On-demand webinar
Aligning with CMS: Medicare Content Navigator and InterQual Transparency
Discover how to meet the latest regulatory requirements for Medicare Advantage plans.
Welcome to the aligning with C
MS Medicare content Navigator
and Inter QL transparency webinar.
My name is Christine Long.
I'm a registered nurse with over 35
years in the health care industry, specializing
in clinical consulting and utilization
management.
I'm excited to present our Medicare
content Navigator and intergral
transparency tools. Today.
Everyone is aware that the UN process
is cumbersome and time consuming.
Couple that with our growing Medicare
population and the issues are compounded.
There are gonna be more than 70 million
Medicare beneficiaries by
2025. That's
just shy of two short years
away from now. Hard to believe
when we think about ensuring medical necessity
for requested services for these beneficiaries.
We know that the NC, DS LC
DS and policy articles are difficult to find
wading into the C MS
website to find a specific document
takes up too much of your valuable time.
And because those documents are written in prose
format, the results of a review
can be inconsistent from clinician
to clinician. This can be problematic
on audit for sure.
Add in the ever changing regulatory
and compliance requirements such
as the impending rule change related to
the Medicare Advantage plans, adherence
to existing Medicare policies
and it's a lot to keep track of.
We have some solutions to help you maintain
compliance and increase accuracy
and efficiency
in just a few short months. Effective
January 1st 2024
all Medicare Advantage plans must
ensure they are following existing
coverage policy for Medicare
benefits. Specifically,
Medicare Advantage plans must follow
all existing Medicare national
and local coverage determinations
and C DS and LC DS.
This means that adherence to the
NC Ds and LC Ds is required
for Medicare Advantage plans beginning
11 of 2024.
If there is no N CD or
L CD in Medicare for a specific
intervention, treatment or service,
then criteria sourced to
evidence based medicine such
as Inter Q may be used.
These criteria must be made
publicly available to C MS enrollees
and providers.
This is where Inter Q solutions
come in
the Medicare content. Navigator is
strictly aligned with C MS
N CD L CD and policy
articles.
And again in the absence of an
N CD L CD or policy article.
Inter qual criteria can be
used as decision support to cover
those gaps
as it relates to making criteria
publicly available to Medicare enrollees
and providers.
Our transparency tool allows
for the required disclosure of the criteria
to all key stakeholders in
a read only interface that references
inter Q Medicare and
custom criteria.
Our Medicare content Navigator
helps you increase efficiency and consistency
of medical necessity reviews with
the application of the latest Medicare
policies and it supports compliance
by converting hundreds of N CD
L CD and policy articles into
a structured interactive tool.
The Medicare content Navigator helps
payers and providers streamline
and improve the medical review process
for Medicare beneficiaries while
reducing their administrative burden.
All of our Medicare content, Navigator
products are fully aligned with the C MS
N CD L CD and policy articles.
Whenever there is an N CD
L CD or policy article that includes
medical necessity criteria, we'll
develop a subset to address it.
The content is comprehensive and
includes over 1300
N CD L CD and policy articles
within over 400 subsets.
The content and our software
provide the medical necessity support
for appropriate utilization management
for your Medicare beneficiaries
and where appropriate will include
quantity and time frame. Utilization
limits as well as non covered
indications and services.
The content is fully integrated
into our inner qual connect software
and it's all in question and answer
format.
It's also important to note that we do
have the functionality to allow for
updates every four weeks so
that we keep you as up to date as
possible.
Now, let's talk about those products specifically
Medicare behavioral health. This
module includes procedures, diagnostic
tests and behavioral health level
of care.
It's set up a bit differently than the other
content because it includes the different
behavioral health specialties altogether.
Medicare imaging has more
than 35 subsets which we
call test families. And
within those subsets resides the many
unique imaging tests,
we group them together into families
to allow for the most appropriate test sequencing
and to provide recommendations for alternate
testing when appropriate and in
accordance with C MS
Medicare molecular diagnostics and
lab. This module is specific
to molecular diagnostics and
lab tests and contains over
100 subsets.
C MS LC DS can
refer to FDA approved tests,
FDA clear tests
and LDTS or laboratory develop
tests. So it does not necessarily
have to be FDA approved.
You are all likely aware that Medicare
does not cover predictive prognostic
or screening tests.
Beneficiaries must actually have
the condition and testing must
affect treatment.
Medicare currently covers
FDA approved comprehensive tumor
tests
using next generation sequencing
for predicting drug response.
So you will find N
CD L CD based content
within the tool to address those tests.
Medicare Pharmacy for non
oncology. The criteria are based
on best evidence from C MS
and not solely on FDA
approval
and oncology will be consistent
with requirements for off label indications.
It contains over 40 subsets.
Medicare, post acute and DME
contains over 60 subsets
and includes all the major categories
from cardiac to respiratory and
wound care
and finally Medicare procedures.
This module is specific to procedures
and encompasses all the surgical specialties
within more than 100 and 50 subsets.
So, some of the key features,
it has some really wonderful
key features to help you gain efficiencies
and help ensure accurate, consistent
reviews.
The first question you are presented within
the review algorithm asks you
to select the appropriate Medicare administrator
ensuring you're applying the right content.
There are embedded links that take
you directly to the source documents.
The N CD L CD and parl articles
on the C MS website.
The content includes CPT and I CD
10 codes. The informational
notes that are included in the criteria
contain language taken directly from
C MS.
The C MS length of stay benchmarks
are included when appropriate.
And when you get to a recommendation, whether
services are recommended as medically necessary
or not. The Medicare N
CD L CD or policy article
identification numbers are
used on the review summary.
This is super efficient and allows
for transparency between provider
and payer.
Let's review the alignment of Inter
QL to Medicare across our
product suites.
When there is an absence of an N CD
L CD or policy article, you
are allowed to use a nationally
recognized decision support tool.
C MS wants to ensure that
whatever is used is based
on solid evidence and is rigorously
developed. They referenced inter
Q within the rule
with that said this slide nicely
lays out our alignment with Medicare
across our products
for the acute care. This content
is evidence based and it includes a workflow
that is specific to the C MS
to midnight goal.
This helps reviewers understand how
to apply inter Q criteria
as it relates to Medicare beneficiaries,
the content incorporate clinical stability
criteria relevant to the patient's condition,
complications or comorbidities
to support level of care, continued
stay or a determination
of discharge readiness.
There is a discharge planning support
tool throughout the content
and we include the C MS inpatient
only list as a reference within
our clinical reference tools
for post acute. We are consistent
with the guidelines. Subacute sniff
is structured to align with
the PD PM
and the citations used to build that content
is the C MS Medicare benefit summary
chapter eight and the federal register.
Our home care content includes content
related to the home loan status requirement
and includes maintenance therapy.
Our rehab content is based
on evidence and C MS program requirements.
It also includes responder
criteria to assist in determining when
the patient has maximized their rehab potential.
It includes the 13 required
components from C MS.
Our outpatient rehab content also
includes maintenance therapy in accordance with
ac A requirements
for behavioral health. We provide a crosswalk
to current C MS NC Ds and LC
Ds and the policy manual as a resource
for you.
And finally, for our ambulatory care
planning criteria, we do provide
the C MS inpatient only list as
a reference for you.
Now, let's talk about our inter Q cloud
based technology specifically
inter Q transparency
Interpol transparency can provide
both members and providers
access to a health plans decision
support criteria
for health plans. The Interpol transparency
tool
offers members and providers
read only real time
access to Interpol criteria
industry content and
any custom criteria that the payer
organization has developed
through their portals.
Providers have access to
exactly the same content that
your um team is using to render decisions.
Members would access the content
through the member portal. This is
a requirement from C MS coverage
criteria must be made publicly available
to C MS enrollees and
providers.
This capability allows
for more efficient un process by
decreasing the back and forth that occurs
today between payers and providers.
Providers know what is required
of them in terms of submitting clinical information
to substantiate the services they are delivering.
It's in an ereader format which
allows the end user to view all
necessary criteria and content
including notes and citations.
And finally, it supports adherence
to federal regulations such
as the new regulation going live on 11
2024 state regulations
and NCQ A guidelines.
Ok. Let's see the tool in action
for our case. One scenario. We're gonna be
reviewing a Medicare procedure request
using the N CD.
Our patient is a 65 year
old male with morbid obesity and type
two diabetes.
The request is for bariatric surgery.
Ru ny gastric bypass
for his history and physical. The diagnosis
is morbid obesity,
hypertension type two diabetes.
Melody the patients on
Metformin and Losartan,
the patient has failed conservative weight
loss treatment. Having tried weight Watchers,
medical, weight loss and nutritional counseling.
The patient is unable to sustain any weight
loss.
His vital signs are stable.
His BM I is 40. His
A one C is nine.
The planned intervention is RU Ny
gastric bypass.
Now I'm in my Interpol demo screen.
I'm going to go in and select
Medicare procedures.
I'm gonna use my keyword, search
and search bariatric.
I'm going to select bariatric
surgery
and the first place that you land
is the subset information
note, you can see that this
is the
2023 March release
Medicare procedures for Bariatric
surgery.
You have the ability to see the codes
that are included, the CPT codes
and the I CD 10
diagnosis codes
you can see right away the inpatient outpatient
setting. So for
a biliopancreatic diversion with duodenal
switch, that's on the C MS inpatient
only list revision procedures.
Ru Ny gastric bypass
is on the C MS inpatient only list
sleeve gastrectomy again
on the C MS inpatient only list
all other procedures are considered
outpatient
as we scroll through this subset information.
Note, you can see that you're first presented
with the N CD for Bariatric
Surgery.
Here's that link I spoke about that will take
you directly to the source document.
When I select that link, it
takes you directly to the C MS website
directly to the source document used
to build this criteria subset.
It's the N CD for bariatric
surgery for treatment for of
comorbid conditions related to morbid obesity.
So right there at the click
of a finger, you're taken directly
to that source document
further. We'll tell you what version,
the version date, we'll tell you the
procedures that are included,
the Medicare non covered procedures.
And as you scroll down, you'll
see that there are LC DS available
for this procedure as well.
Again, you'll see the original effective
date.
You'll see the procedures included, those
Medicare non covered procedures
and so on.
You'll see all of the LC
DS, those Medicare administrators that
have content to address bariatric
surgery listed in the subset
overview. Note,
my next step is to go ahead and begin
the medical review.
So as I mentioned, you can see that the first
question that you are posed is
to select your Medicare administrator
and I'm gonna demonstrate this case
using the national
coverage determination.
Now, the algorithm is going to drive
you through the review in accordance with
the information that's on the N CD.
So here the rule is choose all
that apply.
It's at least two except
other clinical information.
Anytime you select other
clinical information,
it takes you off the pathway
to a recommendation
because you are indicating that you are no longer
adhering to the evidence
or in this particular instance,
the N CD for bariatric
surgery.
So I'm gonna say the patients
uh morbid obesity with A BM I greater
than 35. We said that patient's BM,
I was 40
I'm gonna select the BM I
greater than equal to 35.
I'm gonna make a note patient BM
I
40
best practices to include
notes to substantiate your selection
of the criteria.
The patient has ha has at least
one comorbidity related to obesity.
That is true. The patient has hypertension
and diabetes.
Again, you would add that information to
your note.
You're going to select next.
And now they're looking for you to validate
whether there is medical treatment for obesity
that was unsuccessful. And
I'm gonna say yes, because if you recall,
he's tried Weight Watchers, medical weight
loss and nutritional counseling.
I would put that information
in the comment bubble.
Now, I'm ready to view recommendations
and you can see services
are recommended,
evidence support services is medically necessary
and you will see the list
of procedures that is
covered under the N CD.
We said our patient was gonna have
a ru ny gastric bypass.
I'm going to select open or laparoscopic
ru ny gastric bypass.
I then have the capability to
select a diagnosis
and AC PT code
down. There's also
a note that indicates this is on the C
MS inpatient only list.
I can look at the benchmarks
and you'll see that there is the
C MS geometric mean length of stay
presented here for you.
You would select to
determine the the most appropriate
benchmark length of stay the
DRG, that's most appropriate
for this particular patient.
So this one is 6 19
or procedures for obesity with MC
C. This next
one is 6 20 or procedures
with CCS.
That's the one I am going to select.
And you can see that the average length of stay,
the C MS geometric mean benchmark
length of stay is 1.7
days.
My next step is to go to the review summary
where you'll see that criteria
is met using Medicare procedures,
the bariatric surgery, subset
the version. And then here's
that N CD determination
number
so that it's crystal clear what
source document you used to
obtain this recommendation.
There is the utilization benchmark. I selected
that I selected the open or
laparoscopic ru ny gastric
bypass with the CPT and the
di the diagnosis code.
And then all of the criteria
that I selected and the notes
that I wrote during the course of doing
my review is presented there for
you. This is now ready
to share back and forth between provider
and payer
case. Scenario two is a
Medicare procedure request using
a Medicare administrator.
Our patient is a 65 year old
male with morbid obesity and type
two diabetes.
The request is for bariatric surgery.
Ru Ny gastric bypass. He
resides in Mississippi.
His history and physical diagnosis
is morbid obesity, hypertension
type two diabetes. Melody,
he's on Metformin and Losartan.
He's failed conservative weight loss
treatment. Having tried weight Watchers medical
weight loss and nutritional counseling.
He's unable to sustain any weight loss
he has no identified behavioral health
diagnoses.
He has a full understanding of the procedure
and willingness to make life changes. He
can provide informed consent
and he has no behavioral health risks
that have been identified.
He has no cardiac respiratory
hepatic surgical risks identified.
There's no history of eating disorders
and he does not smoke.
His vital signs are stable. His BM
I is 40 his A one C is
nine.
The planned intervention is RU
Ny gastric bypass.
Again. I'm gonna go down and
select my Medicare Procedures
product
and I can either search by
CPT code or keyword search.
I'm gonna search for the CPT
code this time to show you that functionality.
Once I select, find subsets,
you'll see that it returns bariatric
surgery.
I'm gonna go ahead again and open up that subset
again. Here's that subset information
note you have the ability once
again to see your codes that are included here.
It'll tell you the inpatient outpatient
settings.
There's that N CD we already reviewed
and now I'm gonna go ahead and
I'm gonna scroll down this patient lives
in Mississippi
and I'm going to
just show you
the Novatos
L CD.
Remember I said we included
links directly to the C MS website
to the source document used to
build this content.
I'm gonna go ahead and select that link
because this is an L CD and they
do include CPT codes. There is
AC PT click through here. You've got to accept
the terms for this
fourth edition CPT I'll accept.
But again, you're taken directly to that
source document in this particular instance
for Novatos, the L CD
for Bariatric surgical management of morbid
obesity,
super slick, super
efficient getting you directly to
the source document.
I'm gonna go ahead and begin my medical review.
Recall that the first question
you're posed is what
Medicare administrative contractor
to use or Mac,
whether you use the N CD as we did
previously or the Mac
or L CD
as we are doing. Now,
recall this member
lived in Mississippi
and we know by checking the criteria
end point notes,
which Mac
has the jurisdiction that includes
Mississippi and you can see its novatos
solutions jurisdiction H
covers the state of Mississippi.
I'll select novatos
now
and now you can see how the questions are
in a little bit of a different format. That's because
we've gone from the first review of using
the N CD to this review, using
the L CD. This patient lives in Mississippi
and will be having services in Mississippi.
So I'm going to go ahead and say that this
is an initial bariatric surgery.
Again, I'm going to use the notes
to say the patient has a
BM I
of 40
and
as
M and HTN
diabetes and hypertension,
morbid obesity BM I of at least
35. Yes, his BM
I is 40. You could also include
it in the note there.
Now, we're looking for that, those comorbid
conditions and there needs to be at least one.
So I said he had type two diabetes
and I said that he had hypertension.
Now, hypertension
isn't listed here. Refractory hypertension
is listed here. When you open
up that note,
this is the information note that's included
in the C MS L CD
specific to refractory hypertension.
So this is the definition according
to the L CD of refractory hypertension,
this patient does not have refractory hypertension.
The rule here is at least one. I'm
gonna select diabetes type
two and move through my
review.
I'll have made a note
in the in the comment bubble that the patient
has diabetes
as well as hypertension.
Here's our next question. Choose all that apply.
It needs to be at least two.
Again, accept other clinical information
as we discussed previously.
Now we're looking for a documented
history of participation in a structured dietary
program
and recall. I did say that he was
in Weight Watchers, medical weight loss and nutritional
counseling
and that he had been unable to achieve
or maintain a healthy body weight.
Again, you'd be using the comment bubble to document
your clinical information.
Now, here choose one
history of psychiatric or psychological
disorder or psychotropic medication use,
diagnosable psychological
disorder identified
no diagnosable psychological
disorder identified. And if you recall,
I said he had no documented psychological
disorders.
Now we're at choose all that apply. It needs
to be at least four
patient demonstrates knowledge and willingness
to achieve lifestyle, lifelong lifestyle
changes.
He is able to personally provide informed
consent. He understands
the procedure, postprocedure, compliance
and follow up care.
The patient is not at risk for post-operative,
psychological or psychiatric decompensation.
All of that information was included
in the prior authorization request. If you recall,
you would be documenting that again. Using your
comment bubble.
I'm gonna select next.
Now, I'm at choose all that apply.
It needs to be at least five.
And you can see now
the distinct differentiators between
the types of questions that the N CD was
asking you
and the types of very detailed questions
this L CD is asking you.
So I'm gonna go ahead and start the review
here
must be at least five.
No prohibitive perioperative risk
of cardiac complications.
We said no, no severe
chronic obstructive airway disease,
no history of significant eating disorders,
no active hepatic disease with
inflammation,
no tobacco use by history or
tobacco cessation.
And again, if you recall that information was included
in the prior authorization request.
I'm gonna go ahead and select next after documenting
in the comment bubble.
Now, they're asking you to pick the
procedure that the patient is going to have
and so
bariatric surgery plan, you
could use your conversation bubble there, there's
a note here.
It's the reference
that we that was used specifically
as part of this L CD.
We said this patient was going to have an open
or laparoscopic ru ny gastric
bypass.
And now I've got no remaining questions
and I'm ready to view my recommendations.
Recommended evidence supports services
as medically necessary.
We selected open or laparoscopic
ru Ny, I'm going to select it here.
You can see that it specifically
notes novatos,
it's inpatient.
I'm gonna go ahead and select a diagnosis.
I can go ahead and select my CPT.
I can now look at my benchmark length of stay.
So you can see that there are two drgs
that cover open or laparoscopic
ru ny
one is with CCS
comorbid conditions and one is without
comorbid conditions or multiple co morbid
conditions. So I'm gonna go ahead and select
with comorbid conditions.
And again, my next step is to look at that review
summary where you can see that criteria
was met.
Medicare procedures, bariatric
surgery.
The release, here's the L
CD number.
This is the L CD that we used
and again your benchmarks,
your procedure with your codes
that you used. Novo talk
and that all of the questions that you answered
along with any substantiating documentation
is contained within this review summary
that is now ready to share between provider
and payer
super slick, super
efficient, strictly aligned
with the Novatos L CD.
Our case three scenario is a request
for gerbil medical equipment.
The patient is a 66 year old female
with type two diabetes. The
request is for home blood glucose
monitor code EO 607
she resides in North
Carolina.
She has a history of severe
diabetes. Melody type two
patient is insulin dependent.
She does daily blood sugar testing.
She's closely followed by her PC
P with every six month in person
visits.
And the device being requested
is a home blood glucose monitor
and strips code EO
607.
My first step within the intercall tool
is to select the product. I'm going
to be selecting the Medicare
post acute and durable medical equipment
product.
You can see the functionality is the same.
I can search by keyword, I can search by medical
code.
I'm gonna go ahead and, and search CGM
here for continuous glucose monitors.
I'm gonna go ahead and select my glucose
monitor.
And again, you can see that the subset information
note is set up in the same way as
it was in procedures listing your LC
DS. Here you do have the ability to see your codes.
If need be,
it will tell you what's included in the L CD,
what's non covered? There's a policy
article
again,
if we were to select
that link out
to the L CD, it would take you
directly to the L CD. So
if I look at the L CD for glucose monitors,
it's going to take me directly to the source
document for the glucose
monitor.
Super slick, super efficient.
No need to spend hours in the
C MS website looking for the most
appropriate N CD L CD or policy
article
as you scroll down, you'll see that there is a policy
article associated with this uh particular
device as well. You could certainly select
that and evaluate that.
There is a list of alternate names for
continuous glucose monitors
and some other helpful information here that
was again taken directly from the information
on C MS website.
I'm gonna go ahead and begin my medical review.
Remember these criteria, end point
notes contain the jurisdictions
that each administrator addresses. So
you can see North Carolina is
addressed by CGs. We
said our patient lived in North Carolina.
I'm gonna go ahead and select CG SI
were to look at the criteria and point note
for Nian, it will tell you all of the jurisdictions,
the two jurisdictions in all of the states
that meridian covers.
But our patient lives in North Carolina,
we're gonna use CGs.
So choose all that apply. It needs
to again be two, at least
two. The patient has diabetes
and the treating practitioner has provided
a prescription for the monitor supplies and testing
frequency and that information was
submitted on the request.
Again, you're gonna be using your comment bubbles
to document your clinical.
Let me go ahead and select next.
It's choose one.
What was the request for? It
was for a home blood glucose or
continuous glucose monitor and
supplies.
It was for a home blood glucose
monitor eo 607
specified in the
request.
Now it's choose one
So it's noninsulin dependent
or insulin dependent or non insulin
dependent. Again, insulin dependent,
depending on how many strips I'm gonna say
this patient is insulin dependent,
requiring up to
300 test strips per month.
Once I select that criteria,
you'll see that I have no remaining questions.
And I'm ready to view my recommendation.
As you can see, services are
recommended. Evidence support services
is medically necessary for a home blood
glucose monitor and supply
allowance.
And again, you have the ability to select your
codes.
I'll go ahead and select a hick P code
E 607.
And I am ready to look at my review
summary.
So you can see criteria is met
for Medicare post acute and durable medical
equipment
or a glucose monitor.
The version
and here are the determination numbers,
the L CD number and the policy
article number are listed there for you.
Home glucose monitor was recommended
EO 607.
We use CGs as our administrator
because our patient lived in North Carolina
and we answered all the questions and made
appropriate clinical notes throughout the review.
And again,
your final step is to share this between
provider and payer.
So in summary,
with the new Medicare advantage rule
change set to be implemented in January
of 2024. It's more
important than ever to ensure N CD
L CD and policy article compliance
to do that. You need the latest
decision support criteria from
C MS
in A format that improves accuracy,
consistency and efficiency.
Medicare Navigator is comprehensive.
It includes over 1300
N CD L CD and policy articles
that are updated monthly in accordance
with C MS updates.
Medicare Navigator is convenient.
The policies are at your fingertips
all in one place, right?
Within our Interpol cloud technology
tools,
Interpol transparency builds trust.
Medicare content, intercall content
and any custom criteria
are available for everyone to see
ensuring alignment between payers
and providers and supporting
federal and state regulatory requirements.
As well as NCQ A guidelines,
increasing appropriate
medically necessary services should
be a priority for us all,
we all have a role to play in
making this process transparent,
trusted and efficient.
Interpol has a proven track record
of being dedicated to and partnering
with our customers
helping ensure the right care
at the right place at the right
time is being delivered.
Thank you so much for your time today.
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