Retrieving Information on HMOs
Our Dogged Research Pays Off
Welcome to the 16th annual agents’ guide to managed care. Each year California Broker surveys health maintenance organizations (HMOs) in the state with direct questions about their plans. We then present the answers to such questions here for you – the professional agent or broker. We hope that this valuable information will help you serve your savvy healthcare clients better.
1. Do you guarantee a time limit on getting referral/treatment routine, urgent, emergency? If not, how many days does it take?
Aetna: Our internal policy is five days for routine, two days for urgent pre-certification, and no referral is required for urgent or emergency care.
Anthem Blue Cross: Authorization by the PMG/IPA requires a decision in the following time frames: 72 hours for an urgent request; 14 calendar days for specialty referrals; and no prior authorization is required for emergency services.
Blue Shield of California: Our appointment wait time standards are as follows:
• Preventive care (annual physical, annual GYN exam): within 30 calendar days
• Non-acute and routine care with personal physician: within 7 calendar days
• Non-acute or routine care with a specialist: within 14 calendar days
• Urgent care appointment: within 24 hours
•Emergency care (acute, life-threatening): immediately.
Cigna: While we don’t guarantee a time limit on getting appointments or referrals, we do have appointment accessibility standards and we monitor performance against these standards annually. Performance is monitored by analyzing several questions on the annual CAHPS (customer satisfaction) survey and reviewing customer concerns regarding appointment access.
Health Net of CA: For urgent pre-service requests, a decision must be made in a timely fashion appropriate for the member’s condition, not to exceed 72 hours after receipt of the request. The practitioner needs to be notified within 24 hours of the decision, not to exceed 72 hours of receipt of the request (for approvals and denials). For non-urgent, elective or routine pre-service referrals, the decision is made within five days. The member is to be notified within 72 hours of the request (for approval decisions). For standing referrals, a decision must be made in a timely fashion appropriate for the member’s condition, not to exceed three business days from receipt of the request.
Kaiser Permanente: While we can’t guarantee the wait times for all types of appointments, we do offer an array of options for determining the type of care that best suits a member’s needs and schedule appointments accordingly. Wait times for routine and urgent care usually depends on the member’s medical history and the urgency of their condition and they may be able to make urgent or routine same day appointments.
Our guidelines for appointments are as follows:
•Urgent Care: 0-2 days (this includes urgent / same day / walk-in / acute care visits)
•Specialist consultation: 14 days (physician- or member-initiated appointments for initial consultations with a specialist)
•Routine appointments: 30 days (requests for specific medical conditions, for tests and test results with a doctor, or for regular health maintenance and preventive care)
PacifiCare: Optimally, the specialist referral process should take less than 30 days from referral to appointment. We monitor this standard annually using the Consumer Assessment of Health Plans Survey (CAHPS) member satisfaction survey. We adjust our goals by market depending upon past performance and national percentile benchmarks. Our standards are as follows: Routine Appointment <30 days, specialist appointment <30 calendar days, and urgent care <24 hours. We also have the Express Referrals program that streamlines the referral process. A primary care physician (PCP) in a participating Express Referrals provider group may refer a member to a specialist in one of many specialties in their group without prior authorization from the group’s utilization review committee. Members pay their normal office visit co-payment for a referral to a specialist.
2.Do you have any conditions/diagnoses/symptoms that are referred automatically?
Anthem Blue Cross: The PCP, PMG/IPA determines automatic referrals for conditions, diagnoses, and symptoms. Members can self-refer to a contracted OB/GYN provider. Provider groups can participate in the Speedy Referral and Direct Access programs for referral of certain types of specialties for initial consultation and evaluation. There are also requirements for standing specialist referrals for chronic conditions and HIV/AIDS diagnoses.
Blue Shield of California: No; however, Blue Shield requires that our contracted IPAs and medical groups employ a standard referral processing guideline of 24 hours from the time the necessary information is received.
Our Access+ HMO plan has been designed to ensure members have a great deal of flexibility in accessing care inside the HMO network. Each Access+ HMO member chooses a primary care physician from an extensive network of general and family practitioners, internists, pediatricians, and OB/GYNs. We also ask our HMO physicians to refer members to specialists within their IPA or medical group; since we fully capitate all professional services, in-network referrals help control cost and utilization.
Health Net of CA: Health Net delegates medical management activities to participating physician groups (PPGs). Each PPG has its pre-certification requirements and systems, which may include direct access to specialty care. For members who are not delegated to a PPG for management, such as Health Net’s Direct Network HMO membership or other fee-for-service membership, authorization for specialty consultations is not required.
Members with a chronic condition or disease that requires continuing specialized medical care are eligible for a standing referral to a specialist. A standing referral allows extended access to a specialist for members who have life-threatening, degenerative or disabling conditions.
Kaiser Permanente: Members identified who are with specific chronic or high-risk conditions, diagnoses, or symptoms are automatically referred for enrollment in whichever care management programs are appropriate. Participation in these programs is completely voluntary and if a member chooses not to participate, they may easily opt-out, though less than 1% chose to do so. Members also have direct access to all primary care services and can easily self-refer to specialty care in the Obstetrics/Gynecology, Optometry, Psychiatry, and Chemical Dependency/Addiction Medicine Departments. At some facilities, members may also self-refer for mammograms and Ophthalmology and Dermatology Department services.
3. Can a pregnant member go directly to a gynecologist without waiting for approval?
Anthem Blue Cross: Yes, pregnant members can self-refer to an obstetrician/gynecologist in the PMG/IPA.
Blue Shield of California: Yes, female members may self-refer to an OB/GYN in their personal physician’s Medical Group or IPA for an annual routine well-woman examination. Alternatively, if an IPA or medical group contracts with an OB/GYN as a network primary care physician, female members may select the OB/GYN as a primary care physician, as well.
Health Net of CA: Yes.
Kaiser Permanente: Yes, members have direct access to all primary care services and may self-refer for many types of specialty care including Obstetrics/Gynecology.
4. Do you have self-referral to a gynecologist for an annual well-woman exam?
Anthem Blue Cross: Yes
Blue Shield of California: Yes.
Health Net of CA: Yes.
Kaiser Permanente: Yes, to make access to Obstetrics/Gynecology services as convenient as possible, women can self-refer for Ob/Gyn appointments without the need for approval from their PCP. Routine Ob/Gyn care often includes basic health maintenance counseling and screening such as recommendations and reminders for immunizations, managing cholesterol, smoking cessation, and mammograms.
5. Can a member with severe back pain get an appointment with an orthopedist immediately?
Aetna: The PCP determines this.
Anthem Blue Cross: The PMG/IPA/PCP will evaluate the member’s conditions and symptoms and assess the need for a specialist visit following the group’s process for referrals as necessary.
Blue Shield of California: Yes, Blue Shield developed Access+ Specialist for those times when HMO members want direct access to a specialist or physician other than their personal physician. For a slightly higher fixed co-payment, members can go directly to a specialist or primary care physician in the same medical group or IPA as their personal physician without a referral. To use the Access+ Specialist option, members simply call the physician they wish to see to schedule an appointment. Members can also choose to go through their personal physician to request a specialty referral and pay their usual office visit co-payment.
Cigna: Yes, customers should consult their primary care physician who can contact an orthopedist or other specialist (neurosurgeon, neurologist) to arrange for an immediate appointment. At the direction of the physician, a customer can also be enrolled in Cigna’s chronic condition management program for lower back pain. A registered nurse helps coordinate timely care.
Health Net of CA: Yes, as an emergency.
Kaiser Permanente: We don’t require patients to see the PCP first to triage the patient, but because most back pain can be managed best by the PCP in the context of the person’s whole health. We care for people, not just problems. The PCP most of the time can diagnose and treat the causes of back pain, while ensuring the treatment does not impact a person’s other medical conditions. When pain does not follow the expected course, or is unusual in presentation, our orthopedists are available for immediate consultation. It’s coordinated, complete and convenient care.
PacifiCare: Yes, with a PCP referral.
6. How long does it take to get an MRI or equivalent test when a lump is found in a member’s breast or uterus?
Aetna: The PCP determines this.
Anthem Blue Cross: The PMG/IPA/PCP determines whether to make an urgent referral for diagnostic tests and whether an authorization is needed. When a member faces an imminent and serious threat to her health, this is an emergency situation in which according to the Prudent Lay Person Rule the member is instructed to seek care in an ER. For urgent non-emergent situations it is 72 hours.
Blue Shield of California: Seven days or immediately in an emergency.
Cigna: The customer’s physician determines the exact time frame. But, an appointment can be made immediately if medically necessary.
Health Net of CA: Health Net delegates utilization management activities to medical groups. Therefore, if the member belongs to a delegated participating physician group (PPG), the PPG has its own pre-certification requirements, and an MRI may or may not require pre-certification. If the member does not belong to a delegated PPG and Health Net is responsible for conducting utilization management, MRIs require pre-certification. Health Net processes urgent pre-certification requests within 72 hours of receipt of all information. Requests for elective MRIs are processed within five business days.
Kaiser Permanente: Except for very rare exceptions, the discovery of a lump in a woman’s breast would not prompt the use of magnetic resonance imaging (an MRI) as a diagnostic tool, but would immediately receive a mammogram to better understand the nature of the lump. Similarly, the discovery of an unusual uterine growth would be investigated with more direct methods. In clinical situations that do require other types of imaging – such as ultrasound – can be requested at the discretion of the doctor without the need for additional authorization. Breast MRI may be subject to additional clinical review to ensure that it is only being used in cases where the patient would benefit. Wait times for these tests vary depending on the availability of the testing facilities and the severity of the medical need. In some cases these tests are conducted by facilities contracted by Kaiser Permanente.
7. Can the member get a second opinion outside of the IPA or the medical group?
Aetna: When medically appropriate
Anthem Blue Cross: Yes, members have the right to a second opinion from a qualified healthcare professional in the Anthem network, as long as they have already received one from their PCP or a SCP in the group’s network.
Blue Shield of California: Yes, all Access+ HMO members have the right to get a referral for a second opinion from their personal physician. A physician in the same medical group/IPA generally provides second opinions of care from a personal physician. Any specialist of the same or equivalent specialty in Blue Shield’s HMO network can provide second opinions of care from a specialist. All second opinion consultations outside of an assigned IPA/medical group require Blue Shield authorization.
Health Net of CA: Yes, a member, his or her authorized representative or a provider may request a second opinion for medical, surgical or behavioral health conditions. If the member has an HMO or POS plan and requests a second opinion about care from a Primary Care Physician (PCP), the second opinion should be authorized by the delegated participating physician group (PPG) and provided by another qualified health care professional within the PPG. If the member requests a second opinion about care from a specialist, the member may request a second opinion from any provider of the same or equivalent specialty from within the PPG or IPA. Such specialist referrals within the PPG must be authorized by the PPG. However, if the request is for a specialist outside of the PPG, the referral must be authorized by Health Net.
Kaiser Permanente: Yes, our doctors can refer members to non-plan providers for second opinions when medical expertise relevant to their condition is not available internally. Members must still receive treatment from qualified doctors within our group.
PacifiCare: Members can get a second opinion in accordance with the specifications of the evidence of coverage (EOC) and disclosure form, as summarized below.
A second medical opinion is a reevaluation of your condition or health care treatment by an appropriately qualified provider. This provider must be either a primary care physician or a specialist acting within his or her scope of practice, and must possess the clinical background necessary for examining the illness or condition associated with the request for a second medical opinion. Upon completing the examination, the provider’s opinion is included in a consultation report. Either the patient or the treating participating provider may submit a request for a second medical opinion. For additional information, please refer to evidence of coverage brochure.
8. Where are decisions made about specialist referrals, testing, treatment, surgery, and hospitalization?
Aetna: For our delegated groups, the PCP makes decisions with their PMG/IPA. The health plan makes this determination for non-delegated groups.
Anthem Blue Cross: Delegated PMGs/IPAs make decisions about utilization management approval and denial. The provider group’s medical director makes all denial decisions.
Blue Shield of California: These types of decisions are made by our contracted IPA/medical groups, and involve Blue Shield if there is a question about appropriateness, or if a member is dissatisfied.
Cigna: Primary and specialty care physicians make decisions about referrals, testing, and treatment. At times, they can coordinate care with their medical groups or IPAs. Hospitalization can require authorization from Cigna.
Health Net of CA: A Health Net member’s participating physician group (PPG) authorizes all treatment, including specialty referrals for testing, treatment, surgery or hospitalization. A member with a chronic condition or disease requiring continuing specialized medical care is eligible for a standing referral to a specialist. A standing referral allows extended access to a specialist for members with life-threatening, degenerative or disabling conditions. The member’s PCP will refer the member to practitioners who have demonstrated expertise in treating a condition or disease involving a complicated treatment regimen requiring ongoing monitoring.
Kaiser Permanente: The member’s primary care physician (PCP) makes the decisions about specialist referrals, testing, treatment, surgery, and hospitalization and does not need authorization to put these decisions into action.
PacifiCare: Our contracted PCPs act as the single point of contact, resource, and consultation for all health services provided to members, including specialty referrals. We believe this approach promotes familiarity with the member’s medical history and permits a single physician to monitor the member through complete episodes of care. These physicians look at the whole medical picture, as opposed to looking at symptoms from a specialist’s point of view. This method reinforces a strong doctor-patient relationship, provides early detection of medical problems, and ensures that medical referrals are appropriate and necessary.
9. What criteria are used to authorize or deny specialist referrals, treatments, or tests?
Aetna: There are a variety of reference tools, including Milliman and many that the plan has developed and copyrighted. A medical director must make all denials for medical necessity. In addition, the plan has adopted an external review process for all fully insured members.
Anthem Blue Cross: Referral processes are delegated to PMGs IPAs. Provider groups are required to use evidence based utilization management criteria, which has been reviewed annually, approved, and adopted for use by their utilization management committee. If Anthem Blue Cross has a medical policy concerning a specific service, test or procedure, the provider groups are required to follow these policies.
Blue Shield of California: When requesting prior authorization from Blue Shield, providers are required to supply the following information:
• Member demographic information (name, date of birth, etc.)
• Provider demographic information (Referring and Referred to)
• Requested service/ procedure, including specific CPT/HCPCS Codes, when available
• Member diagnosis (ICD-9 Code and description)
• Clinical indications necessitating service or referral
• Pertinent medical history and treatment
• Location where service will be performed
Once the information is received, an authorization determination is made by a licensed Blue Shield review nurse, based on medical necessity and through the application of Blue Shield’s approved review criteria and guidelines.
Cigna: Cigna uses Milliman care guidelines. In addition, Cigna continually assesses developing technologies using evidence-based medicine and independent expert opinion to develop coverage positions, which are posted on our website. All medical decisions are based on clinical guidelines. A physician who is knowledgeable in the specialty area makes the decisions
Health Net of CA: Health Net utilizes established written guidelines, such as InterQual Clinical criteria, along with the Health Net Medical Policy Manual, clinical practice guidelines, and the Schedule of Benefits.
Kaiser Permanente: Our doctors are not required to seek authorization for medical services so long as the medical specialty, treatment, or test is available within our plan.
PacifiCare: We require our provider groups to demonstrate the use of appropriate medical management guidelines. We conduct annual reviews of written procedures and consider the following factors for cases that may not meet criteria: age, co-morbidities and complications, response to treatment, the psychosocial situation, and home environment. We use written criteria based on sound clinical evidence and specific procedures for applying the criteria to make utilization decisions. In addition, we apply objective and evidence based criteria and consider individual circumstances and the local delivery system. We require our delegated providers to do the same.
10. Are you monitoring the length of time for referral authorizations? What are you doing to reduce or eliminate delays?
Aetna: Yes, timeliness of decisions is part of a monthly case assessment audit. Turn-around time is monitored by annual audits and quarterly report submissions. Audits and training are used to address performance gaps.
Anthem Blue Cross: PMGs/IPAs must have systems to monitor utilization review activities. Anthem evaluates compliance with standards for regulatory and accrediting timeliness through annual on-site audits. If there are issues with non-compliance, the provider group is educated at the audit and a corrective action plan is requested. A subsequent audit is conducted in 180 days. Anthem also monitors this process through the member grievance process. Anthem and the PMGs/IPAs further evaluate this through provider satisfaction surveys. This survey is administered annually to a random sample of PMG/IPA members. The results are included in a medical group quality score, which is used with other quality metrics as the basis of a quality bonus. Groups with higher scores receive larger bonuses.
Blue Shield of California: Blue Shield’s contracted IPA/medical groups are responsible for the timeliness of decisions about referral authorization. They must comply with our standard of two working days to get all necessary information for a non-urgent referral, one calendar day for urgent referral/treatment, and immediately for emergency care. Blue Shield-delegated oversight consultant nurses perform annual audits to ensure that standards for timeliness are met. An IPA/medical group that does not meet timeliness standards for utilization management must take corrective action.
Cigna: Cigna works closely with physicians and medical groups to expedite referrals and measures customer satisfaction with the referral process on a regular basis.
Health Net of CA: Yes, it is done through access audit reports, member satisfaction surveys, HEDIS indicators, physician profiles, medical group comparison reports and member complaints. Delays are remedied through corrective action.
Kaiser Permanente: Our doctors are not required to seek authorization for member’s medical services. Practically every aspect of a member’s encounter with their health care team will later go through our internal utilization review process. If there are any factors found to be slowing the processing of referrals, steps are taken to remove or change those factors.
PacifiCare: Yes. We perform annual utilization management assessments of delegated providers, including re-audits as needed to ensure provider groups are compliant with our standard. As part of the assessment we review a random selection of up to 30 pre-service denials, 30 concurrent denials and 30 retrospective denials (primarily emergency room services) to allow for a full review of authorization patterns, including those for authorizations for referrals. We review for evidence of the following:
• Physician review of denial for medical appropriateness
• Alternative direction for follow-up care when service is denied
• Timeliness of non-urgent, urgent and concurrent decisions
• Timeliness of notification to the practitioner
• Timeliness of written notification to the member and to the practitioner
• Provision of expedited appeal information for urgent or concurrent denial to the Member and to the practitioner
• Consistent gathering of relevant clinical information to support utilization management decision making
• Notification to practitioner of reviewer availability to discuss decision
• Clear documentation of the reason for denial in the written notification, including specific utilization review criteria or benefit provisions used in the determination
• Inclusion of information about the appeals process in all denial notifications
Additionally, we require provider groups to submit for our approval all changes to their denial notices prior to issuance. The groups must submit utilization data at least quarterly. Where organized provider groups are the predominate system of care, we monitor quarterly provider information related to under-utilization, appeals and grievances to identify trends in delays or denial of service.
11. What are the criteria and processes for getting a referral to a specialist outside of the MG/IPA or plan?
Aetna: Out-of-plan approval is done if one or more of these criteria are met: required services are not available in the group or network; required non-emergency service is available in the plan option, but is not accessible in reasonable timeframe; or the patient is a new member and was receiving services from an out-of-plan provider (reviewed on case-by-case basis).
Anthem Blue Cross: If a needed specialty is not available in a signed PMG/IPA, the provider group arranges for the member to be seen by the appropriate specialist. The Anthem Transition Assistance Unit facilitates second opinions outside of the provider group when the member or provider requests it and a PCP or specialist in the provider group’s network has already seen them.
Blue Shield of California: Personal physicians can refer patients out of the network with the agreement of the IPA/medical group or authorization from Blue Shield. Blue Shield is involved in referrals only when an IPA/medical group wants to refer out-of-network and not be financially responsible. The IPA/medical group would then contact Blue Shield for authorization and request that Blue Shield be financially liable.
Cigna: A primary care physician can request a referral for service outside the medical group or plan when the service is not available. Customers can also contact Cigna directly to arrange a second opinion.
Health Net of CA: Health Net’s contracted participating physician groups (PPGs) are delegated to provide member care, including all specialty referrals. If the PPG does not have a particular kind of specialist with which it contracts, the PPG is still responsible to find a specialist out of its network for the member. The PPG has the financial responsibility for paying the specialist. The PPG may deny the request if it has a particular kind of specialist within its network and a member requests to see a specialist that is outside the PPG’s network. The member has the option to appeal the denial with Health Net.
Kaiser Permanente: If a member needs specialty care not available within our plan the chief of the appropriate specialty service is required to research and approve the referral. With a large group of our specialists practicing in more than 75 specialties and subspecialties, we have been able to minimize outside referrals significantly so that our members do not need to leave the continuity of our in-plan care.
PacifiCare: Our contracted provider network is comprehensive and provides a qualified specialist for every covered benefit. When a service is not available within a member’s provider group, the member receives a referral to a qualified provider or specialist outside the member’s provider group, but contracted with PacifiCare. Either the provider group or we will assess the medical necessity for these requests and authorize care as necessary.
Referrals to non-contracted providers rarely happen, generally only in emergencies or for specialized services not available through a contracted provider; therefore, we do not track this statistic.
12. Which complementary medical disciplines are covered or will be covered
Aetna: Chiro rider. Acupuncture is covered when administered.
Anthem Blue Cross: We cover physical therapy, occupational therapy and outpatient speech therapy. Physical therapy and spinal manipulation may be performed by a licensed chiropractor if in the scope of their license.
Blue Shield of California: Complementary medical disciplines that are available include: substance abuse rider; residential treatment rider; chiropractic care rider; acupuncture services; specialty dental care coverage; discount programs for chiropractic, acupuncture, and massage therapy; and vision supplies and services.
Cigna: When medically necessary, some customers can access acupuncture and chiropractic services as a component of short-term rehabilitation. Other benefit plans offer homeopathic and naturopathic services as riders. In addition, Cigna’s Healthy Rewards program offers customers discounts on alternative/complementary medicine services and other health-related programs for acupuncture, chiropractic services, fitness club membership, hearing care/instruments, laser vision correction, massage therapy, vitamins, herbal supplements, non-prescription medications, and smoking cessation programs, among other programs. More information on the Cigna Healthy Rewards program is available to customers through their personalized online portal on mycigna.com.
Health Net of CA: Health Net offers chiropractic and acupuncture benefits as supplemental benefit riders to its traditional medical benefit plans. The riders may be purchased with the HMO and POS medical plans. They are designed to complement the benefits plans, rather than replace them. The rider is only available to groups. A variety of benefit plan designs are available, including chiropractic only, acupuncture only, and a combination of chiropractic and acupuncture.
Kaiser Permanente: Adding value to group health benefits and helping to reduce health care costs, complementary or alternative medicine (CAM) is part of our holistic approach to improving the health and productivity of our members. American Specialty Health Plans of California, Inc. (ASH) helps members with selecting services from a range of wellness disciplines that include acupuncture, chiropractic care, exercise centers, fitness clubs, massage therapy, and naturopathy.
PacifiCare: PacifiCare of California does not offer alternative medIcine benefits as part of its design. However, all members have access to discounts on alternative medicine benefits through an affinity program. Employer groups can purchase supplemental plans that cover acupuncture and chiropractic benefits.
13. Do you cover blood tests for prostate cancer for non-symptomatic men? If so, at what age?
Aetna: Yes, age 40+.
Anthem Blue Cross: Yes, preventive care guidelines address the appropriate frequency of different testing schedules. We cover prostate cancer screenings including, but not limited to, prostate specific antigen (PSA) testing when medically necessary and consistent with good professional practice, regardless of age.
Blue Shield of California: Yes, regardless of age.
Cigna: Yes, for men over 50 annually or more frequently when medically indicated.
Health Net of CA: Yes, as determined by the PCP.
Kaiser Permanente: Yes, prostate cancer screenings are part of our basic coverage regardless of a man’s age, personal medical history, or the medical history of his family. Early detection of prostate cancer can lead to better outcomes. Members do not need a referral to make an appointment for a prostate cancer screening.
PacifiCare: Yes, these blood tests are covered benefits. The member’s primary care physician determines the necessity of this and all other blood tests.
14. Do you cover mammograms for women with no history of breast cancer?
Aetna: Yes, age 40+.
Anthem Blue Cross: Yes, Anthem Blue Cross covers Preventive Services for our members in accordance with U.S. Preventive Services Task Force Guidelines.
Blue Shield of California: Yes, with a personal physician referral.
Cigna: Yes, for women over 40 annually or more frequently as directed by their physician.
Health Net of CA: Yes, typically, every one to two years from ages 40 to 65+, but the PCP may authorize mammograms at his or her discretion.
Kaiser Permanente: Yes, mammograms are part of our basic coverage regardless of a woman’s personal or family history of breast cancer. Early detection of breast cancer can lead to better outcomes, and having regular cancer screenings is an essential part of preventive medicine. Members do not need a referral to make an appointment for a mammogram.
PacifiCare: Yes. Mammograms for women with no history of breast cancer are covered in accordance with U.S. Preventive Services Task Force Guidelines.
15. Do you have an open drug formulary?
Anthem Blue Cross: Yes, Anthem offers a comprehensive formulary with various benefit designs. Options may include an open formulary, a closed formulary, and a selective or partially closed formulary.
Anthem Blue Cross: Yes, Anthem offers a comprehensive formulary with various benefit designs. Options may include an open formulary, a closed formulary, and a selective or partially closed formulary.
Blue Shield of California: The Blue Shield Drug Formulary is a list of preferred generic and brand name drugs that have been reviewed for safety, efficacy, and bio-equivalency, and are approved by the Federal Food and Drug Administration (FDA). This formulary is developed and maintained by the Blue Shield Pharmacy and Therapeutics (P&T) Committee, which meets on a quarterly basis. The P&T Committee consists of independently licensed physicians and pharmacists in community practice and who are not employed by Blue Shield. A drug prior authorization program is available for selected drugs on the formulary as well as 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.
Blue Shield offers the following types of outpatient prescription drug benefits:
• A closed formulary plan provides coverage for generic drugs, formulary brand-name drugs, and specialty drugs. Non-formulary drugs and most specialty drugs are covered only when prior authorization is approved.
• An incentive formulary plan provides coverage for generic drugs, formulary brand-name drugs, and specialty drugs. Non-formulary drugs are also covered for a higher co-payment. Prior authorization may be required to cover some specialty and certain non-formulary drugs. If coverage for a non-formulary drug requiring prior authorization is approved, the member is responsible for the non-formulary co-payment.
Cigna: We traditionally use a closed drug formulary. However, employers can choose a three-tier or two-tier pharmacy plan if specified and agreed to in the contract.
Health Net of CA: Health Net offers a 3-tier Recommended Drug List, an open formulary that includes most generics on Tier 1, recommended brands on Tier 2 and some generics and brands on Tier 3.
Kaiser Permanente: No. We have found there to be greater medical and financial advantages to our established “closed” formulary program that provides physicians with drug treatments proven to be safe and effective. Our formulary is maintained and regularly updated by our doctors and pharmacists working in tandem with our Drug Information Services Team. The team independently analyzes data and reports on new drugs while doctors and pharmacists in our medical facilities research the effectiveness and safety of each. Whenever therapeutically appropriate, we include the generic forms of medicines in our formulary. We have a formulary compliance rate greater than 98% and approximately 80% of those prescriptions are for generic drugs (versus an industry average of 63%). This yields considerable savings given that generic medicines are about 70% less expensive than their equivalent brand-name versions.
PacifiCare: No, we use several managed formularies at different tier levels, but we do not offer an open formulary.
16. If a closed formulary, what happens if a non-formulary drug is necessary?
Aetna: Not applicable.
Anthem Blue Cross: Non-formulary drugs may be approved upon review through a prior authorization process when a medical need exists.
Blue Shield of California: We have drug prior authorizations for selected formulary, non-formulary, and specialty drugs. The goal is to promote patient safety, appropriate first-line therapy for medical necessity manage use of specialized, high cost or highly addictive or habit forming medications, and help keep the cost of healthcare affordable.
The P&T Committee is responsible for establishing and overseeing drug prior authorization policies and procedures. Coverage criteria are developed under evidence-based medicine principles and current medical literature. Requests for prior authorization are considered for the following reasons:
• The requested drug, dose, and/or quantity are safe and medically necessary for the specified indication
• Formulary alternative(s) have failed or are inappropriate
• Treatment is stable and a change to an alternative may cause immediate harm
• Step therapy requirements have been met
• Relevant clinical information supports the use of the requested medication over formulary alternatives
Physicians may contact Blue Shield pharmacy services directly through a toll-free phone or fax number to request prior authorization. Some drugs may be limited to a maximum quantity and require prior authorization if a given drug’s limit is exceeded. The P&T Committee may also determine that a certain quantity of a given medication may need prior authorization to review for medical appropriateness.
All prior authorization requests are reviewed by pharmacists and pharmacy technicians to determine if the criteria approved by the P&T Committee for the requested drug meets the criteria for an exception. A coverage determination can be made via telephone within minutes if all required information is provided. Urgent prior authorization requests sent via fax are reviewed within three business days, while non-urgent requests are reviewed in no more than five business days. The member’s clinical information must be received by Blue Shield in order to start the review process. If the physician does not submit the required information, Blue Shield will send a follow-up request to the doctor. Delays sometimes occur if the physician does not provide the required information in a timely manner. If a non-formulary drug requiring prior authorization is approved under the closed formulary plan, the member is responsible for the applicable brand co-payment. If a non-formulary drug requiring prior authorization is approved under the incentive formulary plan, the member is responsible for the applicable non-formulary co-payment.
If a request from a physician for a drug that requires prior authorization for medical necessity is denied, a denial letter is mailed to the member. Included with the denial letter is the reason for denial, alternative covered therapy, if appropriate, and the Blue Shield Appeals and Grievance procedures. The physician also receives notification of the denial along with a list of preferred formulary alternatives.
Cigna: The customer or their physician can ask for an exception to get a non-formulary drug. Cigna’s clinical staff reviews the request.
Health Net of CA: N/A
Kaiser Permanente: It is at the medical discretion of our doctors to prescribe any FDA-approved non-formulary drug if its use is in the best medical interest of the member. In these cases, the member would pay their usual cost-sharing fee as opposed to the full price they would be charged for a non-formulary medicine.
PacifiCare: Medically necessary non-formulary medications can be approved through our preauthorization exceptions process.
17. Do you have an experimental/investigative exclusion? If so, how does it work?
Aetna: Yes, for the welfare of our members, experimental or investigational procedures are excluded from our health plans. However, the exclusion would not apply with respect to services or supplies (other than drugs) received in connection with a disease, if we determine that: the disease can be expected to cause death within one year, in the absence of effective treatment; and the care or treatment is effective for that disease or shows promise of being effective for that disease as demonstrated by scientific data. In making this determination we would take into account the results of a review by a panel of independent medical professionals. They would be selected by Aetna. This panel would include professionals who treat the type of disease involved. Also, this exclusion would not apply with respect to drugs that have been granted treatment investigational new drug (IND) or Group c/treatment IND status; are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute; or if we have determined that available scientific evidence demonstrates that the drug is effective or the drug shows promise of being effective for the disease.
Anthem Blue Cross: Yes, however, all treatment decisions are based on medical necessity as it applies to a member’s condition. A request would be denied for a procedure that is considered experimental or investigative for a member whose condition has no unique or discerning characteristics. The member can request an independent medical review if we determine that a requested procedure does not meet our medical necessity criteria. Our Corporate Medical Policy and Technology Assessment Committee evaluate new procedures for incorporation into benefit plans.
Blue Shield of California: Yes, based on the BlueCross BlueShield Association assessment criteria for health outcomes, our formulary does not cover drugs that are considered experimental or investigational or that are not recognized in accordance with generally accepted medical standards.
Cigna: Cigna medical directors make decisions about an experimental/investigational request based on medical literature, expert opinion, and the facts of the specific situation. Coverage positions are developed regularly, which assess emerging technologies. They are posted on our website. Physicians can access Cigna’s online health care professional portal to request reviews of technologies for which coverage positions have not yet been developed. Cigna also uses a formal independent expert review process when appropriate.
Health Net of CA: Health Net does not cover experimental or investigational drugs, devices, procedures, or therapies. The member may request an independent medical review of Health Net’s decision from the California Department of Managed Health Care if Health Net denies or delays coverage for a requested treatment on the basis that it is experimental or investigational. The member may request the review if the following criteria are met:
• The member has a life-threatening or seriously debilitating condition.
• The member’s physician certifies to Health Net that the member has a life-threatening or seriously debilitating condition for which standard therapies have not been effective or are otherwise medically inappropriate.
• There is no more beneficial therapy covered by Health Net.
• The member’s physician certifies that the proposed experimental or investigational therapy is likely to be more beneficial than available standard therapies. As an alternative, the member may submit a request for a therapy that is likely to be more beneficial than available standard therapies based on documentation presented from the medical and scientific evidence.
Kaiser Permanente: Yes, we do. However, in keeping with our commitment to health care research, we take a systematic, evidence-based approach to evaluating and implementing new technologies and new applications of existing technologies. This helps ensure members have timely access to new safe and effective treatments. Our integrated health care delivery system enables the coordination of national and regional processes and provides the operational support and infrastructure needed to quickly and effectively review the broad array of new technologies being developed. At the local level, we’re able to deploy new technologies in pilot programs at our medical centers to obtain real-world data on outcomes and effectiveness.
PacifiCare: Yes. We have an experimental/investigative exclusion. Experimental and/or investigational procedures, items and treatments are not covered unless required by an external, independent review panel as described in Section Eight of the Combined Evidence of Coverage and Disclosure Form. Unless otherwise required by federal or state law, decisions as to whether a particular treatment is experimental or investigational and therefore not a covered benefit are determined by a PacifiCare medical director, or his or her designee. For the purposes of the Combined Evidence of Coverage and Disclosure Form, procedures, studies, tests, drugs or equipment will be considered Experimental and/or Investigational if any of the following criteria/guidelines is met:
• It cannot lawfully be marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of its use or proposed use.
• It is a subject of a current investigation of new drug or new device (IND) application on file with the FDA.
• It is the subject of an ongoing clinical trial (Phase I, II or the research arm of Phase III) as defined in regulations and other official publications issued by the FDA and Department of Health and Human Services (DHHS).
• It is being provided pursuant to a written protocol that describes among its objectives the determination of safety, efficacy, toxicity, maximum tolerated dose or effectiveness in comparison to conventional treatments.
• Other facilities studying substantially the same drug, device, medical treatment or procedures refer to it as experimental or as a research project, a study, an invention, a test, a trial or other words of similar effect.
• The predominant opinion among experts as expressed in published, authoritative medical literature is that usage should be confined to research settings.
• It is not Experimental or Investigational itself pursuant to the above criteria, but would not be Medically Necessary except for its use in conjunction with a drug, device or treatment that is Experimental or Investigational (such as, lab tests or imaging ordered to evaluate the effectiveness of an Experimental therapy).
The sources of information to be relied upon by PacifiCare in determining whether a particular treatment is Experimental or Investigational, and therefore not a covered benefit under this plan, include but are not limited to the following:
• The Member’s medical records.
• The protocol(s) pursuant to which the drug, device, treatment or procedure is to be delivered.
• Any informed consent document the Member, or his or her representative, has executed or will be asked to execute, in order to receive the drug, device, treatment or procedure.
• The published authoritative medical and scientific literature regarding the drug, device, treatment, or procedure.
• Expert medical opinion
• Opinions of other agencies or review organizations, e.g., ECRI Health Technology Assessment Information Services, HAYES New Technology Summaries or MCMC Medical Ombudsman.
• Regulations and other official actions and publications issued by agencies such as the FDA, DHHS and Agency for Health Care Policy and Research AHCPR.
• A Member with a Life Threatening or Seriously Debilitating condition may be entitled to an expedited external, independent review of PacifiCare’s coverage determination regarding Experimental or Investigational therapies as described in Section Eight: Overseeing Your Health Care, Experimental or Investigational Treatment.
18. Which requested procedures are denied most frequently based on experimental investigative or not medically necessary exclusions?
Aetna: This information is not readily available.
Blue Shield of California: The following are the most frequently denied procedures due to the absence of medical necessity or because they are considered experimental/investigational:
• Bariatric surgery – morbid obesity surgery
• Reduction mammoplasty
• Varicose veins
• MRI of the breast
• PET Scan of the breasts
Cigna: This data is not available.
Health Net of CA: The most frequently denied requested procedures are those that are not FDA approved/accepted in the medical community as standard, safe and effective.
Kaiser Permanente: If a plan physician determines that a procedure or service is medically appropriate for a member and its omission would adversely affect the member’s health, then it is considered medically necessary. As a result, we do not consider a medically necessary service or procedure to be an exclusion. Additionally, we do not deny experimental or investigative procedures if they are considered medically necessary and appropriate for the member’s care. All procedures and treatments are reviewed on a case-by-case basis with the determination for care made by the doctor often in consultation with the chiefs of service for their own area of practice and other related areas of practice.
PacifiCare: This information is not available. We do not track the number of most frequently denied investigational/experimental or not medically necessary procedures. We do track appeals and grievances. If a member appealed a denial, and it was due to one of the above reasons, we may be able to provide that procedure; however, it would not apply to our book of business.
19. What is the standard hospitalization for normal and a Caesarean birth?
Aetna: The physician determines it.
Anthem Blue Cross: Four days for Caesarian
Blue Shield of California: The standards are two days for a normal birth and four days for a Caesarean.
Cigna: Typical hospitalization is at least 48 hours for normal vaginal delivery and at least 96 hours for a Caesarean section. But, this can be modified based on the physician’s recommendations
Health Net of CA: Standard hospitalization for normal birth is two days and four days for Caesarean birth.
Kaiser Permanente: According to our 2012 HEDIS scores, in Northern California, the average length of hospital maternity stay for all types of births is 2.41 days and 2.48 days in Southern California. We no longer separately track hospitalization stays for C-section delivers.
PacifiCare: The average length of stay is two days for a normal birth and four days for a Caesarean.
20. How many hospital days are utilized in a year for every thousand HMO members?
Blue Shield of California: For HMO in 2011, our utilization for inpatient days per 1,000 was 168.37.
Cigna: Data not available
Health Net of CA: 2011: 198.5 days per 1,000 HMO members.
Kaiser Permanente: According to our 2012 HEDIS scores, in Northern California, the ratio is 3.32 hospital days per 1,000 members and 3.37 hospital days for Southern Californi
PacifiCare: Our total in-patient utilization in 2010 was 160.92 per 1,000 members.
21. What are your loss ratios, administration/medical?
Blue Shield of California: For IFP plans regulated by the Department of Insurance (DOI), we spent 78.2% on medical and 21.8% on administrative, and we met or exceeded medical loss ratios for our IFP, small group, and large group plans regulated by the Department of Managed Healthcare (DMHC).
Cigna: This information is publicly available through reports we submit to federal and state regulators.
Health Net of CA: In 2011, the medical care ratio was 86.3% and the administrative loss ratio was 10.5%.
Kaiser Permanente: Based on our 2011 DMHC Annual Report, our administrative loss ratio plan wide was 4.33% and our medical loss ratio was 94.63%.
It should be noted that we no longer use the phrase “Medical Loss Ratio,” using instead “Medical Benefit Ratio” (MBR) whenever possible. Along with many others in health care, we feel that MBR is a more accurate and descriptive means of describing this important ratio.
PacifiCare: As of December 31, 2011, our commercial medical loss ratio for PacifiCare of California is 85.4 percent. The administrative ratio is 7 percent.
22. Is your plan NCQA accredited?
Aetna: Yes, Aetna Health of CA Inc is accredited and has got Quality Plus distinction in Care Management, Physician and Hospital Quality.
Anthem Blue Cross: Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company have achieved a Commendable Accreditation rating from NCQA. NCQA awards a status of Commendable to organizations with well-established programs for service and clinical quality that meet rigorous requirements for consumer protection and quality improvement.
Blue Shield of California: Yes, the National Committee for Quality Assurance awarded Blue Shield its highest rating of Excellent Accreditation for Commercial HMO/POS products.
Cigna: Yes, our HMO plan has received NCQA’s highest accreditation level of excellent. In addition, Cigna has earned NCQA’s Physician and Hospital Quality (PHQ) Certification. These standards assess how well a plan provides individuals with information about physicians and hospitals in its network to help them make informed health care decisions. Cigna has also earned an NCQA quality rating for its health and wellness programs, and all four of our behavioral health care centers nationwide have earned full accreditation from NCQA.
Health Net of CA: Yes, Commercial HMO, PPO and POS lines of business have received the “Commendable” accreditation status from the National Committee for Quality Assurance (NCQA), and Health Net’s Medicare HMO received the excellent accreditation status.
Kaiser Permanente: Yes, we are. As of the third quarter of 2012, all of our service areas across the country have NCQA ratings of excellent, their highest possible rating, for our HMO and Medicare lines.
PacifiCare: Yes. PacifiCare of California maintains an excellent accreditation rating.
22. Is your plan NCQA accredited?
Aetna: Yes, Aetna Health of CA Inc is accredited and has gotten a Quality Plus distinction in Care Management, Physician and Hospital Quality.
Anthem Blue Cross: Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company have achieved a Commendable Accreditation rating from NCQA. NCQA awards a status of Commendable to organizations with well-established programs for service and clinical quality that meet rigorous requirements for consumer protection and quality improvement.
Cigna: Yes, our HMO plan has received NCQA’s highest accreditation level of “Excellent.” In addition, Cigna has earned NCQA’s Physician and Hospital Quality (PHQ) Certification. These standards assess how well a plan provides individuals with information about physicians and hospitals in its network to help them make informed health care decisions. Cigna has also earned an NCQA quality rating for its health and wellness programs, and all four of our behavioral health care centers nationwide have earned full accreditation from NCQA.
Health Net of CA: Yes, commercial HMO, PPO, and POS lines of business have received the Commendable accreditation status from the National Committee for Quality Assurance (NCQA), and Health Net’s Medicare HMO received the Excellent accreditation status.
Kaiser Permanente: Yes, we are. As of the third quarter of 2012, all of our service areas across the country have NCQA ratings of Excellent for our HMO and Medicare lines, which is their highest possible rating.
PacifiCare: Yes, PacifiCare of California maintains an excellent accreditation rating.
23. What is your ratio of PCPs vs. specialists?
Anthem Blue Cross: 1:2
Cigna: Data not available
Health Net of CA: 2012: 1 to 3.0 specialists.
Kaiser Permanente: The statewide ratio in California of primary care physicians to specialists is approximately 1 PCP to 1.8 Specialists. Primary Care includes General Practice, Family Medicine, general Internal Medicine, and general Pediatrics. Specialty care includes OB/Gyn.
PacifiCare: As of June 30, 2011, our ratio of PCPs to specialists is 1 to 3.1.
24. What is your ratio of members to PCPs?
Health Net of CA: 2012: 66.0 members to 1 PCP.
Kaiser Permanente: We don’t ordinarily release information on our member-to-doctor ratio. Physician and care provider totals are based on current and projected membership numbers. Providing members with access to physicians is essential to delivering high-quality care, and to ensure it, we have developed access standards to help meet our members’ needs. Monitored continuously, these standards are used to help determine the number of physicians and care providers needed as well as the location and size of our medical facilities. As dictated by membership growth and increased volume of patient visits, additional primary care physicians and specialists are added to our professional roster as needed.
PacifiCare: As of June 30, 2011, our ratio of members to PCPs is 131 to 1.
25. Does your contract include binding arbitration?
Anthem Blue Cross: Yes, our HMO contracts include binding arbitration language.
Health Net of CA: Yes.
Kaiser Permanente: Yes, we use binding arbitration to resolve disputes. We find arbitration to be more attuned to the discussion of sensitive matters such as medical and more appropriate for the resolution of disputes with persons who, in many cases, continue to be Health Plan members. Other than Small Claims Court cases, claims subject to a Medicare appeal procedure, or ERISA-regulated benefit claims, arbitration is used to resolve disputes such as those for premises or professional liability matters, including claims alleging medical malpractice.
PacifiCare: Yes, our contract includes binding arbitration.
26. How often can members change their PCP at will?
Aetna: There is no limit.
Anthem Blue Cross: Our HMO member may change to another PCP without restriction. Members may change to a PCP at another PMG/IPA by completing a membership change form and submitting it to their employer, or by calling customer service directly. Because we are concerned with continuity of care, members cannot switch medical groups during a “course of treatment;” however, based on individual need, changes to a PMG assignment can be made effective the first day of the following month after the request is made. Please note: members may only change to a medical group that is within 30 miles of their residence or work address.
Cigna: We encourage our customers to stay with one primary care physician to ensure more effective care management. We also recommend that people not change their doctor while in the middle of care to the extent possible. Customers may request a PCP change once per quarter and/or if their residence or work location changes. Additionally, if a customer has a concern about care quality, he or she can change PCPs after notifying us of the concern.
Health Net of CA: Members may change PCPs within a physician group or from one physician group to another once per month.
Kaiser Permanente: Members can change their PCP at any time and as often as they like. Members can change their PCP online at kp.org, by calling the Physician Selection Service or Appointment/Advice line at their local medical facility, or through the Member Services Department at their local medical facility. Studies have shown that a positive, ongoing relationship with their PCP helps to improve health outcomes and member satisfaction, so we encourage members to choose a PCP who’s right for them and provide the support and systems to make it easy for them to do so.
PacifiCare: Members may request a change of individual provider or provider group at any time, for any reason. Requests received between the first and the 15th of a month take effect on the first day of the next month. Requests received between the 16th and the end of the month take effect on the first day of the second month. Members must select participating providers accepting new patients within 30 miles of their home or work and can identify which providers are accepting new patients by calling our Customer Service department, looking in our provider directory or visiting our Web site.
27. Do you offer a performance guaranty, such as employees will be on the computer by a certain date or have ID cards by a certain date, for example?
Aetna: Yes, we can offer standard performance guarantees to our clients; guarantees may also be customized on a case-by-case basis.
Anthem Blue Cross: Yes, we can offer standard performance guarantees to our clients; guarantees may also be customized on a case-by-case basis, based on client size thresholds.
Cigna: Yes, in most instances, we can work with a company to develop appropriate performance guarantees.
Health Net of CA: Yes, Health Net of California negotiates performance guarantees with clients based on our Corporate Performance Standards, which are derived from marketplace expectations balanced with internal administrative capabilities. An employer group must have and maintain after the plan’s effective date a minimum of 1,000 subscribers in a Health Net of California plan to qualify for performance guarantee consideration. Once the client has been deemed eligible for performance guarantee consideration, Health Net is willing to discuss and negotiate the specifics of a performance guarantee package including appropriate target levels for standards of concern.
Health Net of California provides customers with specific performance guarantees in the area of claims administration, including processing turnaround time (measured within 30 calendar days) and transactional accuracy (i.e. financial, payment, coding and overall). In addition to claims administration, Health Net of California offers corporate performance standards that span all aspects of our business in the areas of: implementation (i.e., identification card production, timeliness and accuracy), member services, provider network, medical management, member satisfaction, customer reporting, and HEDIS reporting. All products can potentially be covered, with the exception of our Medicare HMO due to strict guidelines already in place by the Centers for Medicare & Medicaid Services (CMS). All performance standards are evaluated on an annual basis for compliance. An annual performance standard report, including the calculation of any applicable penalties, is produced approximately 90 days after the close of the plan year.
Kaiser Permanente: Yes, our performance guarantees are made on a group-by-group basis. Our target is for new members to be in our data base within 24 hours of our receiving their information and to have new or replacement ID cards delivered within 7 to 10 work days 90 percent of the time.
PacifiCare: We may agree to performance guarantees upon approval and if the client meets our standard requirements for enterprise-wide performance standards. However, we typically do not agree to performance guarantees for fully insured groups.
28. When a member moves out of state, is any transition coverage available?
Aetna: We have HMO plans in many states; a member might be eligible for coverage in another Aetna HMO service area. Customers may also offer out-of-area plans which provide PPO coverage if members are outside an HMO service area.
Anthem Blue Cross: The utilization management process is delegated to the PMGs/IPAs for our HMO product. They must have established review mechanisms, such as evidenced-based decision criteria and guidelines, which align with accepted medical practice. PMGs/IPAs maintain structured processes for referral management, pre-service, concurrent, and post-service review. Routine and active oversight is conducted to ensure compliance with regulatory and accrediting agency standards.
Cigna: Yes, if we offer similar coverage to the account in that state.
Health Net of CA: Yes, through PPO, POS, and indemnity lines of business.
PacifiCare: If a member moves out of the state permanently, they are no longer in our service area and would be terminated from the plan. Members must live within our service area to be eligible for continued enrollment in our health plan. Members traveling outside their PacifiCare service area for a limited time are covered for emergency services. This also applies to out-of-area student dependents who must also maintain a permanent residence within the service area in order to enroll in the health the plan.
29. Describe the utilization process.
Aetna: Information is gathered from the physician and patient. The nurse consultant or physician reviewer and the attending physician discuss whether a test or treatment is appropriate. The physician reviewer can recommend alternative treatments and further testing. Protocol is reviewed annually. The consulting specialists, who are most familiar with procedure, review and approve any changes.
Anthem Blue Cross: The utilization management process is delegated to the PMGs/IPAs for our HMO product. They must have established review mechanisms, such as evidenced-based decision criteria and guidelines, which align with accepted medical practice. PMGs/IPAs maintain processes for referral management, pre-service, concurrent, and post-service review. Routine and active oversight is conducted to ensure compliance with regulatory and accrediting agency standards.
Cigna: Cigna physicians and nurses perform utilization management for inpatients in coordination with medical groups. To help ensure appropriate care and facilitate discharge planning, Cigna reviews medical records for hospitalized customers and consults with physicians via nurses located on-site at hospitals or by phone. Utilization review for most outpatient services is delegated to IPAs/Medical Groups. Cigna reviews inpatient procedures and hospitalizations, outpatient surgical procedures performed in a facility, transplants, and investigational therapies using Milliman Care Guidelines and Cigna Coverage Positions. Cigna utilization nurses (RNs) also conduct case management. Most outpatient referrals for specialists and procedures do not require prior authorization as long as the primary care physician requests them. However, Cigna performs utilization review of select outpatient services when there is demonstrated value.
Health Net of CA: Health Net provides a multi-dimensional utilization/case management (UM/CM) program to direct and monitor health care services. It involves pre-service, concurrent, and post-service evaluation of the utilization of services provided to members. The UM/CM program is structured to ensure that qualified health professionals make medical decisions using written criteria based on sound clinical evidence without undue influence of Health Net management or concerns for the plan’s fiscal performance.
Kaiser Permanente: Our physicians plan member care and work collaboratively with their peers to ensure appropriate treatment plans and use of resources. Utilization Management staff are available to support doctors in the management of member’s health care needs throughout our continuum of care and provide a variety of services such as discharge planning, utilization review, and care management.
The majority of utilization management, including reviews, is conducted internally as part of our integrated system of health care delivery. Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals, and the Permanente Medical Groups work in partnership to provide and coordinate medical management and review for our Health Plan members.
PacifiCare: We use industry-leading medical management programs to ensure that each enrollee receives the appropriate care necessary and that we control unnecessary health care costs for our clients. Our medical management programs focus on reducing variation, improving the quality of care provided and ensuring cost effectiveness. We base medical decisions on scientific evidence and all of our medical management services include physician guidance and input. We developed online, science-based and objective utilization management criteria as well as technology-based clinical decision support systems related to case, utilization and disease management.
30. Describe the Case Management Process.
Aetna: The following are some ways in which cases are identified: through the PCP or pharmacy, during certification reviews, during PMG/utilization management case reviews, and through other internal reporting and sources including member services, claims, and specialty programs. The case manager coordinates services for members who have multiple and complex needs. The case manager works with the PCP and the member to develop a care plan identifying services, frequency, duration, and goals. A team approach includes the PCP, specialist, member, family, caregiver, healthcare provider community, and internal programs to coordinate care, with a focus on member education and maximizing quality outcomes.
Anthem Blue Cross: The PMGs/IPAs perform in-area case management functions. Anthem case managers support PMGs/IPAs for members with exceptional needs or complex medical conditions. When appropriate, they manage out-of-area emergency admissions and help with transfers to in-area care. They also facilitate communication between healthcare providers and ensure that appropriate follow-up care is arranged with the PMG/IPA.
Cigna: Customers are identified via real-time and claims-based predictive modeling tools, along with referrals from physicians and medical groups, Cigna clinical staff, and employers. Case managers collaborate with physicians, medical group case managers, customers, and employers to facilitate ongoing treatment plans and support the primary care physician. Case managers monitor short-term and long-term goals for inpatient and outpatient care. They document and evaluate the effectiveness of the services provided. In addition to traditional complex and catastrophic case management, Cigna has a number of specialty case management units. They are staffed with RNs who are dedicated to areas such as high-risk maternity, neonatal intensive care, oncology, obesity, and transplant. Cigna has an extensive suite of chronic condition management programs, including those for obesity complications and depression. Cigna also offers telephonic and online access to wellness information, care management services, and health coaching programs.
Health Net of CA: Health Net and its delegates provide case management/disease management programs to deliver individualized assistance to members in all lines of business who are experiencing complex, acute, or catastrophic illnesses or have exceptional needs. Health Net’s approach to utilization management extends far beyond traditional oversight. Health Net provides outreach to members with chronic conditions such as asthma, diabetes, COPD, heart failure, coronary heart disease, preference-sensitive conditions, and identification of members with cardio-metabolic risk; Health Net also uses population-based risk stratification and predictive modeling; and partners with physician groups to improve performance.
Kaiser Permanente: Members in need of case management are identified through clinical and utilization data, pharmacy records, hospital and outpatient visits, and laboratory results. Members can also self-refer to case management or be referred by a doctor or family member. Our case managers are master’s-level clinicians or registered nurses who work directly with a member and their health care team to plan care and provide intensive coordination of services, including inpatient hospitalizations, transitional care, home care, skilled nursing, medications, referrals to community resources, and outpatient care. Using an interdisciplinary approach, case managers help to ensure continuity of care including utilization management, transfer coordination, discharge planning, and obtaining all authorizations or approvals as needed for outside services for members and their families. They’re also responsible for identifying quality-of-care problems and monitoring utilization issues.
PacifiCare: We designed our case management program to identify, intervene, coordinate and monitor care plans that provide high quality and cost-effective care for covered persons with catastrophic and complex health care needs. Our case managers facilitate communication and coordination of care between all parties on the health care team. This program involves the patient and family in the decision making process to minimize fragmentation in the delivery of health care. The case manager assesses the needs of the patient and educates them and the health care delivery team about case management, community resources, insurance benefits, cost factors and issues in all related topics so that informed decisions can be made. The case manager is the link between the patient, the providers, the payer and community.
31. Can the PCP participate in profits or losses in any way at the plan level or the participating medical group/IPA level?
Aetna: In California, Aetna participates in the IHA/7 health plan program of pay-for-performance. PCPs can participate in that IPA pay-for-performance bonus.
Anthem Blue Cross: Anthem established one of the first pay for performance programs in California. We encourage our PMGs and IPAs to maintain a physician rating system with appropriate rewards for quality medical care. Physicians will get increased compensation for quality care. Our contract is not with the individual PCP. It is with the PMG/IPA with which we have risk sharing arrangements. Through a risk sharing arrangement we share cost savings for in-patient, emergency room, outpatient services and generic prescription rates with the PMG/IPA. The medical group/IPA may get incentives up to 50% of savings depending on the amount of costs saved.
Cigna: The primary care physician does not participate in plan profits or losses in any way. The relationship between the PMG/IPA and the PCP is based on the contract between the two parties.
Health Net of CA: In 1993, Health Net of California introduced the Quality Care Improvement Program (QCIP). At the time, it based medical group compensation on member satisfaction scores. This program was enhanced in 1998 by incorporating quality-of-care outcomes into the compensation formula. In addition to contracted compensation, QCIP evaluates medical groups based on member satisfaction rates, quality-of-care outcomes, and collaboration. Additionally, Health Net evaluates medical groups’ cost performance measures. Similar to most health plans, shared-risk pools are incorporated with the compensation details for each Participating Physician Group (PPG). When the budget is established for the PPG’s medical services and hospital care, the PPG shares in the savings if costs do not consume the budget. Conversely, the group shares in paying for additional costs if the cost of care exceeds the budgeted amount. However, at no time does Health Net favor cost performance over quality. Recently, other California health plans have added programs similar to Health Net’s QCIP.
Kaiser Permanente: All of our physicians are eligible for incentive payments based on their own performance as measured by the results of member satisfaction surveys, the quality of care provided to members as perceived by their peers, administrative goals such as their adoption of techniques to allow them to provide better care, and by the overall performance of our organization. Incentive payments make up a very small part of our physician’s annual renumeration.
PacifiCare: We use a Quality Incentive Program (QIP) through which medical groups and IPAs can earn additional revenue by improving and maintaining patient safety, patient satisfaction, and quality of care. The QIP measures key indicators of quality in hospitals and medical groups based on the groups’ service and clinical quality. The QIP rewards medical groups and IPAs for attaining the required performance. The better a provider group performs in these categories the more QIP dollars they can earn. In 2003 the QIP was funded with $14 million and rewarded seventy-fifth percentile performers in 16 measures. Over 140 medical groups received rewards in 2003 and we achieved average mean score improvements in 12 of the 16 measures. In turn, average improvement for these measures increased 30 percent, a remarkable achievement. In 2004 our QIP expanded to include 20 measures, of which 17 improved an average of 20 percent. The incentive pool was $18 million in 2004 and is $65 million in 2005. In 2006, we paid out more than $96 million.
32. How are premiums and risk shared among the plan, MG/IPA
Aetna: The premium is not shared with providers. In California, we have some IPA risk share arrangements and an IPA or medical group share in savings if a target budget is not exceeded.
Anthem Blue Cross: Anthem has a capitated arrangement with the PMG/IPAs, which are responsible for payment of professional services. We promote clinical efficiency through a program of shared savings between the PMG/IPA and Anthem for expenditures related to capitated professional services. We have a program to share the savings for non-capitated inpatient care, outpatient care, and generic pharmacy prescription. Anthem is the largest sponsor of the IHA performance measures in the state and has the second largest pay for performance program in world behind only the United Kingdom’s.
Cigna: Most medical group and IPA arrangements are capitated. Capitation does not contain provisions for withhold payments. For example, a lump sum is withheld and distributed later if the provider meets certain utilization targets. The standard contract is shared risk with Cigna retaining risk for inpatient facility charges.
Health Net of CA: The majority of HMO physician services are paid under a pre-paid capitation payment to the contracted participating physician group (PPG). The PPG, in turn, reimburses the physician directly for services.
Kaiser Permanente: Kaiser Foundation Health Plan (KFHP) contracts with the Permanente Medical Group (TPMG) in Northern California, and the Southern California Permanente Medical Group (SCPMG) to provide comprehensive medical services to KFHP members. The contractual arrangements are reimbursed at negotiated capitation rates as set forth in itemized budgets. The medical groups are reimbursed at negotiated capitation rates. A small portion is paid on an actual cost basis for specific items. Subject to limits on risk sharing, the medical groups are fully at risk for the capitated portion. They share the risk equally with the health plan for the actual cost portion.
PacifiCare: Currently all of our contracted medical groups and independent physician associations (IPA) participate in a risk-sharing arrangement. In addition, we contract with several networks of individual physicians in rural areas that do not participate in risk sharing. We contract with multi-specialty medical groups and independent physician associations (IPA) primarily through split or professional capitation contracts. Both contracts provide a monthly age, gender and benefit adjusted capitation.
33. What happens when a member provider bills a participant for services? How do you deal with the fact that the participant is at financial or credit risk when the dispute is between the provider and the plan?
Aetna: Participating providers are required to accept payment (plus member’s co-payment) as payment in full. Balance billing is not permitted.
Anthem Blue Cross: Our first priority is to protect our membership from inappropriate billing. Our HMO providers are contractually required to refrain from billing members except for co-payments. If a participating provider bills a member, it is brought to the attention of the PMG/IPA liaison and the PMG is directed to pay the claim. If the PMG does not pay the authorized claim in 45 days from receipt, the plan pays the bill and debits the PMGs capitation payment for the ensuing period.
Cigna: First, it’s important for customers to know that using hospitals and doctors who are a part of the network protects them from balance billing because in-network health care professionals agree as part of their contracts not to bill individuals for amounts beyond what their plan pays. If Cigna receives a complaint from a customer who has received such a bill, we work with the contracted health care professional to educate him/her on the terms of the contract. We also require that the health care professional stop billing the customer. Our customer service representatives are available by phone 24 hours a day, seven days a week to assist our customers with any questions about a claim or bill they have received. We also work with our health care professional partners to make the claim payment process as efficient and accurate as possible.
Health Net of CA: Health Net’s HMO contracts have a hold-harmless clause that prohibits medical groups from billing or collecting from members, except for standard co-payments and non-covered services. In the event a provider balance bills a member, Health Net removes the member from the situation and resolves the matter directly with the provider.
Kaiser Permanente: As a precipitated group practice HMO, we do not bill members for individual services. Kaiser Foundation Health Plan (KFHP) contracts with The Permanente Medical Group (TPMG) in Northern California and the Southern California Permanente Medical Group (SCPMG) to provide comprehensive medical services exclusively to KFHP members. Our providers are reimbursed at negotiated capitation rates so no disputes between the providers and the health plan would put members at financial or credit risk.
34. Do you have a nurse or RN on call 24 hours for questions at the plan level? At the PMG/IPA level?
Aetna: Yes, the Informed Health nurse-line is available to members. Network doctors are required to be available 24 hours a day.
Anthem Blue Cross: Anthem has a 24/7 Nurse Advice Line that is available for members. The member’s PCP or other covering practitioner is available to the member after hours and on the weekends if needed for non- emergent issues. The member may access the emergency room as needed for emergencies.
Cigna: Yes, CIGNA offers a 24-hour health information line staffed with nurses.
Health Net of CA: Health Net’s Nurse 24 line offers support for both members and physicians. Members can obtain support on a 24/7 basis from experienced clinicians. The clinicians are nurses licensed in the member’s state and are ready to provide support for members for health and wellness concerns, decisions, and questions. Physicians can make referrals on a 24/7 basis via Health Net’s provider portal. Physicians can also receive support, make referrals, and get information during business hours by calling 800-893-5597 and pressing option #2.
Kaiser Permanente: Yes. Members can easily reach our specially trained advice nurses by telephone 24 hours a day, seven days a week. Using approved protocols, our advice nurses perform comprehensive triage to help members assess their symptoms and determine the level of care they need, such as self-care, an appointment with their PCP, a visit to urgent care or emergency department, or a call to 911. When certain criteria are met, our advice nurses can also arrange for “telephone treatment” where members can get needed prescriptions for certain common conditions-including urinary tract infections, conjunctivitis, and sinusitis-without having to make an unnecessary visit to urgent care or their doctor’s office. Our nurse advice service is fully integrated into our system of care, not a separate carved-out service. This integration gives our advice nurses instant access to information in our members’ electronic medical records, which enables them to provide more individualized assistance to our members. It also makes it easy for an advice nurse to send a message to the member’s personal physician about the call and its outcome and, when appropriate, facilitate continuity of care and the provision of any needed follow-up services.
PacifiCare: Yes, at the plan level there is a 24-hour nurse line and medical audio library. Members can listen to pre-recorded health topics or speak with a licensed registered nurse. The nurse line staff can provide general counseling and triage recommendations. At the PMG/IPA level, PCPs are contractually required to provide after hours call coverage.
35. Do you include treatment by a physician’s assistant (PA) or nurse practitioner (NP), rather than by a physician? Do you guarantee a physician exam for adults when requested by the patient?
Aetna: Yes, but physicians using PAs or NPs are required to oversee services. Members have a right to request a PCP.
Anthem Blue Cross: Treatment by a physician’s assistant or nurse practitioner is included in our coverage, if available at the PMG/IPA level. Members always have the right to see a physician, rather than a PA or NP, if desired.
Cigna: Yes, when appropriate, physician’s assistants or nurse practitioners can work together with a physician. Yes, customers can request an annual physical examination.
Health Net of CA: As long as a physician’s assistant or nurse practitioner is under the physician’s guidance and providing treatments under the scope of his or her license, treatment is covered. Members have the right to have exams conducted by physicians rather than physician assistants or nurse practitioners.
Kaiser Permanente: Yes, members have the option to request treatment by a PCP, physician’s assistant (PA), or nurse practitioner (NP) when they are available and when medically appropriate. PAs and NPs are licensed health care practitioners who work in a variety of specialties, including pediatrics, obstetrics/gynecology, cardiology, pulmonary medicine, and gastroenterology.
PacifiCare: Yes, treatments by Physician’s Assistant (PA) and Nurse Practitioner (NP) are included. However, the member has the right to request a physician examination.
36. Can doctors be terminated for over utilizing services?
Aetna: When inappropriate use of services, under/overutilization or quality issues are identified, the provider is counseled; an action plan for improvement is developed; and service activity is monitored. The provider could be terminated if performance does not improve.
Anthem Blue Cross: Anthem contracts with the PMGs/IPAs, which contract with the individual providers. If a physician does not correct inappropriate utilization after counseling, they may be subject to discipline, including possible termination, by either the PMG/IPA or Anthem Blue Cross.
Cigna: Cigna has never terminated a physician’s contract for over utilizing services unless there was evidence that it was hurting the quality of care or was fraudulent.
Health Net of CA: A Health Net peer review team measures and rates adverse action material submitted by providers and various primary source agencies, including the Medical Board of California, the National Practitioner Data Bank, the Healthcare Integrity and Protection Data Bank, Medicare/Medicaid Sanctions, Office of Inspector General, opt-out Medicare reporting, and the claims history for credentialing and re-credentialing. Health Net also investigates allegations made in the community and by the media. The provider has a right to appeal the decision through a fair hearing. Health Net uses quality data in physician management and evaluation to help identify potential provider issues.
Kaiser Permanente: Our integrated health care system ensures that not only our doctors, but also our entire network functions at optimal efficiency to manage utilization by implementing best practices. Outcomes from HEDIS and internal utilization reports are available online to doctors and administrators to help them assess appropriate care and access levels, capture long-term performance trends, and identify areas of potential over utilization and underutilization. Utilization reports are also used to drive improvements in quality, access, and member services that result in improved outcomes, increased member satisfaction, and lower costs. Exceptions to best practice guidelines are identified, investigated, and corrected as needed.
PacifiCare: Yes. We have terminated a small number of contracts with participating practitioners as well as delegated providers for failing to adhere to quality standards, typically less than one percent annually. The precipitating events included behavior presenting a potential risk of imminent harm to PacifiCare members and behavior contrary to the requirements of state and federal law. Our termination procedures adhere to contractual and regulatory requirements, and include informing the provider with required appeal rights and description of the appeal process.
37. How do you determine with which providers to contract? Do providers get incentives for refusing to contract with other plans (for example, to maintain a semi-exclusive relationship with a managed care plan)?
Aetna: It is monitored based on geographic access with the necessary mix of physician specialties and hospital services. An annual study determines the availability of PCPs relative to residence of member population. Providers don’t get incentives for refusing to contract with other plans.
Anthem Blue Cross: We consider geographic factors, experience of PCPs and specialists, board certification, and quality/reputation factors. We do not provide incentives for refusing to contract with other health plans.
Cigna: Contracting is based on geographic, business, and customer needs. Health care professionals must meet credentialing criteria including verification of education and license status. There are no exclusive or semi-exclusive relationships.
Health Net of CA: To ensure the quality of the Health Net network, all potential Participating Physician Groups (PPGs) are subjected to intensive reviews to ensure they meet or exceed Health Net’s guidelines in the areas of medical management, financial viability and stability, and network accessibility. No incentives are given for refusing to contract with other plans.
Kaiser Permanente: Kaiser Foundation Health Plan (KFHP) contracts exclusively with the Permanente Medical Groups in Northern and Southern California to provide comprehensive medical services to members including primary care, specialty care, laboratory, and imaging services. Our doctors do not contract with other plans. On occasion we will contract health care services from doctors, usually specialists, who are required by their contracts to provide the same high-level of medical and personal service as that from our own internal doctors.
PacifiCare: Once we determine that network expansion is necessary, we research available providers in that area. We contact prospective providers for detailed assessments on their credentialing, quality assurance, and administrative capabilities. Before contracting, we assess area needs and hold initial discussions to gauge mutual interest. If this initial assessment is satisfactory, a provider delivery systems team begins contract negotiations. The length of the process varies depending on the urgency of need for additional providers and the availability of these providers during the auditing and contracting process. The process usually takes from two to six months. We do not offer anti-competitive incentives to any physician.
38. How can a member get information about a doctor’s schooling and malpractice suits?
Aetna: Plan service professionals have access to the plan’s national provider database, which generally includes the medical school of graduation; also members can view DocFind, our online provider directory at www.aetna.com. Malpractice information is not available.
Anthem Blue Cross: Members can get information about a doctor’s board certification status on the Anthem Blue Cross ProviderFinder directory web-based tool. Members can also request information about a doctor’s malpractice and schooling from the Medical Board of California via the Website, phone, in writing or they can contact the PMG/IPA directly. Also, they can call the Medical Board of California for malpractice information.
Cigna: Customers can call our customer service department or look up the information on myCIGNA.com. Malpractice information is available to the public through the state medical board website. A peer review committee, staffed by Cigna-employed doctors and non-employed doctors, reviews individual physicians’ histories before credentialing and re-credentialing the physician into the Cigna network
Health Net of CA: Members may contact Health Net’s Customer Contact Center to get information about a participating physician’s schooling. Members may also access Provider Search at www.healthnet.com for physician languages, board certification information, provider-specific information, and weekly or daily provider updates. Members may contact the Medical Board of California, the American Medical Association, or the applicable specialty board for information about a doctor’s malpractice suits.
Kaiser Permanente: Each medical center maintains physician information, which members can access to verify licensure, medical school graduation, residency, and fellowship training, and board certification. Members can also find physician bios and background information at kp.org and can also contact the California Medical Association for malpractice information on any doctor.
PacifiCare: The member can call customer service for educational history, licensing information and board certification. The member can call the Medical Board of California for malpractice information.
39. What are your grievance procedures?
Aetna: Our customer service professionals can respond to most issues by phone. If the issue cannot be resolved during the call, the customer service professional researches the inquiry and then responds to the member. Our goal is to respond to all inquiries in 15 business days. Members who are not satisfied with the response can file an oral or written grievance. We will forward a written notice stating the result of the review to the member in 30 business days of receiving the grievance. The decision is final and binding unless, in 30 days, the member submits a written request of the notice of the grievance decision for a hearing by the hearing panel/grievance committee. The member’s next course of action is to request an external review. The external reviewer decides in 30 days of the request. Expedited reviews are available when a member’s physician certifies that a delay in service would jeopardize the member’s health. Once the review is complete, we abide by the decision of the external reviewer. The Complaints and Appeals Tracking System was developed to support our national grievances and appeals process.
Anthem Blue Cross: Anthem is responsible for registering, investigating, and responding to member grievances and appeals. The appeal process is not delegated to the PMGs/IPAs. To file a grievance and appeal, the member should call the toll-free Anthem Blue Cross customer service number listed on their ID card or they can also submit a grievance in writing to the Anthem Blue Cross Grievance and Appeals P.O. Box. Members can also file an appeal or grievance online atwww.anthem.com/ca. After we review the member’s grievance and appeal, the member receives a written statement of the resolution within 30 calendar days. The member has the right to request an expedited appeal if their condition is acute or urgent. Expedited appeals are resolved within three calendar days.
Cigna: Customers can call our customer service department or file a written complaint appeal. The complaint is investigated and reviewed in 30 days (when appropriate) and the customer is notified of the decision. An expedited appeal can be filed when the individual or health care professional is concerned with potential loss of life or health or the ability to gain maximum function. When necessary, procedures are modified to meet or exceed applicable regulatory and accreditation guidelines.
Health Net of CA: When members complain about the quality of service provided by the plan or its participating practitioner, the grievance is documented and researched and an acknowledgement letter to the member is sent within five days. The hospital/ PPG/practitioner has seven days to respond to the grievance. The final resolution letter will be sent to the hospital/PPG/practitioner. If it takes longer than 30 days to resolve, a letter of explanation will be sent to the member. The grievance is documented when members complain about the direct provision of care or the quality of care by a participating practitioner. If the matter is urgent, it will be forwarded to a clinical specialist for immediate attention and resolution (if required, care will be provided to the member). An acknowledgement letter and medical records release form will be sent to the member within five days. The hospital/PPG/practitioner has seven days to respond to the grievance. Health Net will determine if the grievance can be resolved with the records at hand if the member does not provide out-of-plan records or if the medical record release form is not signed. If it can’t, the case is closed until all necessary information is provided. After review, a letter to the member will communicate the disposition. The final resolution letter will be sent to the hospital/PPG/practitioner. If the matter takes longer than 30 days to resolve, a letter will be sent to the member to explain the delay and provide an estimated resolution date.
Kaiser Permanente: Our members can submit complaints to the member service representative at each medical facility and through the Member Services Call Center. Complaints are acknowledged within seven calendar days and a response made within 30 days. Our goal is for a complaint or grievance to be resolved within 60 days from the date it was received. An external, independent, third party review process is available to non-Medicare members who have completed the internal grievance/appeals process.
PacifiCare: Our top priority is for members to receive the services they need. If a problem occurs we encourage members to contact our Customer Service department as their first source for resolution. This team will make every effort to find a solution to the member’s situation. If the situation requires additional action, the member may submit a formal complaint requesting an appeal or quality review. The following is a summary of our formal process for appealing a health care decision. The member must submit a grievance in writing within 180 days of the initial decision to: PacifiCare of California Appeals and Grievance Department. Additionally, members in California may file an appeal using the online grievance form available at www.pacificare.com.
40. What systems are in place for assessing participant satisfaction?
Aetna: Member satisfaction is measured yearly at the network level using CAHPS 2.0H survey. The plan administers the most recent survey required by HEDIS to assess satisfaction. We also participate in the Consumer Assessment Survey to evaluate member satisfaction with IPA and Medical Groups.
Anthem Blue Cross: We conduct a variety of surveys each year to measure our members’ health and satisfaction to improve the quality of care and customer service. Each year, Anthem collects feedback from the various constituents that impact our business. We listen to all customer groups (members, employers, health care providers and insurance agents/brokers) and take into account the entire health care experience. Our research efforts provide us with a glimpse into the minds of our customers, telling us how best to deliver superior quality and service. We look at the experience through their eyes. We also collect feedback from our members and providers on an ongoing basis to get an even deeper look at the service experience. A key component of this ongoing survey program is the diagnosis and root cause analysis performed on each call where the surveyed member was neutral or negative about his experience. We use the Member and Provider Call Center Transaction Survey Programs as part of our strategy to improve customer satisfaction. The survey obtains solid, actionable operational-level measures of our customers’ needs and an evaluation of our performance at all key touch points. More than 100,000 surveys are conducted with members annually.
Cigna: Cigna uses the Consumer Assessment of Healthcare Providers and Systems (CAHPS) customer satisfaction survey, which ask consumers and patients to report on and evaluate their experiences with health care. It includes measuring satisfaction with medical groups and addresses utilization management, appointment wait times, office staff, etc. We continually monitor and work to improve customer satisfaction.
Health Net of CA: Health Net offers customer support and satisfaction surveys for members, providers, employer clients, and brokers. Health Net also participates in the annual National Committee of Quality Assurance (NCQA), HEDIS, CAHPS surveys and the Decision Power (disease management program) Satisfaction Survey. These reports are available to employer groups upon request. Additionally, Health Net conducts satisfaction surveys within our consultant and broker networks to ensure that we are meeting the needs of our clients. Health Net’s Customer Contact Center has implemented a post-call survey for all callers (members, providers, employers, and brokers) across all lines of business (Commercial, Medicare, and Medicaid). The survey, which is conducted periodically throughout the year, provides Health Net with valuable insight using the voice of the customer to measure amount of caller effort required to resolve issue, first call resolution, overall satisfaction with service provided, and how likely they are to recommend Health Net to a friend or family member.
Kaiser Permanente: We conduct ongoing surveys to evaluate member and patient satisfaction with doctors, access to services, and quality of care. Survey feedback is disseminated throughout the organization to target areas for improvement.
PacifiCare: PacifiCare uses the NCQA CAHPS annually to assess patient satisfaction with their care. Our satisfaction results are reported in our annual HEDIS results. CAHPS is a mail survey, which fulfills a component of the NCQA accreditation process. A telephone follow-up and interview occurs among non-responders per NCQA specifications.
41. Do you participate in outcomes research? Do you provide physician performance review data to the public?
Aetna: Yes, HEDIS is available for public review through the California Cooperative HEDIS Reporting Initiative.
Anthem Blue Cross: Yes, we have tools that support predictive modeling, provider profiling, hospital profiling, disease management, network analysis, quality assessment, regulatory reporting, and HEDIS submission. Additionally, Anthem has acquired HealthCore Inc., a leading outcomes research company. Performance review data for our PMGs/IPAs is available publicly on our website and in provider directories.
Cigna: Cigna is accredited by NCQA and participates in reporting HEDIS clinical outcome data, which is available for public review. Cigna also participates in the Integrated HealthCare Association’s Pay for Performance program. It provides data at the medical group level, which is reported to the public annually through the state’s Office of the Patient Advocate. Cigna also participates in the California HealthCare Foundation’s CHART hospital quality initiative. Through myCIGNA.com, the company offers an array of information to customers about the quality of health care professionals and facilities.
Health Net of CA: Medical groups are rated on wide-ranging quality-of-service and quality-of-care measurements. Results are available at www.healthnet.com, where members can view the Hospital Comparison Report and Participating Physician Group Report on a number of quality-of-care and service measures.
Kaiser Permanente: The most recent developments in medical outcomes research are incorporated into our evidence-based Clinical Practice Guideline program, assessed by our New Technologies Committee, and incorporated into our extensive library system with online capabilities. In addition, our clinicians are involved in a broad scope of clinical, epidemiological, and health services research projects. We earned ratings of Excellent in the latest review by the National Committee for Quality Assurance and routinely earn high scores in outcomes based surveys, such as HEDIS, Leapfrog, and METEOR, which measures our member satisfaction.
PacifiCare: Yes. Outcome results are incorporated into our provider group profile, which compares each provider group with network averages. We release these performance results to the public through our quality index profiles. The reports look at clinical, service and administrative quality measures. PacifiCare motivates provider compliance by intervening aggressively when deficiencies are found and by sharing best practices when excellence is identified.
42. Do you notify members when their PCP is no longer a member of the plan? How?
Aetna: Yes, members are notified by letter. They are apprised of transition of care issues and instructed on how to select a new PCP.
Anthem Blue Cross: Yes, PMGs/IPAs are required to provide 90 days notice to the plan when a physician within the PMG/IPA leaves the group or is terminated from our network. The PMG/IPA must offer the services of another PCP within the group. The plan provides at least 60 days’ notice in writing to all members enrolled with the terminating PCP. This letter includes the name of their new PCP or medical group.
Cigna: If a PCP is no longer a network physician in our plan, customers are notified by mail about 60 days before the effective date of the change and are encouraged to choose a new PCP.
Health Net of CA: Health Net Participating Physician Groups and individually contracted physicians are required, by contract, to notify us of any changes to the provider network including new physicians joining the PPG, address and telephone number changes, and physician terminations. Health Net notifies members when their PCP leaves the network or becomes affiliated with a different contracting PPG. Members can follow their PCP to a new contracting PPG. Members can choose a new PCP within the network or remain with their PPG if their PCP is no longer available in our network. When possible, members will receive a written notice within 30 to 60 days of the provider’s decision to leave the network. Provider listings are available at www.healthnet.com and are updated daily.
Kaiser Permanente: Yes, each medical center has developed general protocols to facilitate the transition of care to another doctor. Members assigned to a PCP are provided notice of the PCP’s departure 60 days in advance when possible. Members who are scheduled to see the physician for outpatient care are contacted to reschedule with another plan doctor if prior notice to a member is not able to be provided due to timing of the physician’s departure.
PacifiCare: Yes, PacifiCare sends a notification letter to all affected members 30 days prior to the termination date of a physician or medical group. The member selects a new PCP or medical group. If the member does not select a PCP or medical group within 30 days, we automatically assign a PCP or medical group that is geographically closest to their residence. If the member is unhappy with the assigned provider, he or she may request a change at any time by calling customer service.
43. What action is the plan or the IPA/MG taking to have online eligibility, administrative changes, referrals, etc?
Aetna: We participate in the Work Group for Electronic Data Inter-change, the Computerized Patient Record Institute, and the American National Standards Institute. A monthly eligibility file is provided to IPAs and Medical Groups.
Anthem Blue Cross: Through our Internet application, Employer-Access.com, group administrators can process eligibility transactions including additions, changes, and cancellations. (Changes are processed in real-time, assuming a confirmation response is received.) The administrator can also order ID cards; perform quick inquiries on employees; and locate providers via our provider finder. The “EmployerAccess.com” application features confidential and secure data through user ID and personal identification numbers, drop-down menus for easy point-and-click operation, and easy to follow hyper-link steps to guide the administrator through electronic enrollment, benefit changes, and maintenance processes.
Cigna: Cigna recently enhanced our website for health care professionals, offering easy access to online eligibility, detailed benefit information, claims tracking, and a new claim coding disclosure tool, which offers an immediate response to inquiries. For customers, myCIGNA.com offers online eligibility tools, claims support, and other tools that allow people to select or change their PCP and get personalized medical information and quality data about health care professionals. In addition, CignaAccess.com provides a single point of access to online tools and services to help make benefits administration easier. CignaAccess.com is a resource for employers in employee support, benefits administration, and security administration.
Health Net of CA: At www.healthnet.com, providers, members, employers, and brokers can perform wide-ranging administrative functions, including eligibility verification. Health Net uses the Internet to help employer groups make processing eligibility changes and pay bills. It is a free service to employer groups. Employer groups can log onto www.healthnet.com or eServices.healthnet.com. For brokers, Health Net’s Broker Solutions site provides online applications, product and rate information, provider directories, email access, and more. Providers can view mem-
ber eligibility, copays, medical policies, claim status, authorization status, and more. Members can access secure information about their coverage, correspond with Member Services, order ID cards and forms, file grievances, change addresses, check eligibility/benefits, change PCPs/ PPGs, view a pharmacy drug list, search for providers, look up information for their specific needs, get pharmacy refills, and more. Members can also connect to their www.healthnet.com online account via Health Net Mobile. Available free on Apple, Android, BlackBerry and other web-enabled devices, members can use this application to quickly conduct a wide variety of business transactions with Health Net at the push of a button.
Kaiser Permanente: Eligibility files are processed by our extensive online system maintained by our California Service Center in San Diego. Account representatives update membership online via electronic media files from purchasers. Nightly bulk transmissions from all claims and membership systems supply membership eligibility information to other clinical systems as needed.
PacifiCare: PacifiCare providers can check eligibility and claim status; print common forms; and view the specialty referral list at www.pacificare.com. We offer a paper and electronic referral process. In California, providers can access iExchange via the Web for electronic preauthorization requests and hospital admission notifications. The process varies for networks that are delegated and managed by contracted providers. Some providers have electronic referral systems in their own specialist network and others use paper submission. We do not track electronic referrals for these providers since they track these statistics internally.
44. How has your plan changed from last year?
Aetna: Our CA HMO plan now reflects all PPACA/HCR requirements.
Cigna: Several provisions of the Affordable Care Act have gone into effect for non-grandfathered plans, and so our plans have changed to be in compliance with the new law. More information is available on our “Informed on Reform” website on Cigna.com, including FAQs for brokers, employers and customers. In addition, Cigna has been very active and a leader nationally since 2008 in working with health care professionals to establish collaborative accountable care programs that seek to expand patient access to health care, improve care coordination, and achieve the “triple aim” of improved health outcomes (quality), lower total medical costs and increased patient satisfaction. We have partnerships that are showing very positive results, and we recently launched our first collaborative accountable care program in California. Including this program, Cigna is now engaged in 32 collaborative accountable care initiatives in 16 states, encompassing more than 300,000 Cigna customers and more than 4,500 primary care physicians. We have a goal to have 100 collaborative accountable care programs with 1 million customers in place by the end of 2014.
Health Net: Health Net is planning to upgrade our Customer Service Center’s systems and capabilities. This includes integration and expansion of Health Net’s Interactive Voice Response, web and mobile self-service capabilities. The goal of this project is to eliminate non-value-added manual effort and to insure consistent and accurate customer experience regardless of the channel accessed. Health Net is rolling out a new customer service management tool that will assist in contact management, thus making it easier for our staff to facilitate inquires and provide accurate, timely and consistent customer interactions. The new application delivers the ultimate customer experience by providing a single integrated desktop and a consistent workflow across our lines of business. The new system also automatically logs all call notes.
Health Net is successfully promoting culturally appropriate services that reduce health care disparities. In January 2012, Health Net received a National Committee for Quality Assurance (NCQA) Multicultural Health Care (MHC) Distinction. This coveted distinction sets Health Net of California apart from other health plans in that it is only awarded to high quality “organizations that engage in efforts to improve culturally and linguistically appropriate services and reduce health care disparities.” Health Net is the first health plan to receive the distinction for our Medi-Cal line of business and for both Medicaid and commercial lines of business (including our Healthy Families Program business). To date, only seven other health plans across the U.S. have received the distinction. The Distinction is valid for two years. To maintain the Distinction, Health Net must resubmit before the end of the second year.
On April 2, 2012, Health Net, Inc. announced that its subsidiary, Health Net Life Insurance Company, completed the sale of its Medicare stand-alone Prescription Drug Plan (Medicare PDP) business to a subsidiary of CVS Caremark. Health Net will continue to provide prescription drug plans as part of its Medicare Advantage plan offerings.
Kaiser Permanente: Significant changes were made with our plan in 2012 and are expected in 2013. We made several preventive services for women available without the need for a copay, including annual well-woman exam, family planning counseling, breastfeeding support, supplies, and counseling, gestational diabetes screening, domestic violence screening and counseling, human papillomavirus (HPV) testing, sexually transmitted disease counseling, and HIV screening and counseling (certain religious groups may be exempt from covering contraceptive methods and counseling). Medically necessary behavioral health treatment for autism spectrum disorders (ASD), including autistic disorder, Asperger’s syndrome, and pervasive developmental disorder – not otherwise specified are covered. We are expanding our contracted network to include qualified autism service providers, so we can offer members the newly required behavioral health treatment. New and upgraded medical facilities opening in 2012-2013 include the following:
San Mateo Medical Offices (2012)
South Sacramento Medical Center (2012)
Antelope Valley Medical Offices (2012)
Chester Avenue Medical Offices, Bakersfield (2012)
Ontario Medical Center (2012)
Garfield Specialty Center, San Diego (2012)
South Los Angeles Medical Offices (2012)
Orange County-Anaheim Medical Center (2012)
Palomar Medical Center West, Escondido (2012)
Indio medical offices (2012)
Lake Forest medical office building (2012)
Iris II medical office, Moreno Valley (2012)
San Diego medical center expansion, San Diego (2012)
San Marcos medical offices (2012)
Thousand Oaks medical facility (2012)
Tustin Ranch medical office building (2012)
Ventura behavioral health center (2012)
Carmel Valley medical offices (2013)
Fontana Medical Center (2013)
PacifiCare: There are no significant changes to the general plan structure from last year; however, there is flexibility on how plans are quoted. Clients requesting customization work closely with their broker to determine the best possible options for their company.