from approval to implementation...understand and come prepared to discuss roi bring data if you...
TRANSCRIPT
![Page 1: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/1.jpg)
From Approval to
Implementation – The Payor
Perspective
By: Brian Stamm, MBA
![Page 2: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/2.jpg)
Disclaimer
The views expressed during this presentation are solely those of the
presenter; they do not necessarily reflect the views of the Department of
Employee Trust Funds.
I am not receiving any sort of compensation for this presentation.
![Page 3: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/3.jpg)
About
Work Experience
Current:
Deputy Director of the Office of
Strategic Health Policy for Wisconsin’s
Department of Employee Trust Funds
Previous:
4 years as Operations and Quality
Manager with a regional health insurer
4 years as Manager of Operations and
Business Analytics with a university
health center
8 years in pharmacy retail
Education
• Current:
• Master of Public Health – Infectious Disease and Epidemiology
• Johns Hopkins Bloomberg School of Public Health
• Previous:
• Master of Business Administration –Health Sector Management | Leadership & Organizational Transformation
• Boston University’s Questrom School of Management
• BS – Consumer Science – Retail Management
• University of Wisconsin-Madison
![Page 4: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/4.jpg)
Picture Source: https://microbewiki.kenyon.edu/images/6/6c/3D_Yersinia_pestis_model.jpeg
![Page 5: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/5.jpg)
Thomas Vicary
Picture Source: https://en.wikipedia.org/wiki/Thomas_Vicary
![Page 6: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/6.jpg)
Picture Source: https://www.npr.org/sections/goatsandsoda/2017/08/18/542435991/those-iconic-
images-of-the-plague-thats-not-the-plague
Vicary Method
![Page 7: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/7.jpg)
Picture Source: https://www.npr.org/sections/goatsandsoda/2017/08/18/542435991/those-iconic-
images-of-the-plague-thats-not-the-plague
Vicary Method
![Page 8: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/8.jpg)
Medical Practice Constantly
Evolves
Medical Practitioners Continuously Improve
Medical Insurance Consistently Lags Behind
…and so do payments
![Page 9: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/9.jpg)
Welcome to Health
Insurance
The land that logic and reason
forgot
![Page 10: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/10.jpg)
Medical Policy
Medical Policy Committee
Sets the criteria for making medical coverage determinations
Sets the documentation requirements to be considered
Medically Necessary
Defines the scope of services
Medical Policy is typically set well in advance (18
months) of coverage changes – so plan ahead
Tip: Make sure that coverage for Athletic Trainers is not a
Direct Exclusion
Tip: Make sure that coverage for Athletic Trainers is
directly included
![Page 11: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/11.jpg)
Product Configuration
The interpretation of Medical Policy into computer
programing
Claims systems are fragile
Thousands of inter-connected configurations
Thousands of variations by plan
System updates or connected configurations can have ripple
effects
Test, test, and re-test… then audit
![Page 12: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/12.jpg)
Tips & Tricks
Find a champion
Develop a simple explanation of who Athletic Trainers
are
Understand and come prepared to discuss ROI
Bring data
If you don’t understand ROI, then find someone that does
ROI Numerator – more than just earnings
Increased throughput
Increased access & availability
Drive home the “working at the top of licensure” idea
![Page 13: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/13.jpg)
Tips & Tricks (continued)
Understand, train and communicate the documentation
requirements, medical coding requirements, and proper
billing practices needed for a claim to process correctly!
Audit frequently
Needed: more data on the utilization of Athletic Trainers
in ER/Urgent Care settings and ROI
![Page 14: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/14.jpg)
Please Don’t
Don’t add new costs to an already burdened system
Football player at a state university received treatments from
Athletic Trainers over the course of a year
3rd party biller charged over $250,000 in claims
Start small and stick to your scope of services
Poor documentation, bad medical coding, and sloppy
billing practices will ruin progress for yourself and all
others
Don’t scope creep
![Page 15: From Approval to Implementation...Understand and come prepared to discuss ROI Bring data If you don’t understand ROI, then find someone that does ROI Numerator –more than just](https://reader033.vdocument.in/reader033/viewer/2022041921/5e6c163143eb0a2ece4d700f/html5/thumbnails/15.jpg)
Contact
https://www.linkedin.com/in/brian-stamm-mba-ab208063/
Coming Soon:
Wine and Science Podcast www.wineandsciencepodcast.com
Instagram: wineandsciencepodcast
Twitter: @WineAndSciPod