for Blue Cross Blue Shield of Michigan, where he served as liaison for several professional societies

43. Clinical Leadership (continued) James E. Pope, MD – Vice President and Chief Science Officer • Oversees medical and scientific integrity, analytic consultative services, process quality improvements, outcomes and applied research • Extensive publication history and recognized expertise in evaluating well-being interventions that control cost and improve quality of care • Former President of HeartCare Institute of Tampa, former President and Medical Director of Florida Cardiac Network, Inc.

44. Provider Training Tip Identify Member Identify Member plan-type HMO PPO POS ASO If OON, submit to DHP If plan, submit to Healthways If OON, submit to DHP If plan, submit to Healthways Submit to Healthways Submit to Healthways

45. OON Referral Process Provider submits request for service (Navi or via fax) Is there OON coverage? Out of Network services not approved No OR Yes Healthways receives request for OON service OON referral reviewed by DHP UM OON Auth set up with 1-month time span Send information to Healthways for medical necessity review Assumption: Member may be allowed to go out of network for full course of treatment if medical necessity guidelines met Does provider need additional time? Submit new OON auth request to DHP