Aligning with CMS: Medicare Content Navigator and InterQual Transparency

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.