EmblemHealth Reduces Preauthorization Requirements

EmblemHealth has a mission to create healthier futures for our members and communities.  We fulfill that mission by working closely with providers who deliver care. This collaboration informs everything we do.

Therefore, beginning January 1, 2020, we are significantly reducing the number of procedure codes that need our approval before delivering care. This will help members receive the care they need quickly and efficiently. This change affects members in all our plans, including Medicaid managed care, Medicare Advantage, coverage offered through employers, and Individual Market plans on the Exchange.

For our providers, this will allow them to more fully devote their attention to providing the care people deserve. The change is based on national treatment standards developed by physicians and other medical professionals that establish best practices for ensuring people receive high-quality, affordable care and that science leads our decision-making. We also feel it is the right thing to do.

For additional information, including links to the lists of preauthorization codes in effect as of January 1, 2020, click here. A list of codes we will remove on Jan. 1, 2020 for our Medicare, Medicaid, and Commercial lines of business can be found here.

So why is EmblemHealth doing this? In the health care system today, there are too many instances of services being overprescribed, delivered in the most expensive settings, and codes submitted for services that do not meet patient needs. This makes care less affordable. In fact, the Journal of the American Medical Association finds that such waste accounts for about one out of every four dollars spent on health care.1

To read more about EmblemHealth’s perspective on this issue and why making this change was vital, we encourage you to review our whitepaper on the subject.

In addition to the adverse clinical, financial, and emotional impact of unnecessary care receipt, overuse is also a hassle for our members as they undergo unnecessary tests and stay in the hospital when they should be at home. We also know from our experience as a health plan that that our enrollees and their clinicians often view these procedures as burdensome.   

In terms of the number of codes impacted, this change is significant: The list of Utilization Management Preauthorization codes is being slashed from 2,045 unique codes to 1,044. Through careful analysis of our data, we identified services that almost always get approved. These services include some surgical procedures where patients are going to the hospital (i.e. some cardiac and vascular procedures, gallbladder removal, and treatment of glaucoma).

A few other important points:

·      Members in HIP and GHI PPO (non-City of New York) plans will experience this change upon their plan’s renewal.

·      These changes do not apply to vendor or durable medical equipment preauthorization codes.

·      EmblemHealth will continue to request it be notified when enrollees are admitted for inpatient hospitalizations but will not require a medical necessity determination for procedures that are no longer on the prior authorization list.

·      These changes do not apply to inpatient care as that always requires preauthorization. It also does not apply to vendor or durable medical equipment preauthorization codes.

·      Health Care Partners is implementing these changes as well. For further information about preauthorization codes for Montefiore, please visit their website.

·      Starting Feb. 1, 2020, EmblemHealth will be extending its Site of Service preauthorization requirements to its Medicare population, further aligning our Utilization Management rules; more information may be found here.

As a nonprofit health plan, we are interested in our members, not stockholders We are confident our members will benefit from this work and our ongoing, clinically driven analyses that will continue to provide the basis for our coverage policies. For clinicians on the front lines of our care delivery system – the physicians, nurses, and pharmacists – this will mean they have more time to spend with their patients.

1Shrank, William H., MD, MSHS et. al., “Waste in the US Health Care System: Estimated Costs and Potential for Savings”. JAMA. 2019;322(15):1501-1509 (October 7, 2019).