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Orthonet
March 2010
Orthonet meeting with Medical Director Summary
A meeting with the Medical Director of Anthem and the reimbursement committee of the NHAPTA was held the first week of March.
Issues identified
1. Turn around time for approval_ reports from providers were 3-4 days on average. Orthonet statistics show 24 hours the last week of Feb as an average so expect providers to see a difference in March.
2. Fax is quicker than on line posting- In meeting with different therapy practices, most were providing feedback to Anthem they wanted faxes vs. online so this is what orthonet concentrates on. It depended on practice (hospital wanted online, PP wanted fax). The issue is having to go online multiple times to find the approval.
3. Difficulty knowing who needs pre authorization- stated Anthem believed 30-50% of Anthem patients would need orthonet. Experience shared with APTA from providers was closer to 10-20%. As companies renew their plans, the % of patients needing pre authorization will increase.
4. Difficulty to get multiple authorizations for different diagnosis. This is difficult for many to manage because if you create a second account with the same insurance we can get electronic denials for concurrent treatment. He did not have an answer for this and was to get back to us.
5. Pattern for approval- 6 visits for first and 4 for second- He stated it was not suppose to work this way and expected this to smooth out as the reviewers got to know the clinics. He stated they are receiving requests for 30 visits so the process needs to be better understood by both sides. He is reviewing data to monitor.
6. Logistical issues- hard to know what info orthonet wants, they approve clinical notes but then want more info, takes 2 weeks or longer to create an account, still don’t know the difference between Utilization review and consultative review. – He stated it is a good idea to get consultative review so we can have the correct expectations moving forward. We stated there is work but no gain for us- if they give us 6 initial visits we do not need to ask for additional visits so we were not apt to ask for consultative review. He wants providers to work with their Anthem rep to resolve the logistical issues.
Issues which were not reported by membership but were discussed:
1. Some MD’s (Darthmouth docs noted) are doing their own UR and limiting visits on the referral. It is double work to then get increase visits by MD and then increased visits by orthonet.
2. We were provided some statistics. These are from the Anthem network.
a. Nationally medical cost per capita is $8000/year. This is higher in NH. The areas of utilization noted to be higher in New Hampshire include office visits to primary care physicians, MRI’s and therapy. There may be others but they were not mentioned. Anthem is looking at trying to control the cost of these areas in NH. He stated that employers and insured and legislators and regulators only want one thing- decrease the cost of healthcare. Since we (medical community we) have not proven effective in keeping cost down, they are resorting to a gatekeeper.
b. Specific statistics for rehab- nationally 40-60 cases per 1000 insured per year. In NH/Me/Ct 66-99 cases per 1000.
c. Visits per case- national benchmark is 6.6-8.3 visits per case. NH/Me/Ct is 8.7-10.6 visits per case.
3. As therapist move to EMR they want to be able have all electronic authorizations
4. If patient needs to be seen before authorization can be gotten- example was a shoulder surgery on a Friday which needed to be seen over the weekend, the second visit will be covered.
5. Same if a patient is referred for a hand splint and the eval cannot be performed on the same day as the hand splint, the next visit for the eval would also be covered.
6. We asked if statistics in terms of visit/case differed with practice (ownership) type and he stated no and it surprised them.
7. We discussed if Anthem was looking at outcomes since there are practice variations. He stated not in therapy but they do with docs. We offered to meet with him in a few months and present some evidence based outcome tools so they could measure outcomes with their dollars and see where they receive value. NHAPTA will continue to pursue this avenue.
Orthonet Response to Marc Lacroix via email
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