Provider-Payer Relations: Sample Cases. Anand Nilakantan, DO, MBA Aetna Mid-Atlantic Medical Director July 20, 2017
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1 Provider-Payer Relations: Sample Cases Anand Nilakantan, DO, MBA Aetna Mid-Atlantic Medical Director July 20, Presenter Aetna Name Inc. May
2 Documentation Apropos documentation is the vital substrate necessary for the Utilization Management workflow to proceed in as efficient and productive manner as possible Example: 75-year-old male member arrives to the local community Emergency Department from home, with a chief complaint of fevers/chills (Tmax at home = 102 degrees Fahrenheit) and a productive cough for 2 days prior to presentation; he is very active in the community, walks 2 miles/day, does all the cooking at home, and is a never smoker, with no pertinent past medical history He has felt like this before, but it was a long time ago, when I was diagnosed with a bad pneumonia, per member. He does not recall any sick contacts, recent travel, and/or antibiotic use Pertinent physical exam findings include member appearing generally pale and weak, with flattened neck veins, rhonchi auscultated bilaterally, and with diminished breath sounds to left lower lung fields Vital signs: T = degrees Fahrenheit, BP = 82/42, P = 120, RR = 24, SaO2 = 80% on room air 2
3 Documentation Sepsis case: CBC, chemistry panel, lactic acid, procalcitonin, urine Legionella and Streptococcus antigen, influenza panel, blood culture, chest X-ray ordered Notable positive findings: WBC = 15,000, Na = 125, LA = 3, procalcitonin elevated, urine Legionella and Streptococcus Ag wnl, CXR = RML, RLL infiltrative lesions noted; LLL moderate effusion Treatment: member transferred to step-down bed with telemetry, given 0.9% NS at 125 ml/hr, and started empirically on Zosyn, vancomycin, and azithromycin Hospital day #2 = member with improvement in all VS, no longer hypotensive, tachycardic and/or tachypneic WBC down-trending, Na up-trending, LA normalized, and blood culture positive for Streptococcus pneumoniae PSI/PORT score = 125 CURB-65 score =2 3
4 Communication Absolutely key in provider-payer relations within the UM case review setting Why is the case being referred to the payer - E.g., DRG readmission, post-acute disposition, observation versus inpatient - Is the case being referred at the appropriate phase of care of the member - Is the endpoint (or potential endpoint) of the member clear for the payer 4
5 Questions a Payer May Ask Was this member recently admitted, and if so, for what diagnosis Does step-down unit have the same admission criteria in this facility as it does at the local academic medical center Pertinent clinical queries regarding member s PMH, CC, VS, lab abnormalities, imaging Code status and/or member wishes not otherwise specified 5
6 Peer-to-Peer Better understanding Better decisions Better health care experiences At your service Aim to make as collegial and educational an experience as possible Glean as much added and pertinent information as possible from payer standpoint. Glean as much information as possible regarding how provider treats similar member cohort Are all of your like sepsis secondary to pneumonia members transferred to the step-down unit Learn as much as possible regarding facility s unique characteristics Medical-Surgical unit? All similar cases referred for Peer-to- Peer? Formal Physician Advisor program? Specific increased incidence of this bacterium? 6
7 Possible Provider-Payer Relation Solutions Open Electronic Medical Records access for payer t. Augmented transparency of payer decision-making processes. Collaborative relationships Joint decisionmaking regarding Case Management processes Discussing cases in an open forum Sharing resources as much as possible, e.g., evidence-based medicine precepts 7
8 Thank you. Anand Nilakantan, DO, MBA Medical Director, Aetna Mid-Atlantic Region
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