Simplifying Medicare compliance: Solutions to keep you aligned

MONICA: Hello and welcome to today's webinar, Simplifying Medicare compliance: Tools and Strategies to Keep You Aligned. Before we get started, I'd like to review a few housekeeping details. Today's webinar is being recorded, and an online archive of today's event will be available within 1 to 2 business days. If you have trouble seeing the slides at any time during the presentation, please press F5 to refresh your screen on a PC, or command R if you're using a mac. You may ask a question at any time during the presentation by typing your question into the Q&A box located on the right side of your screen and pressing enter. And finally, I'd like to remind you of AHP's antitrust statement, located in the link just below the slide viewer. We will, as always, comply with that statement. Among other things, the antitrust statement prohibits us from discussing competitively sensitive information. We're very fortunate to have with us today, Kristin Calheno-Hill, director of Strategic Clients Decision Support, and Stephan Rubin, director of Product Management Decision Support, both with Optum. At this time, I'd like to turn the floor over to our speakers. Welcome.  KRISTIN: Great, thank you so much and good afternoon, everyone.  KRISTIN: My name is Kristin Calheno-Hill. I'm a senior clinical consultant and the director of Strategic Clients here at Optum. I am a nurse by background and have been working with InterQual content and products for just over 11 years. My role is to support current InterQual clients in optimizing their workflows and also provide consultative services that drive to best practices. Stephan.  STEPHAN: Yeah, good afternoon or good morning, folks, depending on where you are. My name is Stephan Rubin, and I'm a director of Product Management here at Optum on the InterQual team. I've been working with InterQual products and software for over five years. I actually got my start in engineering, have been in the healthcare IT field for over 15 years. About eight of which have been in product, all in interoperability. So really excited to talk with you all today.  KRISTIN: Great. Thank you. So, we're really excited, as Stephan mentioned, to be here with you today to talk about Medicare compliance and the tools that are available to help you, keep you aligned. So just reviewing our agenda, we'll start off our session by providing a quick overview of the evolving Medicare landscape. We'll then move into the Medicare Advantage Final Rule and discuss ways that the InterQual Medicare Navigator and Transparency tool can help support the requirements here. Next, I'll pass it to Stephan, who will dive deeper into CMS 0057, the interoperability and prior auth requirements and how our solutions can help assist your workflows. And we'll also plan to save time at the end for questions that have come in through the chat.  KRISTIN: As I'm sure you're well aware, the Medicare landscape continues to evolve. Significant growth is expected in the Medicare population, which is projected to increase by 10 million members over the next ten years. So, from a utilization standpoint perspective, the implications of this growth include the need for more reviews and potential strain on resources. Today, a reviewer must navigate the CMS website to access those LCDs and NCDs and policy articles in order to make a determination. And this can lead to inconsistencies in the application of criteria, as well as longer review times, which impacts the efficiencies and effectiveness of the auth process. Additionally, we know regulatory, and compliance requirements just keep coming with even more and more complexities.  KRISTIN: So, we're going to focus on two specific regulations today. We know that 0057 is probably top of mind for many of you. But we also want to first discuss CMS 4201 and the final rule here.  KRISTIN: This is something you're likely very familiar with. This final rule went into effect last year, and the goal of the final rule was to promote transparent, evidence based clinical decisions for Medicare Advantage beneficiaries with two main components. So, the first is the requirement to follow existing Medicare coverage policies like NCDs and LCDs. And if no NCD or LCD exists, utilize evidence-based criteria that can be adopted as internal policy in order to assist Medicare Advantage plans with their determinations. Specifically, CMS-cited within the final rule that InterQual was included as appropriate criteria to adopt as policy. The second component to the rule indicated that coverage criteria must be made available to members, providers, and the general public to allow for transparency in the criteria being used for decision making. So, we're going to start off spending a few minutes talking about coverage criteria.  KRISTIN: The InterQual team created the Medicare Navigator about seven years ago to support health plans in utilization of LCDs and NCDs in an efficient, accurate and defensible manner. And use of the Medicare Navigator is really focused on four critical elements. So, the first being efficiencies, and efficiency here are gained with an interactive, intuitive question and answer format that's integrated into workflows. So rather than going out to CMS.gov and looking through their policies there, this actionable workflow integration streamlines the review process, saving time and reducing potential for any errors. The second component here is really accuracy. The Medicare Navigator is fully aligned with CMS, which eliminates the need to manually search the CMS website for those policy details. Additionally, the workflow integration allows for line of criteria, line of business criteria mapping and policy steering. So, when we think about line of business criteria mapping, this allows for InterQual to display different criteria based on the member's line of business. Also, policy steering will automatically select the correct coverage subset, or the coverage criteria for a provider in a portal based on the date and location of service, for example. And then for internal payer workflows, the LCDs and NCDs can be flagged with icons that provide a visual for those payer users based on payer hierarchy or preference for which criteria to use for that specific scenario. This is also configurable for when an LCD or an NCD don't exist and can be applied to commercial or even payer custom policies as well. The third component here is compliance. So, this content, the Medicare Navigator content, is updated monthly to ensure compliance with those rapidly changing CMS policies. So, if CMS issues an update that does not make it into a monthly release, InterQual provides that level of transparency with a pending update flag and also informs the user as to what the updates are. So, was it just a code change? Was it a change to an effective date? Are there changes that would actually impact medical necessity decision making? The tool itself provides that level of transparency to keep the user informed of any upcoming changes that didn't make it into that monthly release. Also, the tool provides audit support with reporting capabilities right within your InterQual workflow. This can help provide valuable data insights as well as the inclusion of policy numbers in the review summary or the output of the review that could support preparing for audit. The last component here that we wanted to focus on is consistency. So, by converting these policies into a question-and-answer format, we can ensure that there's consistency across use across an organization. We want to ensure that the reviewers are applying the criteria the same way, and that standardized policy application and being able to measure inter-rater reliability contribute to those consistent and defensible reviews. This consistency is really critical in maintaining the integrity of the review process and ensuring accurate outcomes.  KRISTIN: So, you can see an example here where our team has utilized expertise in creating these clinical algorithms, that lead to a recommendation. So, the InterQual team has taken the policies from CMS and converted those into the question-and-answer format. The structure of these is identical to the InterQual criteria, which really allows for ease of use and adoption by utilization management teams. For those that are both familiar with InterQual and those who may not be.  KRISTIN: One case study that I would like to highlight is from a large health plan in the northeast that was able to increase their efficiency and consistency with reviews utilizing the Medicare Navigator. This health plan implemented Medicare procedures, which was integrated into their utilization management workflow, and they were able to recognize a 20% decrease in the time per review, which ultimately resulted in performing 24 more reviews per day. They also saw a decrease in the number of reviews, requiring a medical director review, as the primary reviewers were able to clearly understand the requirements to completing a review and if information was missing, clearly understand from the - what was needed from the provider to be able to move forward with the authorization request.  KRISTIN: The InterQual Medicare Navigator is superior to other content on the market that provides access to LCDs and NCDs. You know, we've discussed many of these features already, specifically the frequency of the updates, the pending notification flags, and the workflow configurations. Additionally, I'd like to mention that the criteria sets are modular, meaning a payer can pick and choose what to license in terms of the content modules based on their business needs. You know, rather than licensing an entire suite of Medicare content, for example. The other thing I wanted to mention, which is very exciting and relatively new to InterQual and unique to InterQual, is [inaudible] reasons. Stephan will discuss in more detail in a few moments. Decision reasons provides member-friendly language that can be utilized to support the clinical rationale when issuing an adverse determination. Decision Reasons is available across the InterQual portfolio, including for the Medicare content. So, this really takes the work out of crafting and maintaining clinical rationales as part of a payer denial workflow, while still providing that transparency and clear communication to the member as to why this service is being denied The Decision Reasons are available again, not only for the InterQual criteria, but also for the Medicare LCDs, NCDs and policy articles. And Stephan will be showing you an example in just a few moments.  KRISTIN: Next, we're going to discuss a little bit more about the transparency portion of CMS 4201.  KRISTIN: So InterQual Transparency allows health plans the ability to provide access to the criteria used for decision making to members, prospective members, providers, the general public. And this includes not only the InterQual criteria, but also industry content, as well as any custom policies a health plan may utilize. There's no restrictions or limitations as to what's exposed via Transparency, and the health plan has complete control over this. InterQual Transparency can be accessed by a member or a provider portal, or via a web link that enables this cloud-based access to the coverage criteria. So, this not only decreases that time-consuming back and forth when a member or provider requests a copy of the criteria that was used to make decisions, but also supports the CMS mandates as well as, you know, regulatory bodies like, NCQA requirements to provide this level of transparency.  KRISTIN: The InterQual Transparency tool offers the same user experience for any criteria that's exposed through the tool. So, you can see an example of this here that includes not only access to the criteria, but the notes, the evidence to support the criteria. You also have the ability to print the content as well as access in-app help and tutorials. So, I'm now going to pass this over to Stephan who's going to dive in deeper to CMS-0057-F.  STEPHAN: Great, thanks so much, Kristin. Hi, everyone. Like we said at the top, I'm Stephan Rubin, and I'm a director of product management, here on the InterQual team, working with our InterQual technology, and in particular working with our teams, building products and solutions around, prior auth efficiency, automation and interoperability. So, we heard a lot from Kristin about our compliance efforts, as part of CMS-5201, and I want to talk a little bit about CMS-0057, and some of our efforts to help our health plan customers comply with this important rule.  STEPHAN: So, you know, a lot of attention gets paid to the technical or the API requirements of CMS 0057, but of course, there are other requirements, you know, other parts of the final rule that are aimed at streamlining the prior auth process, you know, so things like decreased turnaround times, you know, providing denial reasons. And then of course, reporting those metrics out to the market. So, we'll start with a couple of those parts of the mandate that take effect in 1126. And in particular, we're going to start with the mandate to bring those turnaround times down. You know, the final rule stipulates that, prior auth turnaround times need to be at seven days for routine ops and 72 hours for urgent auth requests.  STEPHAN: So, the first offering that we're going to talk about today is aimed at reducing turnaround times for your auths that are still going to require a manual review. There are a couple of ways plans are looking at decreasing their turnaround times, from reducing the number of ops required to increasing the number of ops that they auto-approve. But, you know, manual review will still be a part of the auth journey. And we want to try to bring some relief there. You know, at InterQual, we know today that this process is a pretty inconvenient one, you know, having to sift through the documentation that you've gotten from the plan, which is, you know, could be overwhelming because you got so much documentation or maybe not enough. And the documentation that you have is incomplete or insufficient in order to, to complete that review and decision the auth. And so, we've designed a solution that brings AI to both the intake and the review segments of this problem, in a single package. So, our AI-enabled auth accelerator takes in all the submitted documentation comes in as part of the auth, both the structured and the unstructured data, regardless of intake mechanism. So, you know, portal, facts, and then these new CMS APIs for digitizing and automating prior auths, which we'll talk about in a little bit. It takes all that documentation and collates and curates and organizes it so that it's digestible and easy to navigate for the specific purpose of completing a review. It then feeds that document bundle into the only AI that's been trained on InterQual. So, you know, a purpose-built AI, trained on hundreds of evidence-based medical policies spanning dozens of years of evidence, research citations, the entire corpus of InterQual. It feeds that documentation into that AI and maps it against the medical policy that best applies to that auth request, whether that policy is InterQual policy, one of our Medicare navigator policies that we heard about from Kristin, or a custom medical policy that one of our health plan customers has digitized. So, it maps that documentation to that criteria or medical policy and then presents its findings in what we call an AI accelerated review. And our solution is built in what we call co-pilot mode, where the AI is displaying the InterQual criteria or the applicable medical policy, and is displaying  that AI-accelerated review alongside the submitted documentation that collated and curated library and hierarchy of what the provider sent, so that all the information you need to decision that off is right at your fingertips. And another thing that sets our AI apart with this copilot mode you know, to us, what we've done is: the AI is making recommendations to you based on the documentation that's submitted and the criteria that's being evaluated. But your UM teams, the nurses and UM reviewers at the health plan, those clinicians are always in the loop. And this is really important. And I want to state this as clearly and emphatically as I can. This is important because this is not a product or a solution to facilitate AI denial of care. You know, ‘accelerated off’ was a very deliberately chosen turn of phrase because our goal is to accelerate humans using their clinical judgment in the decisioning of prior auths.  STEPHAN: Okay. So, our second offering to help navigate Medicare compliance around CMS-0057 is aimed at bringing InterQual and our team's experience writing criteria to that mandate around denial reasons. And this is a touchy subject that gets all kinds of press and that we at Optum feel is deeply important to handle with transparency and with empathy.  STEPHAN: To state the obvious, you know, no one likes getting a denial letter, you know, myself included. Not only are denial letters usually unpleasant news, they're unpleasant news delivered unpleasantly. You know, we work with all kinds of health plans, and we've seen ADLs from health plans where they might have ten different letters or ten different templates, providing an adverse determination for the same service, same line of business, very similar scenarios. But they're worded ten different ways. You know, there's no consistency. There's no transparency. And it's just - it's this unpleasant news that's kind of wrapped in an indecipherable package. And a lot of times it's bundled with really no context or insight, or recommendations about what to do next. And we wanted to help with this problem. You know, since we're the experts in criteria, and our criteria is often used to inform these adverse determinations. So, how can we make this news a little bit easier to understand? So InterQual developed the Decision Reasons product, to help our payers with the clinical rationale for their adverse determination letters. Decision reasons is a comprehensive library of consumer level content written at a fifth to seventh grade reading level, which pulls directly from the criteria to contextualize and explain those adverse determinations. It's live across much of the InterQual product portfolio, including those Medicare Navigator offerings, which Kristin was telling us about earlier.  STEPHAN: So, decision reasons content is available right within the InterQual workflow. We've embedded it into our medical review service payer site, UM experience. And the content consists of three components. So, here on the screen we can see a member who is admitted to inpatient for heart failure. And we need to write an adverse determination letter. So, we break the letter down into three components or pieces. We have a patient education statement first, which is about providing insight to the member on what service was requested. So, you can see here it says, “hospital care at the inpatient level was requested to treat your heart failure. Based on the records we received, you did not need the type of care and the frequency of services that is normally given at this level, and this was determined by a review of what was medically necessary. It doesn't reflect the quality of care that was given.” So, there's this empathy in the letter to convey to the member that this is not a reflection on their provider or the services they received. It's based on the medical records based on what was submitted. We then have the principal reason for why the request is not appropriate. So, we say things like there are many levels and settings to receive care, and these can be both in the hospital or out of the hospital. And each level is determined by how severe the condition is and what medical care is needed to treat it. So, we're building context around the delivery of care for the member, and then we get into the clinical reason that's specific to that member scenario. And so, we cover things like observation. So, observation is one level of care in the hospital. But it's not the same as being admitted to inpatient. It might mean staying at the hospital overnight or for a few days. Observation is for people who need to be monitored for a short time. And it helps providers decide if you can be discharged safely or if you need more care. And if you need more care, you might be changed to the inpatient level. But the records we received so that you could have been cared for at the observation level. So again, setting a stage for the member, explaining the care that was provided where the criteria comes in. And then we get detailed, we say the plan of care for you did not require the treatments that would need this level of care. And we provide an example again from the criteria. So, a medicine to treat your extra fluid is usually given into your veins. The records we received did not show that you needed this medicine as often. So, providing this level of detail and of context, a plain language explanation for the decision, this can meaningfully cut down on appeals and grievances, and in many cases can be used to direct the member to an appropriate next step in their care journey. I also want to note that these decision reasons modules. These can be customized to add in number specific details and personalize it to the member. You know, we've conducted online live feedback sessions with actual consumers using real world scenarios and draft adverse decision letters that have been crafted using this this tool, this decision reasons product. And we've received really positive feedback from the market on this. You know, we had a consumer testimonial where the consumer was telling us about how the language explains the reasoning behind the decision. It's very thorough, you know, perfectly detailed, with lots of information. You know, everything that I would expect to see in a letter like this. So again, sometimes it's unpleasant news, but we're trying to provide our members with context and perspective and empathy and at least make them feel like they understand and are involved in their care. So, we're continuing to expand our decision-making content to additional InterQual and industry content modules. This is something that we're really excited about.  STEPHAN: Okay. So, the third way that we're equipping our plans to navigate Medicare compliance is around that 2027 mandate to implement these APIs and facilitate interoperability. So CMS 0057 requires plans to digitize and make interoperable their prior auth requirements, documentation and decisioning rules, so that the providers caring for their members can interact with those rules in a standard way, and we remove waste and inefficiency out of the system through standardization and technology to bring those rules closer to the point of care and create transparency with our provider communities.  STEPHAN: So, CMS recommends the use of three APIs to facilitate this interoperability around prior authorization. The first API is called the CRD API, or the Coverage Requirements Discovery API, and this is all about helping health plans digitize their prior auth rules, their prior auth business rules, really. So, think of things like list of services that are covered, services requiring prior authorization, any investments your plans have made in provider gold carding programs, plan specific requirements that you have around employer groups or self-insured plans. Policy selection rules that you have, things like that. Those are covered under CRD. The second of the three APIs is DTR, or documentation templates and rules. This API is about digitizing the documentation requirements that your plan wants included with the auth submission. So, which questionnaires or medical necessity reviews do you expect your providers to complete as part of submitting the auth to you? And then the last API is the PAS API, or the prior auth submission API. And this API is a way for providers to digitally submit and monitor their prior auths. So, this is technology that will probably eventually take the place of the EDI 278, that your plans are receiving today from your providers and make that auth submission and monitoring process more PHIR-enabled. It'll also enable the real-time digital query of auth status, resubmission of auths, solicitations for additional attachments or documentations. Something that we hear about a lot from our health plans as a source of inefficiency and overhead in the prior auth process, things like that.  STEPHAN: So, at InterQual, we're actually doing something I think that's a little bit different from what many of the other vendors in this space are doing. And that's that we're focused almost exclusively on the DTR piece of this set of APIs. And this is because DTR really lines up with InterQual’s core competency, which is clinical rules, clinical documents, clinical questionnaires. VTR, the spec, the API, is all about digital delivery of documentation requirements and questionnaires. And that's what we at InterQual have been doing for decades. And now we're making that same evidence-based criteria available and interoperable through the use of these FHIR APIs. You know, there are some incredibly smart folks at Optum who have been involved in writing these APIs and working on these specifications, really from the beginning, from the very first line. And our team's been really fortunate to be able to bring their experience and their expertise to the process of digitizing medical policy and criteria and making it interoperable and exposing it through FHIR APIs. We believe that the focus on DTR enables our health plans to enact a single source of truth for medical policy. So, you write a policy once, you deploy it into InterQual, and you can push that policy anywhere within your organization or anywhere within the healthcare ecosystem where that policy can drive transparency or efficiency or results. So Optum InterQual is all in on DTR, which naturally invites the question of how will we help plans actually achieve full compliance? I mean, digitizing medical policy is no small task. Our team has been working on this for over a year now. But it's obviously only one piece of the overall picture. And so DTR on its own doesn't make a compliant health plan. So, what's our play here? And in a word, it's what we've always done. It's partnerships and great partnerships. You know, InterQual has a track record of partnering, across the continuum of care, to bring our criteria into both payer and provider workflows through dozens of partner integrations across the industry. And what that enables is, those partners get to do what they do best. They get to focus on their problem areas. They get to bring their ideas about how to bring value and efficiency to the system into the marketplace. And we get to bring our criteria and our software into their workflows. And so, these APIs really are just a logical continuation of that trend. It's more of us just doing what we've always done to help our customers achieve their goals.  STEPHAN: So, our partners bring their CRD and their PAS capabilities, and then we work with them to bring InterQual criteria and our digitized medical policies into those CRD and PAS workflows, again using the same criteria library and the same policy selection rules that our customers are using today to their existing InterQual products, and we can now bring those to additional workflows and partnerships through FHIR and our work with our partners. And so we've unlocked the ability to deploy criteria and deploy medical policy across the enterprise, whether it's in a provider portal for a provider who's submitting an auth, an EMR, where a provider is maybe natively interacting with the criteria, a payer side UMCM system where a payer is using medical review service to complete InterQual reviews or accelerated reviews, using our AI accelerator to their members and their constituencies through InterQual transparency. And then now through these APIs, through interoperability as well.  STEPHAN: So, to summarize, we believe that we've set our customers up to thrive and succeed and really excel in this era of interoperable prior auth. So, through InterQual Digital Criteria Hub, we're able to offer our customers a single source of truth for all of their medical policies, including their custom policies and the corpus of Medicare policies, which, as Kristin said, update quite a bit. And through our work with our partner organizations, we make deploying that single source of knowledge easy, since it's compatible with the products and tools you already use. And we're building new partnerships with exciting organizations coming into market with new and interesting ideas about how to automate prior auth. And so, we'll bring our criteria to those partnerships as well, for any vendors your plans may want to consider using in the future. And finally, having your medical policy and your criteria digitized and managed by a team of criteria experts, we believe it enables responsible deployment of AI at scale. As we look to manage costs and remove inefficiencies from the prior auth process. You know, we believe, as I'm sure you all do, that AI will no doubt be a powerful means to that end. But making sure that that AI is deployed on a solid foundation, you know, we believe that's vital to avoiding some of the less-than-ideal outcomes that can come with the use of AI, especially at scale. So, accuracy of digitization is really, really important. And so, with that, I'll send it back to Kristin to close us out. Thank you.  KRISTIN: Thanks, Stephan, I needed unmute there. Can you hear me okay, Stephan? I just want to make sure that I'm unmuted, okay.  STEPHAN: Yep. You're clear.  KRISTIN: Great. Okay, thank you. So, yes, just to recap some of the key takeaways, from our time with you together today is, you know, we really want to ensure you understand how InterQual can be your trusted partner for compliance and efficiency with this evolving Medicare landscape. So, thinking about our Medicare Content Navigator that ensures that Medicare policies are applied consistently and accurately within your existing workflows. InterQual Transparency, which makes coverage criteria publicly accessible to both members, providers, the general public, really promoting that transparency and trust. Our AI-enabled prior auth leverages clinically-validated AI to streamline and standardize prior auth reviews, enhancing both efficiencies and decision making. Decision Reasons, as we talked about, provide that clear and efficient communication for the specific reasons for the denials, which improves member satisfaction and transparency. And finally, the InterQual Digital Criteria hub that standardizes and digitizes the documents required for prior auth, ensuring that seamless and efficient processes. So, we really feel strongly that together these tools and strategies can empower you to navigate the complexities of the Medicare compliance with confidence and ease. We really thank you for your time today, and we're looking forward to taking some of the questions in the chat. So, Stephan, I can probably take the first question, which is, “how does the InterQual team develop the algorithms for the Medicare Content Navigator?” So, this is a very systematic and robust process, where we're accessing the CMS weekly reports for the LCDs and NCDs. These reports are published, as I said, weekly, and reflect any new or updated or retired determinations from the previous week. So, we can then look at the revision history to really determine if an update is needed. And if a policy is going to be retired or there's changes to the effective dates, we can make those updates to the Medicare Navigator criteria as well. We then, once we understand the updates, or the new policies that are coming out, we use our expertise developing those question-and-answer algorithms. And the team of clinicians perform a quality review, for consistency and accuracy, with those published determinations or articles, policy articles, to resolve any ambiguity or seek clarification we do submit questions to the medical policy team for that specific math, if necessary. And then we perform quality assurance. We have a stringent validation and QA process prior to releasing the content into the software. And this is something, like I said, that we do on a monthly basis. And then if there are updates that come from CMS that don't make it into that monthly release, we do publish those notification flags right on the content so that the user is aware that there might be a pending update, that hasn't been captured. So very systematic and robust process that our content team follows.  KRISTIN: I can take this.  STEPHAN This next one might be for me.  KRISTIN: Sure, go ahead.  STEPHAN: Oh, you want to take the... Yeah, I was going to say, I was going to take this question about expanding on the work that we're doing with our partner organizations around CRD and PAS with the DaVinci APIs. This is a great question. I really like this one because I think it underscores both how complicated this is, but also how powerful it can be. So, in addition to developing the DTR API as it's documented and implemented in the DaVinci Burden Reduction spec, we've talked to the groups and steering committees that work on the CRD and PAS workstreams. You know, again, within Optum and some folks within InterQual that we have exposure to, as part of the broader prior auth community. And we've built these kind of complementary or supplementary set of APIs whose primary purpose is to bring InterQual into the CRD and PAS flows but do so in a way that makes allowances for the different ways and different ideas our partners have about how to implement those work streams. And so, the partner can sort of work with their customers to understand and work with us, to understand where is the right place to insert InterQual into this workflow and insert policy guidelines and policy selection rules into the workflow. So, for CRD, for example, we've written an API that that I like to say is, is DaVinci-like or DaVinci Lite, and that it behaves like a standard API, but it is not one that's documented in the official spec. And it's our documentation requirements API. And so, what our documentation requirements API has the ability to do is say, for a given auth request that's come in and is being processed through a coverage requirements workflow. Right? So various rules are being evaluated, various assertions are being tested. You know we take those off parameters. So, you know, things like the service code, the line of business, stuff like that. And we go to a given health plans InterQual library. So, the universe of criteria and policies that they're managing through our InterQual cloud solutions. And we say, “what is the appropriate medical policy or policies that apply to this auth request?” So, in other words, if prior auth is required and the medical necessity review is part of that auth requirement, how do we make sure that the provider who's submitting the auth completes the appropriate review? And so, what our documentation requirements API does is says, “here are all of the policies and criteria that apply to this auth request, based on the rules that this plan has set up already, and that they're deploying and using throughout their various InterQual workflows. So, think like medical review service and a provider portal type scenario. And we don't just return the policy name or description. We actually return the link to the policy itself. So, when the provider-side client goes to actually retrieve the questionnaire, there's no ambiguity about whether the questionnaire they're filling out is the right one. We give them the actual link to the actual criteria that applies and the actual policy that they need to fill out, again based off of that payer’s individually configured rule. And then on the PAS side, what we've done is we've basically created an API that allows health vendors who are implementing PAS to hook into a payer customer’s library of InterQual criteria, take a completed  medical necessity review that comes in as part of a prior submission, and make a criteria met/not met assertion against that completed questionnaire. So as part of applying and evaluating the various other auth rules that the plan may have in place around decisioning auths in an automated fashion. There's a kind of hook that the vendor can use to make InterQual a part of that evaluation process. Great question.  KRISTIN: Great. We have another question that I can take. So, the question is if a plan uses InterQual’s created criteria, how is that cited on a plan’s public site and on a denial rationale on an IDN? As it was my understanding that if outside sources such as InterQual or MCG, or even an LCD that is not applicable to the plan service area, InterQual criteria must... excuse me, Internal criteria must then be created with those sources cited. So, in terms of exposing the criteria you're using, that can be accomplished on your website, you know, through the transparency tool. You could also craft a statement as part of your medical policy, portions of your website that indicate the criteria that you use to make decisions, which may include InterQual or other criteria. In terms of stating that in a denial letter, we commonly see that most health plans refer to the exact criteria version that was used, including the subset that was used. So, there's a variety of ways that you could, you know, craft that language in your letter. Of course, if you're utilizing decision reasons, the clinical rationale will be specific to the InterQual criteria. But typically, we see a letter that says, “as part of making this determination, we've utilized InterQual version 2025” with the subset title. In terms of what is being used to make the decision for that request. In terms of the second part of your question, it was your understanding that outside sources are used, internal criteria must then be created, with those sources cited. I wouldn't say that content needs to be recreated. Your medical policy team has to agree to adopt the criteria you're using as policy. So, if there's no LCD or NCD that exists, you're agreeing to then adopt InterQual, for example, as your internal policy. But you don't have to recreate the content or recreate the criteria citing InterQual you can just have that be part of your medical policy teams process is that they are signing off on, and agreeing to the criteria that's being used, that's outside of an LCD or an NCD, and that will help you comply with those regulations. Another question that came in was: which criteria modules support the licensing of decision reasons? So which modules have decision reasons today? This is available widely across the InterQual portfolio. So, the acute adult, acute pediatric, the majority of the post-acute criteria. So LTAC, [inaudible], inpatient rehab, it's also available throughout the behavioral health content. So, adult and geriatric psychiatry, child and adolescent psychiatry, substance use disorders, prior auth content for behavioral health. It's also available in the prior auth space for imaging. Excuse me, procedures and durable medical equipment and soon expanding into imaging. That was top of my mind, for our next release. And then in the Medicare space, we have decision reasons for our behavioral health LCDs and NCDs procedures as well as DME, and we continue to expand on those for each InterQual update. So, October of this year will have an additional, additional content suites where we have decision reasons. Stephan, there's a question about safeguards that we have in place to ensure AI-enabled reviews are conducted responsibly through our new solution. STEPHAN: Yeah. You bet, Kristin. I'll take this one for sure. So, you know, I said in my remarks earlier that responsible use of AI is something that we take really, really seriously here, and something that really is baked into a lot of the decision making that we have around this product. And so, there's a couple points that I want to hit here about how our product is ensuring that AI-assisted reviews are conducted responsibly. And the first one is to kind of draw your attention back to this idea of the copilot mode, which is a key design consideration of how our AI- enabled solution works is that you know, especially as we, grow our use of AI, keeping a human in the loop was a non-negotiable for us. You know these are clinicians with years of training. They understand nuance. They understand policy. They understand clinical documentation. And while we believe AI can be an accelerant to helping them be more efficient and be more effective, keeping the human in the loop was vitally important to us. You know, we can see a future where maybe for certain scenarios, health plans have a level of comfort with removing the human from the loop. But in the beginning, again, human in the loop was a nonnegotiable for us. The other thing that we do, that I think we're really fortunate we're able to do, as the creators of InterQual is we actually have a clinical validation process that each piece of InterQual goes through as part of being launched into, our auth accelerator. So, the clinical team conducts reviews that the team that writes InterQual and that works with the team that's building the AI. They conduct reviews and validate that the AI conforms not just to, you know, the letter of the criteria, but kind of the intent of the content as well. So, no piece of clinical content can be accelerated without first passing through a clinical validation process, that is driven and managed by the team that writes the criteria themselves and has been writing this criteria for a long time. So, we keep humans in the loop on the AI side as well, I like to say. The third thing that we have to go through is because we're part of the Optum family. Optum has an AI review board process that every single product across the portfolio has to go through, as part of being brought to market. And so, the AI review board has, you know, robust internal processes and checks around responsible use of AI. There's risks that we need to mitigate, bias we need to account for, and we need to demonstrate to a level of their satisfaction that our tool is unbiased or incorporates bias risk mitigation, things like that. So, not just with this product, but, you know, with a whole family of Optum products, there's an AI review board. And, you know, those folks are very, very rigorous in how they review and approve AI-enabled products, that come to market. And then the fourth thing that we do in this area is around, essentially observability metrics. So, because the product is integrated into the medical review experience. We have the ability to track if a given reviewer is using the AI the way it is intended. And so, for example, we track whether a reviewer is actually reviewing the evidence that is being used to support an AI recommendation, or is the reviewer just accepting the AI recommended answer uncritically? Right? In the same way, anytime a reviewer makes a determination that is different from the determination that the AI has made. So, the AI is making one recommendation, but the reviewer determines in their clinical experience that actually a different recommendation applies. You know, we track that as well, and we have regular evaluations and assessments of that data. Where are there meaningful divergences from what the AI is recommending, versus what a reviewer is doing? We do this through cohorted studies as well. Taking large bodies of reviews and kind of saying, "where are there scenarios where human reviewers are arriving at different conclusions than the AI is arriving at, and then making sure that those get reflected and updated into the product? So again, those are just some of the things that there's more things, but I'm happy to talk at length about this, as it's something I think is really, really important. So, thank you for the question.  KRISTIN: Okay. And it looks like we have one additional question we'll be able to get to, which is how will my organization's custom policies be easily integrated into the InterQual Digital Criteria hub? What customization options are available for digitizing internal medical necessity policies within the solution? So, maybe I'll take part two Stephan and pass it to you for the Digital Criteria hub.  STEPHAN: Sure.  KRISTIN: InterQual has a very robust customization tool. This allows you to customize your internal payer policies and expose those in the InterQual workflow. So, you could either update something that InterQual has, to better align with your internal policy. You could create a custom policy from scratch, based on your medical policies. You could create that custom subset. And these can be exposed for your internal staff, your providers, as well as on the Transparency tool. So, anything that you create in the InterQual customization tool can be exposed in a variety of ways, as Stephan had mentioned earlier. This is something that we help health plans with all the time. So, we can do this work for a health plan to convert their policies into a question-and-answer format and customize that inside of InterQual. We also train payer customers to do this work themselves. We also can do a hybrid approach where we're doing some of the work to assist the health plan, and the health plan is maintaining some of their own customs as well. So, there's a variety of options to be able to digitize your policies and put them into the workflow, which then sets them up to be eligible to be utilized, within the Digital Criteria hub. Do you want to speak to that, Stephan?  STEPHAN: Yeah, sure. I love this question because the answer seems so easy, but it's delightfully efficient, which is that, if you have a medical policy that you have digitized using InterQual technology, whether it's an InterQual policy, right? So, it's InterQual, it's the criteria that's written and promoted every year by our clinical teams, whether it's industry content, such as our Medicare Navigator product that that we talked about, or whether it's a custom policy that you digitize, either yourself through InterQual customize or through, our customization consulting services, like Kristin was talking about. Once that medical policy is digitized in the InterQual cloud, it is available through Digital Criteria Hub. So, the entire universe of InterQual criteria is, you know, FHIR-native, FHIR-enabled today, through InterQual Cloud and Digital Criteria hub. So Digital Criteria Hub is just the FHIR-enabled arm of InterQual. So, once you have a custom policy and you author it or digitize it using IQ customize, you're then able to load that policy into IQ cloud, into InterQual cloud and deploy it across your organization, which includes into the Digital Criteria hub.  KRISTIN: Great. I'm just checking the chat, but I don't see any additional questions.  STEPHAN: Yeah. Me neither.  KRISTIN: Okay. Well, again, we thank you so much for your time today. And I think, Monica, you were going to close us out.  MONICA: Yes. Thank you so much. Thanks both of you. Thank you for that great presentation and for sharing your thoughts. And thank you to the audience for participating in today's webinar.  MONICA: This concludes today's presentation. We thank you and enjoy the rest of your day.  KRISTIN: Thank you.