From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you...
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From Approval to Implementation – The Payor Perspective By: Brian Stamm, MBA
Transcript of From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you...
From Approval to
Implementation – The Payor
Perspective
By: Brian Stamm, MBA
Disclaimer
The views expressed during this presentation are solely those of the
presenter; they do not necessarily reflect the views of the Department of
Employee Trust Funds.
I am not receiving any sort of compensation for this presentation.
About
Work Experience
Current:
Deputy Director of the Office of
Strategic Health Policy for Wisconsin’s
Department of Employee Trust Funds
Previous:
4 years as Operations and Quality
Manager with a regional health insurer
4 years as Manager of Operations and
Business Analytics with a university
health center
8 years in pharmacy retail
Education
• Current:
• Master of Public Health – Infectious Disease and Epidemiology
• Johns Hopkins Bloomberg School of Public Health
• Previous:
• Master of Business Administration –Health Sector Management | Leadership & Organizational Transformation
• Boston University’s Questrom School of Management
• BS – Consumer Science – Retail Management
• University of Wisconsin-Madison
Picture Source: https://microbewiki.kenyon.edu/images/6/6c/3D_Yersinia_pestis_model.jpeg
Thomas Vicary
Picture Source: https://en.wikipedia.org/wiki/Thomas_Vicary
Picture Source: https://www.npr.org/sections/goatsandsoda/2017/08/18/542435991/those-iconic-
images-of-the-plague-thats-not-the-plague
Vicary Method
Picture Source: https://www.npr.org/sections/goatsandsoda/2017/08/18/542435991/those-iconic-
images-of-the-plague-thats-not-the-plague
Vicary Method
Medical Practice Constantly
Evolves
Medical Practitioners Continuously Improve
Medical Insurance Consistently Lags Behind
…and so do payments
Welcome to Health
Insurance
The land that logic and reason
forgot
Medical Policy
Medical Policy Committee
Sets the criteria for making medical coverage determinations
Sets the documentation requirements to be considered
Medically Necessary
Defines the scope of services
Medical Policy is typically set well in advance (18
months) of coverage changes – so plan ahead
Tip: Make sure that coverage for Athletic Trainers is not a
Direct Exclusion
Tip: Make sure that coverage for Athletic Trainers is
directly included
Product Configuration
The interpretation of Medical Policy into computer
programing
Claims systems are fragile
Thousands of inter-connected configurations
Thousands of variations by plan
System updates or connected configurations can have ripple
effects
Test, test, and re-test… then audit
Tips & Tricks
Find a champion
Develop a simple explanation of who Athletic Trainers
are
Understand and come prepared to discuss ROI
Bring data
If you don’t understand ROI, then find someone that does
ROI Numerator – more than just earnings
Increased throughput
Increased access & availability
Drive home the “working at the top of licensure” idea
Tips & Tricks (continued)
Understand, train and communicate the documentation
requirements, medical coding requirements, and proper
billing practices needed for a claim to process correctly!
Audit frequently
Needed: more data on the utilization of Athletic Trainers
in ER/Urgent Care settings and ROI
Please Don’t
Don’t add new costs to an already burdened system
Football player at a state university received treatments from
Athletic Trainers over the course of a year
3rd party biller charged over $250,000 in claims
Start small and stick to your scope of services
Poor documentation, bad medical coding, and sloppy
billing practices will ruin progress for yourself and all
others
Don’t scope creep
Contact
https://www.linkedin.com/in/brian-stamm-mba-ab208063/
Coming Soon:
Wine and Science Podcast www.wineandsciencepodcast.com
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