Typically, medical directors of health plans are responsible for the oversight and implementation of coverage policies and utilization management. Hence, establishing a rapport with the medical director of your state or regional plan is an excellent way to advocate coverage for procedures or devices, which have been inappropriately denied or bundled. Generally, private payers base their coverage policies on different methods such as technology assessments (from state or federal agencies, or independent non-profit organizations), in-house reviews of medical evidence, clinical practice guidelines, Medicare coverage determinations, and sometimes based on the cost effectiveness of the procedures or devices. As such, it is imperative that you (or your staff) consider the following factors:
Medicare Evidence Development & Coverage Advisory Committee (MedCAC): Established in 1998, MedCAC provides independent guidance and expert advice to the Centers for Medicare and Medicaid Services (CMS) on specific clinical topics, technology, and science.
Technology Evaluation Center (TEC): Operated by the national Blue Cross Blue Shield Association and has collaboration with Kaiser Permanente, creates assessments of medical technologies based on “a comprehensive evaluation of the clinical effectiveness and appropriateness of a given medical technology.”
National Guidelines Clearing House (NGC): A comprehensive database of evidence-based clinical practice guidelines and related documents. It is an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.
The Cochrane Collaboration: An international non-profit and independent organization that produces and disseminates systematic reviews of healthcare interventions, and promotes the search for evidence in the form of clinical trials and other studies.
Your approach to the medical director should be collegial, professional, and educational with an emphasis on your desire to provide the best patient care. When possible, try to avoid becoming confrontational, especially since other issues may arise in the future.
Workshops held in cities nationwide will help otolaryngologists, their staff, and other healthcare professionals code correctly, learn risk reduction strategies, and organize business systems.