Zero Access Fees (ZAP) Available on Case-by-Case Basis

If you access U.R.N. through Summit Re, you also have access to ZAP. You can elect at the time of each transplant referral to use U.R.N.’s traditional facility terms, which have the access fee, or use the ZAP contract and not pay an access fee. Your actual transplant costs will be determined based on the terms you have chosen. Generally, the traditional terms will provide for a lower cost, even with consideration of the access fee, if the transplant situation turns out to be average or worse than average. On the other hand, the ZAP terms will generally perform better if it turns out that the transplant situation is much better than average.

ZAP provides contract terms which U.R.N. believes are superior to their competitors. While U.R.N. does not guarantee to always beat the competition, it is U.R.N.’s intent to maintain the best contracts as compared to its competitors, regardless of which U.R.N. option is selected.

Reinsurance incentives for the use of either U.R.N. program are available. For clients who choose the traditional access fee product, the access fee will continue to be treated as a claim cost. Summit Re receives no incentive payments for offering these network products to our clients. Our interest is to bring you effective programs and services to help manage your catastrophic risk. Please note that this program is only available through Summit Re.

U.R.N. Transplant Information and Reports

U.R.N. provides an extranet site, www.urnclient.com that contains the detailed quantitative and qualitative information collected during the network credentialing process. The site also contains contract information for each participating provider, maps for each U.R.N. network, referrals submitted to U.R.N., and the status of claims repricing for individuals referred for services through U.R.N. Many of the transplant contracts are negotiated based on “phases” of transplant. Below are the definitions of the phases:

Phase I Pre-Transplant Evaluation	All health services required to access and evaluate a member for acceptance into a transplant program.  Phase I ends upon the member’s listing with United Network for Organ Sharing (UNOS). For living donor organ transplants or organ transplants not listed with UNOS, Phase I ends upon the member’s acceptance into a transplant program.
Phase II Pre-Transplant Care	All health services provided to a member following acceptance into a transplant program, or listing with UNOS, and before the admission for the authorized transplant.
Phase III Transplant Procedure	All health services provided to a member from the day of admission for the authorized transplant until the earlier of the member’s discharge from the transplant facility following the transplant admission or transfer to transplant facility’s inpatient rehabilitation unit or facility.
Phase IV Follow-up Care	All health services provided to a member during the 90 day period immediately following Phase III.
Phase V Post Phase IV Health Services	All health services provided to a member during the one-year period immediately following Phase IV.

Quarterly Reports

During the month following each quarter, U.R.N. compiles a client network activity summary report reviewing all referrals received for transplants for that quarter. The status of the referrals and claims payments, access fees paid, and cost savings are included in the report. The report is forwarded to all Summit Re clients accessing U.R.N. through Summit Re. If you have any questions about the reports you receive, please contact Debbie Stubbs RN, MS, CCM at dstubbs@Summit-Re.com or Kari Lee at kari.lee@UHC.com.

Flexible, Multi-tiered Approach to Transplant Management

As the nation’s leading provider of transplant benefit management services, U.R.N. leverages over 46 million lives and its expertise to offer access to the most advantageous provider contracts available. To address all the needs identified by clients, U.R.N. has developed a multi-tiered approach for transplant patient management, which includes the following: Transplant Resources Services

TRS provides individuals in need of transplant services with access to expertise through the U.R.N. Transplant Centers of Excellence Network (COE). The COE Network is evaluated annually to help ensure that only those programs that excel in transplantation participate as members. The COE Network developed through U.R.N. offers the highest quality of care for patients, greater volume for providers, and lowest total cost for payers. Clients typically experience an average savings of 43% per transplant episode as compared to industry standard transplant costs.

Transplant Access Program

TAP was developed to address the challenge clients face when their members decide to use a non-COE Network transplant program. TAP provides geographical access and economic relief through prearranged contracts for transplantation at medical centers through the US.

Supplemental Contracts (Extra Contractual Services )

U.R.N.’s contracting expertise is available on a case-by-case basis through Supplemental Contracts, when a patient referral falls outside of both the COE and TAP Networks.  U.R.N. is able to negotiate discounts at these facilities for transplants and related services to provide economic protection for clients. U.R.N. is able to negotiate an average discount of 35% of billed charges.

Specialized Physician Review

Specialty physicians are available to review clinical information related to requests for transplantation and congenital heart disease (CHD) surgery/treatment.  Clients may elect to receive one or three written opinions by board certified, actively practicing physicians regarding the appropriateness of the transplant or CHD surgery/treatment. The clinical status and proposed protocol are addressed. Each clinical summary includes disease treatment statement, literature review, alternatives to care and community standards.

TransAdvise

A single phone call lets clients reach a U.R.N. nurse to request consultation regarding transplants, CHD surgery and complex cancer care. The nurses have extensive experience in the area in which they consult and have access to the most updated information regarding the types of care provided in each U.R.N. facility.

U.R.N Programs for Specific Diseases: Cancer Resource Services (CRS)

Treatment of many cancers is complex and costly, representing approximately $18 million per 100,000 lives per year. CRS targets the relatively small number of complex cancer patients that drive the majority of medical expense. The new cancer annual incident rate is 0.23%, with 1/3 of those cases considered complex. (SEER Cancer Statistics Review 1975-2000, National Cancer Institute.) There are significant practice variability trends for complex cancers. CRS provides unparalleled clinical and economic value in managing complex cancers by:

• Helping patients make informed decisions about their cancer care
• Connecting patients with experts at the 15 cancer centers in the
• U.R.N. Cancer Centers of Excellence Network.
• Helping payers manage their cancer costs by providing contractual discounts and realizing cost avoidance savings
• Procedure case rates for major surgical procedures in some contracts
• Discounts of 15%-35% for outpatient and physician services
• Lower case costs with shorter length of stay and cost avoidance by reducing unnecessary and inappropriate treatment

The U.R.N. Cancer Centers of Excellence delivers proven results.  An ROI of 2:1 to 4:1 is very achievable with good communication and implementation of referral strategies. U.R.N.’s fees are based on a percentage of savings.

Not all cancer diagnoses are appropriate for referral to CRS. Contact Debbie Stubbs at Summit Re if you would like a copy of the CRS referral diagnosis list.

U.R.N. Programs for Specific Diseases: Kidney Resource Services

End stage renal disease (ESRD) is a complex condition with considerable economic implications. Ongoing care can cost $15,000 – $40,000 per month and kidney failure leads to multiple co-morbidities such as cardiovascular disease, which is twice as common in ESRD patients. There is a significant variance in the quality of care provided to dialysis patients, with 40% of Medicare-certified dialysis facilities not meeting minimum standards of anemia management for 80% of their patients. U.R.N. provides clinical consulting and administrative services that can reduce complications and costs associated with ESRD, and U.R.N. fee structure ensures clients receive a high ROI for these services. Absence of negotiated contracts is costly, with some clients facing markups of over 500% on dialysis services.  Non-standard billing is not uncommon. U.R.N.’s Chronic Kidney Disease Extended Provider Network Services can help manage the cost while maintaining quality of care by focusing on the following:

• Medicare Eligibility Management
• Contractual Discounts
• Claim Audit/Re-pricing

Why Manage Chronic Disease?

  Employers, insurers and federal lawmakers increasingly are focusing on early intervention for potential chronic diseases to avoid hospital admissions and complications later in the disease process. Disease management is one of the fastest-growing areas in health care.

Federal Efforts

The federal government launched a disease management initiative to test capitated payment arrangements with qualified organizations for the case management of specific diseases. The targeted populations include Medicare beneficiaries with chronic illnesses and special populations, such as those eligible for both Medicare and Medicaid and the frail elderly. Historically, a small proportion of Medicare beneficiaries has accounted from the major proportion of Medicare expenditures. In 1996, 12.1% of all Medicare enrollees accounted for 75.5% ($126.1 billion) of all Medicare fee-for-service program payments.1   

Many of these beneficiaries have specific, chronic diseases and the majority of the care is for repeat hospitalizations. As the general population continues to age, the estimated cost of care for these individuals is expected to grow dramatically.

Private Sector Efforts

The level of interest regarding disease management is increasing. The Disease Management Association of America was formed to advance the practice of disease management and the National Association of Quality Assurance has established standards for disease management programs. Managed care organizations usually have some form of disease management programs in place, since there are clear incentives for managing care effectively. The  programs may be internally developed or outsourced to a disease management vendor.

Program Features

The definition of disease management and the program objectives may vary, but there are certain features that are common to all programs:

• Identification of members and assessment of severity and the need for interventions
• Use of evidence-based practice guidelines
• Monitoring compliance with the plan of care
• Promoting patient self management
• Routine reporting and feedback with patients, physicians, the health plan, and ancillary providers
• Collection and analysis of process and outcomes data

Programs may include the use of information technology, such as specialized tracking and documentation software, data registries, automated decision  support tools, and call-back systems.

Chronic Diseases

The majority of disease management vendors offer programs for asthma, diabetes, cardiovascular disease (congestive heart failure, hypertension), chronic obstructive pulmonary disease, maternity management (including high-risk pregnancy), and end stage renal disease.

Intervention

Levels of intervention are offered, ranging from distribution of educational information to frequent phone contact with patients and physicians. The level of intervention provided is based on the assessed needs of the  patient. Many disease management vendors now offer predictive modeling as a part of their programs. The predictive modeling system can analyze data from a variety of health plan sources to identify the patients who are consuming the greatest portion of healthcare dollars and have the greatest potential for future complications and admissions. This information can then be used to focus disease managementefforts on patients who have the greatest need and who offer the potential for the greatest return on investment.

End Stage Renal Disease

Among the chronic diseases typically managed by disease management firms, the diagnostic group that is most likely to result in a reinsurance claim is end stage renal disease (ESRD) with resulting dialysis. The average monthly cost for an ESRD patient is $15,000 to $40,000. The average time on the kidney transplant waiting list is 5 years. In addition, the majority of these patients have co-morbid conditions, such as hypertension, diabetes and cardiovascular disease, which result in costly hospital admissions. Eight out of every 100 Americans have some form of kidney failure.2   By 2010, 725,000  people are projected to have ESRD and to need dialysis or a transplant.3  ESRD cost the U.S. health care system nearly $19.3 billion in 2000. Costs are projected to double by 2010.4,5   The management of ESRD patients can vary widely, so having an ESRD disease management program is beneficial to a health plan where this disease is prevalent in the population.

Sources:

1. Federal Register Notices, Vol. 68, No. 40, February 28, 2003.
2. NKF-K/DOQI estimate.
3. USRDS 2003 ADR Report.
4. Hostetter, NKDEP presentation, 2003
5. Trivedi, et al, Am J K D, Vol. 39, No. 4, 2002

Reduce Costs With Case Management Notices

When members reach 50% of the reinsurance deductible, according to the reinsurance agreement, we must be notified. The issue is timing. The finance or claims department sends notices based on claims received and/or paid, but often bills are not submitted by the medical facility until the member is discharged, after the claim has reached or exceeded the 50% level. Summit ReSources would like to help reduce your costs; however, once claims are paid, it is harder to intervene with cost-reducing strategies. Usually your medical management department is aware of a potentially high-cost case because the utilization management staff are following the progress of the member and authorizing continued services. Summit Re has developed a case management notification process so that utilization management staff and case managers can notify us of potentially catastrophic, high-cost cases as soon as possible.

All of the case management notices received are reviewed by Debbie Stubbs, RN, MS, CCM to determine if there are ways to reduce cost while maintaining quality of care. Debbie will contact you to offer recommendations and alternatives.

Cases may also be referred even if there is little potential for reinsurance reimbursement if you want an objective, third-party review. Below are actual cases that were recently referred to Summit ReSources.

We are committed to helping you find cost-effective solutions. Regardless of whether the reinsurance deductible is expected to be exceeded, we encourage you to submit case management notices so we can put our resources to work for you. We have a form that can be used but will accept information in any format that works best for you. If you would like a copy of the case management notification form, please contact Debbie Stubbs.

Case Management Example 1

A member requested to go to a specific facility for cancer treatment. The facility was not in the health plan’s network but the request was approved. Global Claim Services, Inc. contacted the facility prior to services being rendered and negotiated a discount for the health plan.

Case Management Example 2

A member required surgery for congenital heart disease and the plan did not have a facility nearby that performed the necessary surgery. Summit ReSources provided the plan with   information about centers with the most favorable outcomes.

Case Management Example 3

A severely burned member was facing a lengthy hospitalization with a complex treatment plan. Paradigm Health provided an assessment by physicians and nurses highly experienced in the care of burn patients and developed a plan of care in conjunction with the treating team.

Summit ReSources Portfolio of Services

As a result of the survey and client conversations, the following Summit ReSources portfolio of services was structured.  Each vendor underwent a stringent due diligence process. An onsite visit to the primary facility providing the service was part of the process for the majority of the vendors. If you would like to learn more about any of the programs or have any questions, please contact Debbie Stubbs or Laura Pearce.   If there are other programs you think we should consider adding to Summit ReSources, please let us know. Transplant Management

United Resource Networks (URN)

URN offers consulting expertise and access to over 100 of the nation's most prestigious medical centers specializing in organ and tissue transplantation. Specialized Physician Review services are also available, whereby our customers can obtain independent, expert medical opinions of the appropriateness of proposed transplants for     specific members and in the area of congenital heart disease.

URN also has a Congenital HeartDisease program, which includes   access to a network of facilities that excel in the treatment of congenital heart disease (CHD).  The CHD programs complement the heart transplant expertise found within the URN transplant network.

Claim Recovery

Health Decisions, Inc. (HDI)

HDI specializes in benefit management services that produce a 3:1    return on investment within 12 months, while leaving current coverage intact.  HDI provides claim recovery and enrollment support services.

Disease Management

See related article (click here).

National PPO Network

GlobalCare, Inc.

By offering access to a 24-hours-a-day, 7-days-a-week Medical Help Desk, as well as through relationships with over 100 PPO networks andnegotiators, GlobalCare allows your members to have medical assistance and network access anywhere in the United States and around the world.

Predictive Modeling

Integrated Healthcare Information Services, Inc. (IHCIS)

Impact Pro is IHCIS’s industry-leading, rules-based predictive modeling tool that produces a measure of future relative risk, a prediction of future health care costs,  relative risk for an inpatient admission and the probability of one or more admissions for each   enrolled member of a health plan. These measures of risk can be used in medical management and have financial, actuarial and underwriting     applications. Impact Pro is used by leading health plans and clinicians across the United States, serving more than 30 million Americans.

Non-Network Claims Management

Global Claim Services (GCS)

GCS specializes in clinical and financial claims reviews, offering a personalized, process-oriented approach for out-of-network medical claims and fee negotiations for inpatient and out-patient facilities, professional services and ancillary fees.

Neonatal Intensive Care Management

See related article (click here).

Catastrophic Illness and Injury

Paradigm Health Systems, Inc,

The highly skilled staff specializes in management of a variety of catastrophic medical events, such as brain injuries, spinal cord injuries, complex burns and severe trauma.

Survey: Managed Care Programs Accessed by HMOs

To ensure that our services match the needs of our clients, we conducted a survey shortly after forming Summit ReSources. The purpose of the survey was to determine our clients’ satisfaction with the managed care vendors they had been accessing prior to the formation of Summit ReSources.  We also wanted feedback as to what types of managed care vendors would be most beneficial. Many of our clients were also contacted by phone or in person to determine what types of managed care programs they currently have in place. All clients have some form of utilization management, consisting of preauthorization for admissions and certain other services, and concurrent review of inpatient admissions.

Disease management programs are primarily internally developed and  focus on the diseases most prevalent within the particular health plan. The sophistication of the programs varies, as well as the degree of outcome reporting. Few health plans have a specific end stage renal disease program, which may be needed in the future.

Almost all clients have contracts with pharmacy benefit managers, which may include reduced pricing for high-cost specialty pharmaceuticals, or they have contracts with separate companies for those drugs. The contracts provide discounts off of the average wholesale prices of the drugs. Some companies also include supplies and home nursing (when medically indicated) as a part of the contracts.

The majority of Summit Re clients  access United Resource Networks (URN) for transplant services and are satisfied with the services provided.

Approximately 25% of our clients have contracted with a neonatal intensive care unit (NICU) management vendor.

About half have some form of out-of-network repricing. Price negotiations are done internally for some health plans or contracted out to a national PPO/repricing vendor.

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Did you know?

• URN access fees for transplant services may be submitted as a reinsurance claim expense if the member reaches the reinsurance deductible.
• NICU management fees for programs accessed through Summit ReSources are eligible claim expenses if the member reaches the reinsurance deductible.

Summit ReSources: Make It Your Managed Care Resource

Summit Re established its own managed care department, Summit ReSources, to give you  access to a comprehensive portfolio of services, specifically designed to reduce costs while improving quality of care. The primary goal of Summit ReSources is to be your managed care resource. Consultative Case Management

We are available for consultative case management which includes, but is not limited to, assessment and recommendations regarding utilization, disease and case management programs, access to external managed care vendors at preferred prices, catastrophic case discussions, specialty pharmacy issues and out of area solutions. There is no additional cost for accessing our consultative case management service.

Educational Resources

Summit ReSources has access to a variety of educational opportunities and information about medical management. As information becomes available, we share it with you.

Portfolio

A portfolio of services has been negotiated to help you manage your claims. They include:

Transplant Management

National PPO Network

Non-network Claims Management

Catastrophic Injury/Illness

Recovery/Coordination of Benefits

Neonatal Intensive Care Management

Predictive Modeling

Chronic Disease Management

Summit ReSources was created in September of 2004.  Debbie Stubbs is the primary contact and Laura Pearce is Debbie’s backup for managed care issues.  You will find more information about Summit ReSources on our website at www.summit-re.com/managedcare.asp.