Avoiding PPO Sales Slip-Ups

Forewarned is Forearmed With Our Annual PPO Survey
Welcome to Part I of our eighth annual PPO survey. For this survey, 10 PPOs in California diligently answered direct questions about their plans. Our readers, who are savvy health brokers, suggested many of the questions. We hope this information will help the professional agent or broker better serve sophisticated healthcare clients. We offer a special thanks to the insurance carriers that took the time to answer our lengthy questionnaire. We interpret their careful responses as a sure sign of their high level of commitment to the professional agent. Look for Part II in our April issue.

1. Is an Approval Procedure required for Getting a Specialist Referral or a Diagnostic Test or Treatment In-Network or Out-of-Network?

Aetna: There is a new high tech radiology pre-certification requirement
for some customers.
Blue Cross: Not required for PPO plans, but the member ends up paying more if they go out-of-network without getting an out of network approval.
Blue Shield: No, PPO plan members can generally self-refer to any doctor for care. They can choose to use in-network and out-of-network benefits with claims reimbursement based on their benefit plan. Out-of-network services are usually subject to a higher deductible and co-payment amount.
Cigna: No, referrals or approvals are required since the PPO benefit plan is an open-access program. Members are covered whether or not they get care from PPO network providers. Members who use services from an in-network provider may have reduced copayments and lower out of pocket costs.
Guardian: No, Guardian has no required approval procedure for getting a specialist referral or a diagnostic test or treatment in-network or out-of-network
Health Net: There are no approval procedure requirements for visits to in-network or out-of-network specialists. A prior authorization list for diagnostic tests or treatments is included in the member’s evidence of coverage.
Kaiser Permanente: No, the PPO plan does not require a referral to see a specialist. Diagnostic tests are covered provided they are ordered by a member’s doctor covered benefit and are medically necessary.
Nippon Life: No.
UnitedHealthcare: To strengthen the patient-physician relationship, primary physicians are not required to request an authorization when they refer a patient to a network specialist for an office visit. Primary physicians are very effective at making sure that our enrolled people get medically appropriate and necessary specialty care. In fact, practice pattern analysis shows that primary physician referrals to network specialists have been almost 100% effective and medically appropriate. However, our network physicians and other healthcare professionals are contractually obligated to refer to our network hospitals. If a network physician refers an individual to a non-network specialist or hospital without our authorization, the physician is sanctioned. Payment is made to the non-network physician and the individual is not held responsible. Physicians with multiple sanctions may be closed for future UnitedHealthcare membership or may even be terminated from our network.

2. Are there any restrictions on Getting Second Opinions from an In-Network Provider or an Out-Of-Network Provider?

Aetna: A member who has the option of an out-of-network benefit, can arrange their own second surgical opinion with a non-participating provider.
Blue Cross: No.
Blue Shield: A member can get a second opinion from any in-network or out-of-network provider. When an out-of-network provider is used, the member is responsible for any difference between Blue Shield of California’s payment and the billed amount. There would be no restrictions of this kind since Blue Shield does not require physicians to belong to certain IPAs or medical groups in order to participate in our PPO network.
Cigna: There are no restrictions. The PPO is an open access plan, allowing members to seek care in-network and out-of-network at any time. By using a network provider, members have a lower out-of-pocket cost for each service.
Guardian: No, there are no restrictions on getting second opinions from an in-network provider or an out-of-network provider
Health Net: Health Net members can see any in-network or out-of-net work provider for a second opinion without obtaining a referral. Members are encouraged to call the customer service center with any questions about their benefits.
Kaiser Permanente: Second medical opinions are covered. Coverage is limited to charges for physician consultation and any additional X-rays, laboratory tests, and other diagnostic studies. Benefits will not be payable for X-ray, laboratory tests, or diagnostic studies that are repetitive of those obtained as part of the original medical opinion or for which Kaiser Permanente Insurance Company paid benefits. For benefits to be payable, the second medical opinion must be rendered by a physician who agrees not to treat the covered person’s diagnosed condition. The physician offering the second medical opinion may not be affiliated with the physician who is offering the original medical opinion.
Nippon Life: No.
UnitedHealthcare: We do not require consumers to get second surgical opinions. Instead, we offer information throughout the care coordination process to help consumers understand their treatment options. We also identify proposed care that does not meet evidence-based criteria for efficacy or quality. In these situations, a medical director will contact the consumer’s physician to discuss the case and identify opportunities to facilitate needed health services more efficiently. Also, treatment decision support is integrated into our care-management program. It focuses on engaging consumers in understanding their conditions and their treatment alternatives, finding the highest quality and most efficient providers, and understanding what to expect based on their course of care. Through this program, we strive to ensure that members have full information on their conditions and treatment alternatives. We also offer information to consumers through 24-hour telephone nurse line and through online decision support resources at www.myuhc.com. Decision support resources include “Best Treatments,” a site produced by the publishers of Clinical Evidence. Best Treatments is available to physicians on our physician Internet portal, UnitedHealthcare Online. By offering these information and decision support services, we no longer need to require a mandatory second opinion program.

3. Where are Decisions Made About Specialist Referrals, Testing, Treatment, Surgery, and Hospitalization?

Aetna: Our patient-management staff is centrally located. The region is determined by the location of the customer.
Blue Cross: Members may see specialists without referrals. Our Utilization Management department handles the review and approval for services that require pre-authorization.
Blue Shield: Physician members and participating ancillary providers are expected to refer to other network providers for services. However, members can choose to see an out-of-network specialists and pay higher coinsurance. Generally, Blue Shield’s PPO plans do not require authorizations in the referral process.
Cigna: These decisions are made with a member’s physician in partnership with the member and the CIGNA nurse and physicians.
Guardian: UM vendor for surgery and hospitalizations. Specialty vendors for prescriptions, behavior management, NICU admissions, and transplants.
Health Net: Decisions about specialty referrals for testing, treatment, surgery, or hospitalization are made with the member, the member’s physician, Health Net’s Care Management team, and Health Net’s Decision Power health coaches, if the member chooses. The coaches will provide additional information to help the member through the decision-making process.
Kaiser Permanente: In most cases, the member does not need a referral to see a specialist. The member and their physician make decisions about testing, treatment, surgery, and hospitalization. The member does need to get pre-certification for any hospitalization or certain special procedures as defined in the member’s certificate of insurance. Pre-certification is performed by SHPS.
Nippon Life: Insureds call our health information hotline to get approval for hospital admission and some surgeries. Failure to get approval results in a financial penalty, but coverage is still provided subject to medical necessity.
UnitedHealthcare: The treating healthcare professional and the patient make decisions about providing specialist referrals, testing, treatment, surgery, and hospitalization. We determine whether such services are covered by referencing the member’s certificate of coverage.

4. Which Complementary Medical Disciplines are Covered Under the PPO or Will be Covered Under the PPO?

Aetna: Members get special rates on visits to acupuncturists, chiropractors, massage therapists, and nutritional counselors, which they pay directly to the participating provider. Participating providers and vendors in the alternative healthcare programs are solely responsible for their products and services. We have not credentialed or reviewed them. Members can save on over-the-counter vitamins and supplements, aromatherapy, foot care, and natural body-care products.
Blue Cross: Physical therapy, occupational therapy, chiropractic care, speech therapy, DME and acupressure/acupuncture.
Blue Shield: Resources include the following:
• Alternative health and wellness services are available through credible providers that don’t cost employers more money. Members living in California can get discounts of 25% or more on alternative services, such as acupuncture, chiropractic, and massage therapy.
• Blueshieldca.com provides personalized information on fitness and nutrition, parenting, women’s health, pregnancy, alternative health, and more. It also includes Mayo Clinic’s Health Topics A–Z.
• Information and brochures are available on preventative health.
• LifeMAP Member Advocacy Program educates PPO members who are scheduled for selected surgeries. Pre-surgical guided imagery is part of the growing alternative medicine movement.
• Lifepath Advisers provide high-level work-life support, round-the-clock online and telephone access to experts in financial planning, education, law, along with personal consultations, and a nurse line for health questions.
• Blue Shield has a directly contracted statewide network with more than 5,000 licensed chiropractors who deliver services for our members with our PPO benefit plans.
Cigna: Complementary medical disciplines such as acupuncture, massage therapy, and chiropractic care may be covered if they meet CIGNA’s evidence-based medical necessity guidelines, which are accessible on-line. Members can take advantage of generous discounts from Healthy Rewards on variety of health and wellness products and services including alternative therapies, such as massage, acupuncture and chiropractic care, plus discounts on laser vision correction, fitness club memberships, hearing care products and services, guided imagery mind body techniques and vision care. Healthy Rewards also offers savings on herbals, vitamins, and non-prescription health and beauty products. CIGNA’s enhanced personal web portal, myCIGNA.com provides members with access to online provider directories, benefit and claim information, pharmacy services, and specific health information (including complementary medicine topics), among other things.
Guardian: Chiropractic, physical therapy, occupational therapy, speech therapy, and acupuncture are covered when medically necessary.
Health Net: Complementary medical disciplines vary by each employer contract. If an employer offers complementary medicine, Health Net’s program offers direct referral to chiropractic and acupuncture care. However, all PPO members get discounts on the following:
• Chiropractic, acupuncture, relaxation and massage therapy.
• Hearing aids and screenings
• Children’s health products
• Eye exams, frames, lenses, contacts, and LASIK
• Fitness clubs, vitamins, herbs, supplements, weight management services, and many other services. Members can log onto www.healthnet.com It’s Your Life—Wellsite: Member Discounts to learn more about these discounts and how to access them.
Kaiser Permanente: The PPO plan does not currently offer coverage for any complementary and alternative medicine (CAM) services. However, members choose to purchase the chiropractic/acupuncture rider. The rider offers a combined $1,000 or $2,000 benefit maximum and the member pays coinsurance for services received.
Nippon Life: Chiropractic and physical therapy are covered. Coverage up to $500 per calendar year is provided for acupuncture.
UnitedHealthcare: American Chiropractic Network (ACN), a business segment of UnitedHealth Group, provides chiropractic benefits and discounts for the following complementary alternative medicine (CAM) services to our enrolled people:
• Acupuncture
• Massage therapy
• Nutritional counseling
• Naturopathic medicine services (in states where naturopathic physicians are licensed). UnitedHealthcare also offers employers an optional acupuncture benefit. Finally, through UnitedHealth Wellness programs, we provide discounts on products and services for nutrition, weight-management, fitness, stress management, and other wellness products and services.

5. Describe Your Coverage For Mammograms.

Aetna: Mammograms are included in the clinical screening once between 35 to 39 and annually beginning at age 40. This is only part of physical exam benefit when the customer’s benefit plan does not include a separate benefit.
Blue Cross: Once a year routine mammograms when ordered by a physician. No limit in frequency, meaning as medically necessary for “sick/medical conditions”, again, when ordered by a physician.
Blue Shield: One annual mammography test is covered for screening
and diagnostic purposes without illness or injury being present.
Guardian: This is covered under the CA as follows: one baseline mammogram for women 35 to 39; one mammogram for women 40 to 49 every two years or more frequently if recommended by a physician, nurse practitioners, or certified nurse midwives; and an annual mammogram for women age 50 and older.
Cigna: Mammograms are covered annually for women 40 and over or more frequently and at younger ages when medically indicated.
Health Net: Health Net’s PPO coverage for mammograms is as follows: One baseline mammogram for women 35 to 39; one mammogram every one to two calendar years for women 40 to 49 and one mammogram every calendar year for women 50 and older.
Kaiser Permanente: Mammograms are covered as part of the adult preventive screenings benefits as follows:: One baseline mammogram for women 35 to 39; one mammogram every one to two calendar years for women 40 to 49 and one mammogram every calendar year for women 50 and older.
Nippon Life: Mammograms are covered the same as any other condition.
UnitedHealthcare: UnitedHealthcare Options PPO provides coverage for mammograms as part of our standard outpatient surgery, diagnostic and therapeutic services benefit. It is covered both as a preventive and diagnostic service.

6. Do You Cover PSA Tests For Non-Symptomatic Men? If So, at What Age?

Aetna: Yes, if a state has specific legislation, we will pay it in accordance with the law. There is no age limit unless it’s being paid under a specific benefit, like the trust benefit, which has a contractual limit.
Blue Cross: Yes, when ordered by a physician.
Blue Shield: Coverage includes, but is not limited to, prostate-specific antigen testing and digital rectal examinations, when medically necessary and consistent with good professional practice. There is no age limit for PSA testing when billed with a preventive-care diagnosis.
Cigna: It is covered based on the determination by the treating physician.
Guardian: If the preventive care rider is purchased, the age we start allowing is 50.
Health Net: Preventive care and diagnostic procedures for adults (age 17 and older) are covered at a physician’s direction. When medically indicated for men age 50 and above, test and procedures include, but not limited to, prostate-specific antigen testing (PSA) and digital rectal examinations.
Kaiser Permanente: The following PSA tests are covered as part of the adult preventive screenings benefits, which are available at age 18: screening and diagnosis of prostate cancer, including but not limited to PSA testing and digital rectal examination when medically necessary and consistent with good professional practice. This coverage does not cover the surgical and other procedures known as radical prostatectomy, external beam radiation therapy, radiation seed implants, or combined hormonal therapy.
Nippon Life: Yes, there is no age requirement.
UnitedHealthcare: Network physicians are encouraged to follow the Guide to Clinical Preventive Services of the United States Preventive Services Task Force (USPSTF) as the basis for preventive care. We cover PSA tests regardless of age even though the USPSTF indicates this screening lacks clinical value.

7. Describe Your Drug Formulary. (Three Tier etc.) If it’s a Closed Formulary, What Happens if a Non-Formulary Drug is Needed?

Aetna: The formulary may be open or closed depending on the benefit plan. In plans with an open formulary, both formulary and non-formulary drugs are generally covered subject to applicable limitations and conditions. With a closed formulary, formulary and non-formulary drugs are generally covered except for drugs on the formulary exclusions list. Formulary exclusions provide less overall value than therapeutically equivalent formulary drugs. The member’s physician can request approval for coverage for a formulary exclusion.
Blue Cross: Non-formulary or non-preferred drugs that have a formulary or non-prescription equivalent are not covered unless the prescribing doctor indicates that the drug should be dispensed as written on the prescription.
Blue Shield: The Blue Shield three-tiered open formulary benefit allows members to get generic drugs at the lowest co-payment, brand-name drugs at a higher brand co-payment, and non-formulary drugs at the highest non-formulary co-payment. A drug prior authorization program is in place for selected drugs on the formulary and for non-formulary drugs to promote appropriate first-line therapy or to reserve use of certain medications with specialized uses or significant potential for misuse or overuse. The Pharmacy and Therapeutics Committee is responsible for establishing and oversight of the drug prior authorization policies and procedures and the maintenance of the Medication Policy Coverage Criteria. By encouraging the use of generic and brand formulary drugs, savings are realized by the employer, the member, and Blue Shield of California.
Cigna: We offer several kinds of formulary including open, closed, and tiered.
Guardian: Medco Health Solutions Inc. pioneered formulary management and continues to be a leader in the industry with innovative formulary compliance programs. The Guardian has contracted with Medco to manage the formulary, which is approved by independent medical professionals on the Pharmacy and Therapeutics Committee for safety and efficacy. The Formulary consists of FDA-approved drugs, which were selected based on their safety, efficacy, and cost. For three-tier plans, The plan may prefer some medications over others. These are called “preferred drugs,” and their co-payment is lower. The amount of the member’s co-payment depends on which drug the doctor prescribes for the member. Member can pay the following:
• Lowest co-payment for generic drugs.
• Higher co-payment for preferred, brand-name drugs.
• Highest co-payment for non-preferred, brand-name drugs.
Health Net: The most common pharmacy-benefit structure is a three--tier plan, although a small number of employers have selected a closed formulary. When members with access to a closed formulary get a prescription for a non-formulary drug, coverage for the drug is not typically available unless it meets medical necessity guidelines.
Kaiser Permanente: The PPO plan has an open formulary. All FDA-approved drugs are covered for the member except those listed in the Exclusions and Limitations. The member pays a co-pay based on whether the drug is generic or brand.
Nippon Life: Nippon Life uses an open drug formulary for the three-tier plans. We pay for non-formulary drugs at the third tier.
UnitedHealthcare: We have moved beyond the traditional limitations of drug formularies and established a prescription drug list (PDL), which is the foundation of how we drive value for our customers and members. We offer a three-tier plan and an open benefit design. Unlike a formulary, the PDL does not imply any drug therapy recommendations. Rather, we assign prescription medications a co-payment tier based on an evaluation of clinical, economic, and pharmacoeconomic evidence. Unlike our competitors, some brand drugs will be placed in Tier 1 and some generic drugs will be placed in Tier 2 or Tier 3 based on the overall value (for example, lowest net cost that they offer our clients). Tier 1 drugs represent the lowest co-payment option and include many generic drugs. Tier 2 drugs represent a middle co-payment option, and include many brand name drugs. Tier 3 drugs represent the most costly drugs, often with Tier 1 or Tier 2 alternatives, and therefore have the highest co-pay option. A drug’s tier placement is subject to change when its value changes as a result of a patent expiration, new product introduction, or other important clinical, safety or economic information. When a generic drug is more costly than the brand drug, UnitedHealth Pharmaceutical Solutions may place the generic in Tier 2 and move the generic to Tier 1 once the price decreases during a six-month exclusivity arrangement this period.