Utilization Management: Addressing Crucial Challenges for Health Plans


October 20-21, 2020
Embassy Suites by Hilton | Fort Lauderdale, FL
#UMIEN

This event was rescheduled from the original dates of April 23-24

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20

October 2020

Tuesday

Day One

  • 7:45 AM
    Workshop Registration & Networking Breakfast
  • 8:30 AM

    OPTIONAL PRE-CONFERENCE SPECIAL WORKSHOP:
    Success with UM Requirements for Health Plan Accreditation

    • • Lessons learned from achieving UM standards for various types of health plan accreditation
    • • Strategies for success on NCQA’s two new “must-pass” UM elements
    • • Update on other UM standards changes for 2020
    • • Best practices for meeting timeliness standards for utilization management decision-making using approved evidence-based criteria, guidelines or benefit provisions, including:
      • • Collection and use of relevant clinical information to make utilization management decisions
      • • Ensuring qualified health professionals are assessing requests and making UM decisions
      • • Timeliness of UM decisions

    Kelli C Davis, Principal
    DAVIS HEALTHCARE CONSULTING

    Kirk McDonald, Program Manager, Clinical Operations
    SAN FRANCISCO HEALTH PLAN

  • 11:15 AM
    CONFERENCE REGISTRATION BEGINS
  • 11:30 AM
    Networking Luncheon
  • 12:30 PM

    Chair’s Welcome and Opening Remarks

  • 12:40 PM

    Examining the Challenges of Observation Status vs. Inpatient Admission—Health Plan and Hospital Perspectives

    One of the most difficult aspects of managing a hospital stay, both for the health plan and the hospital, can be determining whether the patient should be placed in observation or admitted as an inpatient. This session looks at:

    • • Making sense of evolving criteria
    • • Helping hospital physicians make accurate decisions
    • • Ensuring the care delivered is at the most appropriate levels
    • • Evaluating potential financial consequences for members

    Timothy Law, DO, MBA, Senior Medical Director
    HIGHMARK

    Carissa Tyo, MD, Medical Director, Clinical Decision Unit
    UNIVERSITY OF ILLINOIS HOSPITAL

    Tiffany Victor, MSN, RN, ACM-RN, Director Discharge Planning and Utilization Management
    UNIVERSITY OF ILLINOIS HOSPITAL

  • 1:30 PM

    Special Feature: Effectively Managing Gender Reassignment Surgery and Treatment

    San Francisco Health Plan has been on the leading edge in working with members in this rapidly evolving area. This session features their insights on:

    • • Formulating policies for gender reassignment procedures
    • • Establishing a criteria set
    • • Setting up an appropriate network of providers
    • • Partnering with community agencies
    • • Coordinating gender reassignment with cosmetic surgery
    • • Provision of necessary non-surgical services
    • • Resolving claims system challenges
    • • Building patient education programs

    Monica Baldzikowski, RN, PHN, Senior Manager, Prior Authorizations and Quality Review
    SAN FRANCISCO HEALTH PLAN

    Kirk McDonald, Program Manager, Clinical Operations
    SAN FRANCISCO HEALTH PLAN

  • 2:30 PM
    Extended Afternoon Networking Break
  • 3:00 PM

    SPECIAL 2-PART FEATURE—SOCIAL DETERMINANTS OF HEALTH

    Part I: Integrating Social Determinants of Health into UM and Care Management Processes to Optimize Outcomes and Improve Value

    Systematically assessing for, understanding, and communicating non-clinical SDOH risk factors throughout the care continuum is an essential component of comprehensive health care, particularly for low-income adult populations with complex chronic disease and limited resources. This session looks at improving outcomes through strategies for addressing social needs as part of care management processes.

    • • Screening to detect social needs as part of care
    • • Identifying which social factors that are negatively affecting a member’s health
    • • Integrating social needs considerations into treatment
    • • Ensuring access to care

    Jim Milanowski, President/CEO
    GENESEE HEALTH PLAN

    Mouhanad Hammami, MD, SVP, Safety Net Transformation, Community Health and Wellbeing
    TRINITY HEALTH

  • 3:45 PM

    Part II: Case Studies of Unique Care Management Initiatives that Effectively Address Social Determinants of Health

    These health plans have achieved success in improving outcomes and reducing readmissions by integrating community health navigators as care management allies to work with members, helping them define and find help in addressing their social needs.

    • • Helping members comprehend how addressing their social needs can improve health outcomes
    • • Identifying appropriate community-based organizations and other resources
    • • Examining results achieved
    • • Case examples

    Mairead McInerney, MSW, LCSW, CCM, Corporate Director, Population Health Integration
    AMERIHEALTH CARITAS

    Valeon Waller, MHSA, BSN, CCM, Market Clinical Director, Population Health
    BLUE CROSS COMPLETE OF MICHIGAN

  • 4:30 PM

    Networking Roundtables

    This is a unique opportunity to compare notes with other UM experts. Choose a topic and go deep— get answers to your specific questions and hear insights from fellow attendees on the challenges you face.

    • Topic A: TBD
    • Topic B: TBD
    • Topic C: TBD
  • 5:15 PM
    Networking Reception

21

October 2020

Wednesday

Day Two

  • 8:00 AM
    Networking Breakfast
  • 9:00 AM

    Chairperson’s Welcome Back

  • 9:10 AM

    Improving Outcomes and Containing Costs by Detecting Unrecognized or Unmet Behavioral Health Needs

    National studies estimate that in a one-year period, up to 30% of American adults suffer from one or more mental health problems. Research shows that:

    • • Behavioral health problems often present in primary care and rarely present in isolation
    • • Behavioral health problems are often co-morbid with physical health problems
    • • If behavioral health problems go un- or under-treated, it is more challenging to address patients’ physical health problems
    • • Treating behavioral health and medical problems together can improve outcomes for both

    This session examines strategies for identifying potentially hidden behavioral health problems and integrating their care into comprehensive care management.

    Andrew Philip, PhD, LP, Senior Director, Clinical & Population Health
    PRIMARY CARE DEVELOPMENT CORPORATION

  • 10:00 AM

    Managing Telehealth Benefits to Ensure Effective Care

    The American Hospital Association recently said that “by increasing access to physicians and specialists, telehealth can help ensure patients receive the right care, at the right place, at the right time.” And telehealth can reduce the cost of care by eliminating the physical barriers that prevent patients from managing their health, encompassing video consultations as well the collection of health data and images. Telehealth is rapidly growing in terms of claims, even gaining support from CMS for Medicare Advantage coverage in 2020. But how can organizations be sure that telehealth is used most effectively? This session examines:

    • • Discussing real-world effectiveness of digital health solutions
    • • Exploring current reimbursement legal landscape impacting various payer sources: Commercial, Medicare, Medicaid
    • • Utilizing specific new CPT codes for telehealth claims
    • • Establishing best practices and resources for physicians in employing telehealth
    • • Strategically integrating digital health into care management in order to avoid overlap or duplication of existing care

    Kyle Faget, JD, Special Counsel
    FOLEY & LARDNER

    Til Jolly, MD, Emergency Physician
    INOVA HEALTH SYSTEM

  • 10:45 AM
    Morning Networking Break
  • 11:00 AM

    Featured Panel Discussion: Ensuring UM, Care Management and Quality Improvement Departments All Work Together More Effectively

    Ensuring care is appropriate and effective, containing costs, improving care outcomes and ensuring value are all parallel goals in a healthcare organization. This session looks at how these objectives can be more effectively achieved by closer collaboration between UM, care management and quality improvement experts.

    • • Utilizing QI data to make more accurate UM decisions
    • • Ensuring quality improvement goals are reflected in UM policies
    • • Breaking down silos around the departments
    • • Incorporating insights from UM in designing care management

    Moderator/Panelist:
    Jim Milanowski, President/CEO
    GENESEE HEALTH PLAN

    Panelists:
    Timothy Law, DO, MBA, Senior Medical Director
    HIGHMARK

    Monica Baldzikowski, RN, PHN, Senior Manager, Prior Authorizations and Quality Review
    SAN FRANCISCO HEALTH PLAN

    Sandy Jones, RN, BSN, PHN, MBA, Director, Care Management
    BLUE CROSS BLUE SHIELD OF MINNESOTA

  • 11:50 AM

    Case Study: An Innovative MTM Program that Improves Quality and Controls Cost

    This session examines a hybrid program where a dedicated internal MTM pharmacist enables the health plan to work more effectively with their external MTM company. It has been successful in reducing cost as well as improving member satisfaction, and the health plan has achieved a 5-Star rating on MTM for the past 2 years.

    • • Using medical and pharmacy claims data to enable the health plan pharmacist to target higher risk MTM qualified members for specific interventions
    • • Working with the case or disease management nurse to improve medication adherence and member understanding of prescribed medications
    • • Collaboration between the MTM pharmacist and the quality improvement team to improve Part C measures

    Gary Melis R.Ph., Pharmacist
    NETWORK HEALTH PLAN

  • 12:30 PM
    Networking Luncheon
  • 1:30 PM

    Ten Strategies for Improving Management of Patients with Complex Needs: Innovations and Best Practices

    Drawing from leading-edge research as well as more than fifteen years’ experience in optimizing care management, our speaker shares proven strategies for preventing hospital readmissions, reducing length of stay, and improving outcomes in managing complex patient populations including:

    • • Optimizing early identification and intervention
    • • Keys to a successful transition
    • • Reinventing the interdisciplinary discussion
    • • Effectively managing patient and family expectations
    • • Utilizing a playbook for options and standardization

    Bonnie Geld, President
    CENTER FOR CASE MANAGEMENT

  • 2:15 PM

    Case Study: Optimizing Outcomes through Improved Payer/Provider Collaboration

    Beginning with the true story of a health plan member’s challenges in navigating the healthcare system, this case study examines how health plans and health systems can work more closely in care management to improve outcomes, including results of a collaborative pilot study based on this experience.

    MJ Tran, MBA, SVP, ACO Director
    HCA HEALTHCARE & EASTERN IDAHO CARE PARTNERS ACO

  • 3:00 PM
    Conference Concludes
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