The Art of Asking the Best Questions

The Quality Management staff members at MRIoA are happy to help make your questions strong and specific. Collectively, the three of us have over 52 years of experience at MRIoA, and we know how effective the right question set can be.

We learn and benefit from both negative and positive feedback. MRIoA appreciates the opportunity that complaints offer for us to improve and better meet needs; however, ideally, we want high caliber review reports that exceed expectation and do not generate complaints. The worst complaint is the one we do not receive, the one we are not aware of, the one we cannot correct and make right.

Asking the right questions can improve results. Quality Management documents and tracks all complaints received. Any “slight expression of dissatisfaction” is considered to be a complaint. We review data collected on complaints and analyze outcomes based on the type of complaint (report quality, turn-around-time, etc.). Spreadsheets can be generated for any time frame and sorted to check for trends and identify opportunities for improvement. Individual educational opportunities are also identified and acted upon case by case.

Client-specific complaints are reviewed so that action may be taken to correct trends; reviewers whose cases have received complaints are educated; and staff members whose work may reveal trends, or who might be associated with specific complaints, are coached. This work also helps us identify and update processes to best meet client needs.

Analysis of recent complaint documentation indicates a higher percentage of concerns are received regarding the review report answering questions, as they have been asked. The best way to elicit a clear and specific answer is to pose a clear and specific question.

Clearly state the exact service(s) being reviewed in the question set.

– Is maxillary sinus surgery medically necessary?
(Rather than “Is this service medically necessary?” This question requires the reviewer to comment on all procedures outlined as proposed in the documentation; septoplasty and genioplasty may also be proposed, but have specific exclusions. It is in no one’s best interest for the reviewer to approve a septoplasty as necessary when it is specifically excluded by plan language that may not have been submitted for review.)
– Is the proposed, repeat MRI within community standards and medically appropriate?
(Rather than, “Is MRI within community standards and medically appropriate?” This question may suggest that the reviewer needs address any/all MRI services documented in the records, including the initial MRI, which is documented in the records, but is not in question. The reviewer may take additional time to review indications for the initial MRI and add unnecessary references about initial MRI in the patient’s clinical situation that are irrelevant to the proposed, repeat MRI.

Clearly indicate the specific criteria the reviewer is to use in evaluation of the service being reviewed, and list the Medical Policy number.

– Does Botox meet the Medical Policy renewal criteria – A25876.7?
– Does Botox meet the Medical Policy initial criteria – A25876.7?
(Rather than “Does Botox meet the Medical Policy criteria?” This question requires that the reviewer check the entire Medical Policy, rather than focusing on the one section of criteria that apply, and compare the Medical Policy to the patient’s clinical status and history to determine which set of criteria are correct.)
Listing the Medical Policy number helps us ensure that we have received the correct and most applicable Medical Policy for the case. There are many Medical Policies that overlap.
– Does this patient meet the attached LCD criteria for motorized wheelchair?
(Rather than “Does the patient meet criteria for a motorized wheelchair? This may allow reviewer to think that society or ODG criteria could be used.
– Does the March 3-March 14, 2016 hospital confinement meet criteria? Please address both MCG and ODG criteria. (Both attached.)
Many times clients sent multiple criteria sets with cases. Sending only the criteria set you wish to have applied, or specifying that the reviewer address two specific sets, if needed, will clear confusion.

Clearly identify the specific dates of service in question.

– Is continued chiropractic care from May 17, 2016 through present medically appropriate?
(Rather than, “Is continued chiropractic care medically necessary?” This question may be interpreted to mean only from this point forward.

Specifically request the amount of rationale you are in need of.

– For reviews other than Initial Medical Director and Summary/Summary Plus type reviews, we do not want reviewers spending unnecessary time and resources to supply extensive rationale and references if they are not necessary; however, there are times when detailed, specific rationale is exactly what is needed. Please convey what you need.
– It is perfectly fine to add “Please be concise.” “Please provide detailed rationale and quotes from the literature cited.” “Please explain.” “Why or why not?” “Please provide current literature with large, cohort studies to support your conclusion.” These type statements can be added to any question set submitted. This will help our reviewer and our staff members know how much detail you are in need of.

It is perfectly acceptable to provide a background statement for context for the reviewer.

– Air ambulance services have been denied as it was determined that appropriate care could have been provided at a close location (23 minutes), the patient’s clinical situation did not preclude ground transport, and ground ambulance transport would have been safe. (Add questions.) This does not “lead” the reviewer, but rather, provides insight. This invites the reviewer to address the denial reason in the rationale, whether or not he/she is in agreement, and provides important discussion to support the conclusion.

These suggestions should save reviewer time by ensuring that the correct services and criteria are applied without guesswork or unnecessary back and forth for verification. This will help keep review costs down and allow us to complete cases on a timely basis, with fewer delays. Posing questions in this manner will ensure that our Case Assignment staff easily finds the best reviewer fit for the case, and that the particular service in question clear not only to the reviewer, but to all staff members involved in the process. Additionally, it will be clear how much explanation, detail, and rationale are needed.

The Quality Management team is experienced, and available to help with questions. We can assist on a case by case basis, or with standard question sets to ensure that review responses are consistent and elicit the information needed by our clients. We can also assist with appropriate questions for unique or unusual requests. It is in our best interest to make sure review reports are complete, provide the information sought with the required level of detail, and that all questions are appropriately answered as they have been asked. Working closely with our clients helps build mutually beneficial relationships and understanding on both sides. We are happy to help.

Valerie Surber
Director of Quality Management

MRIoA Obtains HITRUST Certification

In January this year, MRIoA was notified that we had earned our HITRUST certification. This came after yearlong effort to update and implement policies that are HITRUST compliant. Fortunately, MRIoA’s security culture made adapting to the necessary changes required only slightly painful. But as a result, our program is stronger than ever. To further demonstrate our commitment to the HITRUST certification, MRIoA will be undergoing a Service Organization Control Trust Service Principles (SOC 2 Type 2) audit at the end of this year. The American Institute of CPAs (AICPA), who audits and delivers the SOC report has worked with HITRUST to extend their report to include the HITRUST controls. This will be a great document to share with our clients looking to better understand the maturity of our program.

As part of a HITRUST certified security program, or any good security program, entities should always be investigating ways to improve their security controls and overall security awareness. With Phishing attacks still being one of the most successful attacks against organizations, we partnered with the leading firm in phishing awareness to continually test, monitor and report our staff’s ability to identify phishing attempts. Email links clicked, or documents downloaded from these test phishing emails, will help us identify weakness and provide more specific training to our more vulnerable employees.

One additional security feature we will be releasing on our ClientTools portal will be the ability for clients to opt their users into requiring dual factor authentication in order to connect with our website. The implementation will requiring a randomly generated code be sent during the log in process to the email address on file for that user. The login process will only complete by successfully entering the code in a limited time window. This process will require the user to not only know the username and password, but have access to the email account of record. Combining this with our client’s ability to restrict access to our site from specific IP addresses for their users will greatly reduce unauthorized access due to compromised credentials. More information about this feature will be forthcoming.

Again, we always look forward to your feedback about anything we can do to improve our service and security. Please feel free to contact me at any time with your thoughts and ideas at don.murphy@mrioa.com.

Donald Murphy Jr. MS, CISSP
Vice President, Information Technology

CMS Part D Memo

In October 2016, CMS released a memo to all Part D sponsors which provided new guidance on outreach requirements when completing coverage determinations. More recently, CMS released a clarifying memo that provided additional insight as to the standard Part D sponsors would now be held to as it related to conducting outreach for information to support coverage decisions. In the most recent memo, CMS states the new principles are to be seen as best practices until Chapters 13 and 18 are updated later this year.

The goal of the new guidance on what constitutes appropriate outreach is for a more timely and accurate coverage decision for beneficiaries. This latest guidance from CMS outlines the best practices for conducting outreach for both standard and expedited requests on the following:

• Number and timing of the attempts made to contact a provider
• Documentation of the plan’s efforts to contact a provider
• Potential method(s) of contact
• Specific content of messaging to the provider when information is requested,
• Responsibilities in documenting requests for information

Of all the new guidance, likely the most impactful for Part D sponsors is the requirement to have the physician reviewer conduct an outreach attempt with the provider prior to issuing an adverse determination based on lack of medical necessity because of a lack of clinical information. The specific citation reads:

• When adjudicating reconsiderations and redeterminations, if the plan expects to uphold its initial adverse decision based on lack of medical necessity because the plan needs information from the provider or prescriber to approve coverage, the physician making the decision should attempt to communicate with the provider or prescriber about the request before issuing the decision.

Although the intent of this new guidance is to improve the timeliness and accuracy of a plan’s coverage decisions, Part D sponsors may find it difficult to have their physician reviewers comply with the new outreach requirements, either because of the sheer number of cases that now require outreach or their limited physician reviewer resources.

If you have questions or would like to discuss how MRIoA can help with these new CMS best practices, please contact Byron.Harris@mrioa.com

Byron Harris, PharmD, BCPS, CGP
Director of Pharmacy Services

Targeted Training

MRIoA recently added to its information security staff to help meet the ever growing needs in this highly demanding and important department. One area we hope to improve on with this additional resource is with respect to our ongoing staff security awareness training. Historical evidence of past breaches in the healthcare sector have shown that social engineering and lack of awareness by staff has been the number one attack point. Improving employee awareness and behaviors can only improve this troubling statistic.

After a long discussion about the many important topics we felt we needed to cover, we realized that we were really uncertain as to the existing knowledge of our staff across the wide scope of information security topics. To help us better understand this so that training could be targeted to the true areas of weakness, we chose to investigate the actual knowledge of our employees.

A mandatory awareness survey was created to explore a number of topics and to find out whether the actual concepts were understood. Instead of the typical multiple choice type answers many awareness quizzes utilize, we asked our employees to explain their understanding of the concepts. These ranged from why strong passwords are beneficial to how encryption actually protects data. The results of this test will be used to tailor our security awareness program to areas of most concern with the least amount of understanding. Our hopes are to truly help people with the fundamental understanding of how they are integral to our company actually being secure. I will follow up with our findings in a future article.

Donald W. Murphy Jr. MS, CISSP
Vice President, Information Technology

Baby Boomer Generation Impacting Medicare D Programs Like a Tsunami

Each day thousands of “Baby Boomers” sign up for the various Medicare programs. In simple terms, “Part A” deals with hospital “room and board” and hospice care; “Part B” deals with inpatient and outpatient tests and procedures, medical devices and certain types of medication;” “Part C” refers to “HMO” type plans, which include Parts A, B, and D. Medicare “Part D” deals with qualifying medications, which are not covered by Medicare “B”.

Pharmacy benefit managers, (PBM’s) or pharmacy sponsors are very aware of the complicated, intricate rules and regulations of Medicare “D”.

At MRIoA, we are always working to improve our expertise involving Medicare programs and other PBM products. Commercial insurance programs have their own unique variations, which are partly determined by the state laws in which they do business. Each Commercial plan may have its own definition of “Medical Necessity”, “Experimental/ Investigational” as well as what level of evidence is required in order to provide a medication.

For Medicare “D” the details of the relevant portions of policies and procedures are contained in chapters 6, 15, and 18 of CMS law and apply to all Medicare “D” medications.

The compendia required for support as well as the level of support are precisely delineated for cancer cases. Specific rules for making Prior-Authorizations Exceptions or Formulary Exceptions are also defined.

While this summary may create the idea that the adjudication of Medicare “D” cases is straightforward, it is actually quite difficult.

MRIoA is dedicating a lot of resources to keeping our team of Medical Directors skilled in adjudicating Medicare cases. Our team of Medical Directors is all board certified in various medical specialties including Emergency Medicine, Family Practice, Internal Medicine, Physical and Rehabilitation Medicine, Neurology, Pathology, and Otolaryngology.

We are ready for the tremendous growth the “Baby Boomers” will bring to all parts of Medicare, particularly Medicare “D”.

Bennion D. Buchanan, MD, FACEP, MBA
Medical Director

Help Us Help You

Quality and compliance requirements are equally important. MRIoA must meet client needs and at the same time ensure that both our clients and MRIoA avoid being put at risk due to non-compliance. When audited (by accrediting organizations such as URAQ or NCQA, or at the state or federal level) documentation must demonstrate that guidelines, laws and rules have been followed, and that appropriate processes have been followed. The most exquisite and objective review report, supported by extensive peer-reviewed literature and medical evidence, completed in a timely manner, may be rendered unusable if even one portion of a requirement is not followed. This is not in the best interest of patients, providers, or clients. Knowing the rules and providing valuable information when cases are submitted can help avoid potential incidents.

The online submittal form is a valuable tool for our clients to convey their needs, and for MRIoA to ensure not only that those needs are met, but that all are in compliance. The more information that a client provides to MRIoA using the designated fields on the submittal form, the better we are able to meet their needs, not only in terms of the review specialist, but the level of the review, and compliance with state and accrediting body requirements. Additionally, it will help both MRIoA and you, our clients, to provide accurate reporting to regulatory bodies. Much of the information included in the designated fields of the MRIoA submittal form can be tracked in our system, allowing for more robust reporting capabilities. Not including some of the information could result in delay of the case, clarifications and/or complaints due to our analysts having to reach out to the client to clarify or obtain necessary information.

Help us by accurately indicating the Case Level (Initial, Reconsideration, 1st Appeal, 2nd Appeal, Federal IRO, State IRO). This will allow MRIoA to help you by ensuring the appropriate URAC, NCQA, state, and federal requirements are met, such as specialty match, turn-around time, etc.

Help us by accurately indicating the plan type (fully-insured, self-funded) and plan state on each and every case. This is important because MRIoA must follow different sets of requirements for fully-insured and self-funded cases, and it will allow MRIoA to help you provide accurate reporting to accrediting and regulatory bodies.

Help us and avoid confusion by knowing the state guidelines for the fully insured cases you submit to MRIoA. We will help you by advising that this information is available to you in the Resources section on the ClientTools website for your reference.

Example 1 – Texas requires that URAs afford the treating provider a reasonable opportunity to discuss the case prior to issuing an adverse determination. “Reasonable opportunity” is defined as follows:

“At least one documented good faith attempt to contact the provider of record that provides an opportunity for the provider of record to discuss the services under review with the URA during normal business hours prior to issuing a prospective, concurrent, or retrospective utilization review adverse determination:

(A) no less than one working day prior to issuing a prospective utilization review adverse determination;
(B) no less than five working days prior to issuing a retrospective utilization review adverse determination; or
(C) prior to issuing a concurrent or post-stabilization review adverse determination.” 28 TAC § 19.1703

Translation: If a case is submitted with a requested 24 hour turn-around time, MRIoA might be unable to comply with both the state requirement and the client’s requested turn-around time unless the reviewer is able to approve without a peer-to-peer. For example, if a fully-insured Texas prospective case is submitted to MRIoA at 3 pm Mountain Time, it is likely that the reviewer will not be able to make a peer to peer attempt during the treating provider’s business hours until the morning of the next business day, and subsequently may need to wait the full duration of the required time frame as described above (one business day for prospective; five business days for retrospective) before rendering an adverse determination.

Example 2 – The appeal process in Massachusetts differs slightly from many other states. Massachusetts considers a “reconsideration” to be an appeal requested by the treating provider versus a “grievance”, which is an appeal requested by the insured. Massachusetts requires reconsiderations to be conducted between the treating provider and a Massachusetts licensed reviewer within one working day of receipt of the request. It is not always possible for contact and a discussion between the reviewer and treating provider to occur due to the limited time allowed by state mandate. In these instances, the reviewer will document that an attempt to reach the treating provider was made and complete the review. MRIoA is not able to delay or extend the case for additional call attempts, as doing so will result in noncompliance with the state requirements.

Being aware of the requirements of the various accrediting bodies and states and how they differ from case to case will provide a clear understanding, allow you to plan internal processes to avoid potential delays required to ensure compliance, and keep you from being at risk due to non-compliance. It will also improve the quality process by reducing the number of clarifications and complaints resulting from unfamiliarity with the requirements.

Valerie Surber, Director of Quality Management

Aja Ogzewalla, Director of Regulatory Compliance

Giving Back

MRIoA is built upon 20 value statements that guide us every day in our business relationships with our employees, reviewers, and clients. Some of these values include the following:

• We are Honest
• We act with Competitive Urgency
• We Cherish our Customers
• We are Hard Workers
• We are Committed to High Performance

Three years ago I added an additional value: We Give Back. Since that time MRIoA has funded and built a medical clinic in Ghana, West Africa, and partnered with Camp Kostopulos to build a Yurt and provide other valuable services to this important Salt Lake City charity. Late last year I was looking for a project for our company to participate in. There are so many wonderful causes; I was finding it difficult to choose just one. Then I decided to experiment with a new idea as follows: For every employee that volunteers a minimum of four hours at an MRIoA sponsored service project, we would donate $1,000 to the charity of their choice. I liked this because it accomplished two goals. First, it brings everyone together outside of the office serving those in needs. MRIoA has sponsored numerous projects so far this year including painting graffiti, cleaning hiking trails, working in food banks, and cleaning parks, among others. Our employees gather together in our blue shirts and work side by side. Second, it allows the employee to donate a meaningful sum to a charitable organization that’s important to them.

This year MRIoA will donate significant sums to a large variety of charities helping many in need. At MRIoA “We Give Back” isn’t just a tag line. It’s a value we live.

Bill Low, MBA
President

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Nurse Review

Nurse Review is a new product designed to provide reviews on prior authorization requests, appropriateness of emergency room admissions and other initial services as requested. The Nurse Review service, like the Initial MD review service, has been designed to assist with your prior authorization program.

MRIoA uses an independent RN panel to complete these reviews. The review report includes a summary of the case such as patient complaints, vital signs, pain, physical exam, labs, initial diagnosis, treatment given, final diagnosis and prescriptions given. A decision is made to approve or deny the services based on the information provided. If a Nurse is unable to approve the services in question, the case is forwarded to an internal Medical Director for a determination by a Medical Doctor.

MRIoA has the ability to complete a high volume of these reviews within preauthorization and initial review timeframes. The process is streamlined to minimize any interruption in the claims process.

If you are interested in using this service as a resource, please contact your Marketing Representative for details. The Marketing staff wishes us to convey that, like our Initial MD reviews, this product is Smart, Simple, Streamlined, and completed with Speed and Security resulting in Savings for you!

Valerie Ottman, CPC, CPC-H
Director of Quality Management

New Security Option

In an effort to enhance the security of our ClientTools website, we will soon be releasing an option to allow clients to specify specific IP addresses from which their users may access the portal. This is commonly referred to as ‘whitelisting.’ The process will be quite simple: We will define a group of IP’s that will be associated with a user; these are typically the IP’s associated with the company’s known outbound internet traffic. When that user attempts to connect to our portal with their credentials, a check will be made to ensure they are connecting from one of the registered IP’s. If an IP that is not previously registered is detected, the attempt will be logged and the user will be denied access.

Essentially what this means is users will only be able to access our site and client data from networks approved by the client and as defined by the clients business needs. For instance, a user would not be able to access our portal from their homes or anywhere else other than the office location. This measure could help data loss prevention from users that are legitimately registered but want to access the data from a non-secure location.

We will be formally announcing this feature in the near future with details on how to opt in to the program. We will not be enforcing this, but will highly encourage participation for the added security it provides.

One other future feature being developed and tested is the use of one time passwords sent to a known device like a cellphone (SMS) or an email address, associated with the user, which must be used in conjunction with existing username and passwords. This is a form of dual factor authentication and helps prevent access to our site and client data from usernames and passwords that may have been compromised. In order to successfully access the ClientTools portal, users would also have to have access to the email account and or cell phone related to the user. This technique would significantly lessen the risk of a stolen password and username being used to access confidential client data on the ClientTools website.

MRIoA is always looking to provide more security in all of our processes and with great attention to our outward facing websites that can access client data. We always welcome your thoughts and comments on these matters.

Don Murphy Jr. MS, CISSP
Vice President, Information Technology

Just Because “It Makes Sense”
Doesn’t Mean it is True

For each newsletter we strive to choose topics which are current and controversial. This issue will be no exception. One of the axioms in medicine is “Never be the first nor the last to prescribe a medicine.” There is a lot of wisdom in this simple principal. Being the last to prescribe a medicine implies that one is not keeping up with the science of medicine. On the other hand being one of the first to prescribe a medicine implies practicing in an unproven way. There are many examples in medicine of medications or procedures which initially seemed to be very effective but turned out producing very disappointing results.

Two examples illustrate this concept. In the late 1980’s a new medication was introduced to the market which had been developed to treat PVC’S (Premature Ventricular Contractions). PVC’s are premature heart beats which can range from being simply annoying, but innocuous in young, healthy people, to becoming debilitating and even life threatening in some elderly patients.

The medication clearly decreased the frequency of PVC’S. However it also increased the mortality rate of the same population of patients it was developed to help. In other words, what seemed to make sense, i.e., decreasing the mortality rate of elderly patients by decreasing the frequency of PVC’S, did not turn out to be true.

Another example of an unexpected and disappointing result is the case of metal-on-metal hip replacements in the first decade of this century. In the laboratory this type of prosthetic hip had been shown to be capable of withstanding far more compression cycles than the previous types of materials used in prosthetic hips.

However after several years metal on metal prosthetic hips were taken off the market because of the unacceptably high rate of early failure of the joints. It turned out that when the components of the hip were not perfectly aligned as in the laboratory, the surfaces would rub against each other in an asymmetrical way and would produce small flakes of metal, resulting in a condition called metallosis. The condition of metallosis consists of an entire spectrum of undesirable effects ranging from mildly elevated concentrations of certain heavy metals, to severe local tissue destruction and even severe system adverse effects including a decrease in cognitive function. So once again what seemed to be a logical step forward in medicine turned out to a step backwards

One of the current controversies in medicine is the utilization of a new class of medications called “PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) inhibitor antibodies” which have been designed to lower cholesterol, particularly LDL (low density lipoprotein). For many years it has been known that high cholesterol, especially elevated LDL, has been a risk factor for the development of atherosclerotic cardiovascular disease. Other risk factors include a positive family history, age, smoking, diabetes, diet, and lack of exercise. The main methods used to treat elevated LDL levels have been lifestyle changes (diet, exercise, and weight loss) and medications. While there are a number of medications which have been used to treat elevated cholesterol, including niacin, fish oil, red yeast rice, etc., the mainstay of medical therapy has been the class of medications known as statins. The statins lower LDL cholesterol by acting on metabolic pathways in the liver. Their main clinical benefits are in individuals who already have clinical ASCVD (atherosclerotic cardiovascular disease) such as an MI, embolic stroke, peripheral arterial disease, etc.

The “PCSK9 inhibitor antibodies” have clearly been proven to lower LDL cholesterol by acting on metabolic pathways which are different from the pathways effected by statins. They have also been demonstrated to be relatively safe. The problem is that while they have been proven to lower LDL cholesterol, they have not yet been proven in long term studies to change morbidity and mortality secondary to ASCVD.

On the surface it would seem that if the medications lower LDL cholesterol and are safe there should be no problem. However at this point in time there are two problems:

1) The medications are quite expensive and ordinarily would be prescribed for life.

2) As illustrated by the two cases at the beginning of this article, what seems logical is not always factual.

Only time will tell if this becomes an example of:

Just Because “It Makes Sense” Doesn’t Mean it is True!

Bennion D. Buchanan, MD, FACEP, MBA
Medical Director