PITTSBURGH, June 19, 2012 /PRNewswire/ -- Highmark Inc. will be instituting a new physical medicine program designed to promote appropriate utilization of services and address growing customer concerns over unwarranted variations in the delivery of care that contributes to rising health care costs. Beginning Sept. 1, health care providers will be required to get prior authorization before performing services in physical therapy, occupational therapy and manipulation services. This initiative is designed to improve the quality and appropriateness of care for members seeking services in these areas.
Inappropriate utilization associated with physical medicine services represents a significant cost to Highmark group customers and members. Because of these utilization trends, more employer groups are requesting outpatient prior authorization programs for their members as a means to help control costs.
Highmark has contracted with Healthways (www.healthways.com) on this initiative. Healthways has a great deal of experience in this area working with other insurers, including Blue Cross Blue Shield of Massachusetts.
This program applies to Highmark members in insured groups in Pennsylvania and West Virginia. It also applies to Highmark individual members and Medicare Advantage members in those states. Groups that are self-insured may also participate. Members will not need to take any special steps as a result of this program. Providers will work directly with the vendor (Healthways) to obtain authorizations.
"This program is one of a number of efforts that Highmark is tracking to help reduce unwarranted variations in the delivery of healthcare and to help manage rising health care costs," said Virginia Calega, M.D., Highmark's vice president of medical management and policy. "We are listening to our customers and trying to take steps to ensure members get the right care at the right time and in the right setting."
Dr. Calega also noted that Highmark is protecting members from overutilization because overuse errors can cause harm and waste health care resources. Ultimately, quality care drives cost efficiency.
"This prior authorization requirement only takes effect after the first eight visits," said Dr. Calega. "If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place." Highmark data also shows that nearly two-thirds of members have their needs met and resolved within eight visits.
In addition, a review of Highmark claims data for some practices during the past two years shows chiropractic care is the second highest paid service for members, second only to cardiac care.
"Analysis of data highlighted that nearly a third of member claims may not represent optimal utilization," said Dr. Calega. "We want to ensure that the services are medically appropriate."
Highmark paid more than $100 million for chiropractic-related services in 2010. That same year, the claims data for occupational and physical therapy combined was nearly an additional $100 million in paid claims on behalf of Highmark members. "Working with our vendor, we believe close to one third of these claims may not represent optimal utilization," said Dr. Calega.
"Healthways' analysis of initial claims data indicates a high frequency of visits overall with a handful of members receiving more than 100 visits over the course of a calendar year," said Richard Olson, DC, director of clinical services for Healthways. "The scope of work includes identifying specific services, procedures and frequency for optimum clinical outcomes. The program is designed to ensure members receive clinically indicated, therapeutically directed, medically necessary care in accordance with the policy and benefit."
Highmark is also forming a provider advisory group specifically for this program to help make certain that the highest quality of care is being provided to members in the most efficient manner. The company has a number of other external physician committees that advise the company on a variety of issues. Highmark believes collaboration with health care providers is another important step in the process.
While health care reform law currently does not address the issue of rising health
care costs, initiatives like this one engage providers, insurers and members to more closely address the cost issue in health care.
About Highmark Inc.
Highmark Inc., based in Pittsburgh, is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Highmark serves 4.9 million members in Pennsylvania and West Virginia through the company's health care benefits business and is one of the largest Blue plans in the nation. Highmark has 20,000 employees across the country. For more than 70 years, Highmark's commitment to the community has consistently been among the company's highest priorities as it strives to positively impact the communities where we do business. For more information, visit www.highmark.com.
SOURCE Highmark Inc.