Appendix 3 - Matrix Predicted Savings Impact on Long-Term Previous Initiatives Proposed Changes Impact Implementation Requirements & Strategies State Federal Prior Authorization PA currently Implement required for: $90K $34K Pros: May need to be Implementation Timeline: All concurrent out-of-state review Applies medical necessity criteria to modified with 3-6 mo. • services for inpatient (including ensure appropriate delivery of Enhanced PCCM Savings Realization Timeline: ambulance psychiatric & services air services & reduces overutilization model & for the 6-12 mo. medical for individuals transport) Cons: managed care for Changes: Systems Optional under 21 treatment Increased administrative responsibility LTSS, as those Communication: Providers • services for members for providers companies will likely under age 21 Increased State administrative establish their own • Transportation for responsibility PA continuous Also overlaps with treatments in pharmacy initiatives hospital outpatient setting Elective surgeries $0.8M $0.3M See above May need to be See above Dental services (i.e. modified with Enhanced PCCM dentures, & for the managed orthodontia, TMJ care for LTSS, as surgery, dental those companies will services) Hearing aids likely establish their own PA Certain medical supplies Elective & inductions DME, i.e. $0.85M $0.32M Pros: May need to be See above <39 Reduced C-section rate modified with DME costing more Better outcomes Enhanced PCCM than $699, apnea Shorter labors model, as those monitor, hospital Cons: companies will likely beds, infusion pump, Challenge on how to implement establish their own PA
Appendix 3 - Matrix Previous Initiatives Proposed Changes Predicted Savings Impact Impact on Long-Term Strategies Implementation Requirements & Federal State Prior Authorization PA currently required for: All out-of-state services (including ambulance & air medical transport) Optional treatment services for members under age 21 Transportation for continuous treatments in hospital outpatient setting Dental services (i.e. dentures, orthodontia, TMJ surgery, dental services) Hearing aids Certain medical supplies & DME, i.e. DME costing more than $699, apnea monitor, hospital beds, infusion pump, Implement concurrent review for inpatient psychiatric services for individuals under 21 $90K $34K Pros: • Applies medical necessity criteria to ensure appropriate delivery of services & reduces overutilization Cons: • Increased administrative responsibility for providers • Increased State administrative responsibility May need to be modified with Enhanced PCCM model & for the managed care for LTSS, as those companies will likely establish their own PA Also overlaps with pharmacy initiatives Implementation Timeline: 3-6 mo. Savings Realization Timeline: 6-12 mo. Changes: Systems Communication: Providers Elective surgeries $0.8M $0.3M See above May need to be modified with Enhanced PCCM & for the managed care for LTSS, as those companies will likely establish their own PA See above Elective inductions <39 $0.85M $0.32M Pros: Reduced C-section rate Better outcomes Shorter labors Cons: Challenge on how to implement May need to be modified with Enhanced PCCM model, as those companies will likely establish their own PA See above
recommendation-report12-15-2012.docx