business impact presentation

Portfolio Management Business Impact Assessment

Autonomic Nervous System Testing

Business Impact Assessment

Proposal Type: Full Scale

Date: 06/25/2014

Project Sponsors: David Finley, MD

Business Lead: Dr. Julie Kessel

Presenter: Robb Coutinho

BPMS ID: 13049

Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 1

Overview/Background Information

• Autonomic nervous system (ANS) testing is performed on individuals with specific symptoms to

help diagnose & manage autonomic nervous system dysfunction. CPU will develop and post a

coverage policy and implement CPT codes 95921, 95922, 95923, 95924, 95943 using a PXDX edit.

ANS testing will be COVERED for specific medically necessary diagnosis codes and DENIED as

EIU for all other codes.

• These tests are PROVEN useful to diagnose some conditions; and is UNPROVEN for other

diagnoses. In many conditions testing is not clinically useful.

• Estimated Annual Total Medical Cost Savings: $2.4M

• Estimated Annual Service Denials: 17,870

• Estimated Average Cost per Service: $143

• Medical necessity appeal rights will be issued

• Competitive Landscape: All competitors who have policies agree. Neurological societies agree:

American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic

Medicine


Idea/Concept Name


• The CPU seeks to develop a medical coverage policy for Autonomic

Nervous System Testing. This initiative seeks deny CPT codes 95921,

95922, 92923, 95924 and 95943 in ClaimsXten via a dictionary update

to the MP_PXDX_PROF rule.

WHAT

• Target Date: 02/16/2015

• Neurologists, Cardiologists, Internal Medicine, Pediatricians

• No Vendor Impacts

• These tests are PROVEN useful to diagnose some conditions; and

UNPROVEN for other diagnoses. In many conditions testing is not

clinically useful.

• Estimated Annual TMC = $2.4M

WHY

WHEN

WHO

HOW• Implementation Lever: Dictionary update to the MP_PXDX_PROF rule

using ClaimsXten.


Annualized TMC =$2.4M

Unit cost per deniedclaim = $143

# claims to be denied = 17,870

1,249 unique HCPs denied

88% par utilization 8,876 Unique customers denied

Codes 95921: Cardiovagal function testing95922: Vasomotor function testing95923: Sudomotor function testing95924: Autonomic function, combined testing, with passive tilt95943: Simultaneous function testing, head-up posture

Vendor No Vendor Impacts

Specialties impacted Neurologists, Cardiologists, Internal Medicine, Pediatricians

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What is Autonomic Nervous System (ANS) Testing? • The autonomic nervous system controls how our organs work.

• Autonomic nervous system testing is performed on individuals with specific signs

and symptoms to help diagnose & manage autonomic nervous system dysfunction.

• These tests are PROVEN useful to diagnose some conditions; and is UNPROVEN

for other diagnoses. In many conditions testing is not clinically useful.

What is happening now? • Coverage policy is under development.

• The CPT codes are not implemented and pay for all conditions without review.

What is changing? • CPU will develop and post a coverage policy and implement the codes using a

PXDX edit.

• Autonomic nervous system testing (95921, 95922, 95923, 95924, 95943) will be

COVERED for specific diagnosis codes listed a medically necessary and DENIED

as EIU for all other diagnosis codes.

• Medical necessity appeal rights will be maintained. American Academy of Neurology

American Association of Neuromuscular and Electrodiagnostic Medicine

Aetna, AmeriHealth Caritas (Medicaid) Anthem, Blue Cross

Blue Shield Mississippi, First Coast Service Options (CMS

Regional Carrier)

None found

Scope

PHS and PHS+

Impacted claim platforms in scope: PMHS, Proclaim, Facets

Impacted Product Families? Medical

Impacted Product Types: PPO, OAP, Select, Managed Care (all products)

Impacted Market Segments: Select, Regional and National

Applicable to all states? All States

A national provider contract: N/A

Neurologists, Cardiologists, Internal Medicine, Pediatricians

Non-par providers

Communications: Date for sending: 11/15/2014; 1,109 HCP letters (Figure includes Top 10 Non-Par

HCPs)

TPVs: Out of scope

CGHB: Out of scope

ID card changes: No ID cards will be reissued

On-Line or Paper HCP Directory Updates Needed: No

CareAllies: Out of Scope

Behavioral: Out of Scope

UB-04: Out of Scope


Claim-Customer-HCP Volumes

6Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna

Claims Volumes

Number of Claims/Services 17,870

Number/% Par 88%

Number/% Non-Par 12%

Number of Denied Claims/Services

Avg. Cost of Service $143

Estimated Appeal Volume (Based on previous or similar experience)

894 (5% appeal rate

assumption)

HealthCare Professionals (HCPs)

Number/% Par 1,099

Number/% Non-Par 150

Number of HCPs broken down by Provider Type (FA, AN, PR, AS)N/A

Number of Letters to HCPs* (if applicable)/Target mailing date?

1,109* (11/15/2014)

*Figure includes Top 10 Non-

Par HCPs

**If HCP letters are required will they just be sent to impacted HCP’s or a broader group of HCP’s?

Customers

Unique # of Impacted Customers* 8,876

Number of Letters to Customers* (if applicable)/Target mailing date?N/A

*i.e. Customer disruption due to network change

*Indicate how this number was determined: i.e. expected based on current claims, over the lifetime of initiative,

based on next year's assumptions, etc.

Cost Benefit Analysis


Question Answer and Additional

Clarification

What are the proposed savings? Estimated TMC savings of $2.4M

Cigna Earnings Impact of $360K

What are the assumptions used for the development of savings?Estimated annual denials = 17,870

Average cost = $143

Denial Volume Breakdown: (17,870)

Proclaim: 14,653

PMHS: 1,787

Facets: 1,430

Are there any cost assumptions? Will need cost estimates from the following:

Service Operations (Call, Claim, Appeal, CA/CAT)

PBAB

Sales Effectiveness

HCP Communications

Prepay

Medical Management

Has Medical Economics signed off on benefits? Yes

High Level Implementation Plan/Program Components

Ensure Coverage Policy Updates Have Sign-off with Matrix Partners

• Work with Prepay to complete the Intake form, query development, testing, and approval so claims can

be ‘batched’ and sent to Medical Director for review

• Work with Medical Management & Prepay to update Medical Necessity Denial letters if applicable.

• Work with Legal and Compliance to ensure any state exceptions are properly implemented

Provide Coverage Policy Coding Changes

• The Coverage Policy Unit will develop the Autonomic Nervous System Testing coverage policy

• Provide updated coverage policy coding to Implementation Team

• The Change Request Authorizations will have to be supplied to McKesson by January 1, 2015 for the

updates to take effect in ClaimsXten on February 16, 2015 release date

• Implementation Leads will ensure information is coded into the system accurately.

Update Standard Operating Procedures and Talking Points and Training

• Notify CSAs and Appeals/Claim Processors that Cigna will be enforcing this policy

• Provide the necessary information for Service Operations to update any talking points, scripts, and

standard operating procedures (if needed)

Develop a Communication Plan

• Develop an external communication for customers and HCPs

• Develop an internal communication for sales team and call center representatives

• Assuming a 90-Day Notification period before policy goes live


Customer Experience Impact


Question Answer/Additional

Clarification

Will this initiative increase Dr./Hospital/Clinic/Pharmacy choices, reduce it or

have no effect?

No Impact

Will customers have to change Dr./Hospital/Clinic/Pharmacy as a result of this

initiative? If yes, please explain.

No Impact

Will customers be denied claims that were previously accepted? If yes, please

explain.

Yes. Customers could see claim denials for AutonomicNervous System Testing (CPT codes 95921, 95922, 92923, 95924 and 95943)

Will customers see any reduced or increased out of pocket costs? Yes, a potential for increased out of pocket costs if non-participating HCPs are utilized.

When and how will customers become aware of any changes to their

coverage?

No coverage changes.

Will this create a negative customer experience? Yes Note: Annualized estimated impact = 8K customers

Will this have a significant impact (positive or negative) on customer loyalty

(i.e. likelihood of the customer to recommend Cigna)?

TBD

If a vendor is involved what will the vendor’s responsibilities include? No Vendor Impacts

1. Will the vendor outreach directly to the customer (email, letters, phone,

etc.)?

N/A

2. Will that outreach look and feel like it’s coming from Cigna or the vendor? N/A

3. Will the customer outreach directly to the vendor (phone, web, etc.)? N/A

4. Will the vendor act and feel like Cigna? N/A

5. If the customer calls Cigna but should have called the vendor, will the

customer be warm transferred?

N/A

Sales / Client Experience ImpactQuestion Answer/Additional Clarification

# of impacted Clients & # of Claims including Customer & dollar impact) (Sales to

determine criteria as to when a Client list is required, may include at least a 12

month look back )

1,911

Client/Sales risks or impacts to Customers? Balance billing from Non-Participating HCPs

Will this create a negative client experience? Yes

Will letters need to be sent to Clients? If yes, who will receive letters, when, and the

volume?

None are planned as part of the project proposal

When creating new programs/pilots, would the client be able to “opt out” of the

program or pilot? If so, who would be responsible for that opt out process and what

criteria will Sales need to submit? Where will the opt out information be stored and

accessed by internal partners (e.g. Benefit Access)?

Exception requests will be considered on a one by one

basis.

Market Segment Specific impacts? All Segments

Vertical impacts? (Hospital, Government & Education verticals) Could this project

impact the special vertical needs of each of those markets.

N/A

Impacts to SBCs (summary of benefits & coverage), SPDs (summary plan

descriptions) and Benefit Summaries?

N/A

What’s the TMC, ROI, What is the ROI for the client and is there a need for a Sales

Talking Points ? cost or outcome driving the need for this change to Sales?

The CPU will partner with Sales Effectiveness to

provide talking points

Is there a cost that will be charged to the Client? Will the client see new Banking

info, line items? (e.g. billed charge; bank charge) If yes, what is the benefit the Client

can expect? Why is this change needed? (Client return)

N/A

Impacts to Contracts or ASO agreements? N/A

Can this proposal be incorporated into on-renewal experience? If not, why? N/A

Reporting Needs - Who will own reporting? Who would own report requests? Medical Economics will track ROI

If it’s a new plan or plan based change when are new plans effective? When are

enrollments slated to occur?

N/A


Other potential topics to include

See the pre-IA Questionnaire at end of this presentation for a complete listing of potential impacts


Question Answer/Additional Clarification

Impact to Product team? Can Product support the request? No Impact

If vendor is involved provide contract progress to date, vendor

responsibilities, contractor, etc. and has a contract been signed? If not, is

there a letter of intent?

N/A

Are there any online services required? N/A

Are specific Cigna coverage policies impacted? If so, what are they? Does

the Cigna policy support the actions of the vendor? If not, is a reconciliation

underway that includes Dx and Px codes?

The Coverage Policy Unit will develop a coverage policy for


Are there regulatory and compliances issues identified for the specific states

or accrediting organizations?

Compliance considerations are under review (Emily Pickering)

Will the change impact any claim processes If so, how? N/A

Are there current and/or requested prepay edits/processes or macros

impacted? If so, provide example/detail.

No

Will the change impact the pre-cert process? If so, how? N/A

What types of non-standard requests could be anticipated with the result of

the project or process improvement implementation? How many?

TBD

When creating new programs/pilots, would the client be able to “opt out” of

the program or pilot? If so, who would be responsible for that opt out process

and what criteria will Sales need to opt out of a program/pilot?

N/A

Links

BPMS 13049

IA Working Folder

Autonomic Nervous System Testing Client/HCP Detail

IA Response Form

Kickoff & Deep Dive meeting minutes Meeting minutes

Supporting Documentation:

IT/BA Enterprise Architecture Guidance (if applicable)


http://bpms.healthcare.cigna.com/Web/Portfolio/Summary/View/13049

https://centralhub.cigna.com/team/CPUMAP/Project Plan/95921-95924 and 95943 Not Covered Provider and Account Detail.xls

Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company.

"Cigna," and the "Tree of Life" logo and "GO YOU" are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating

subsidiaries. All products and services are provided by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General

Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. All

models are used for illustrative purposes only.

864805 05/13 © 2013 Cigna. Some content provided under license.

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