Clinical Notification Triggers

The clinical notice form should be used by the medical management staff to notify Summit Re of potential cases where Summit ReSources may be of assistance to you. Use the clinical notification triggers list as a guide. The list is not all inclusive, so feel free to submit a clinical notification on any case for which Summit Re may be of assistance to you.

Diagnosis

• High cost pharmacy, such as Flolan, Factor VII, Factor VIII, Cerezyme / ICD-9: 272.7, 286.0, 415.0, 416.0, 416.8 
• Major burns with a potential for a prolonged hospitalization / ICD-9: 941.0, 942.0, 943.0, 945.0, 948.2-9
• ESRD/dialysis with monthly dialysis costs greater than $10,000 / ICD-9: V56.0, V56.8, V45.1 
• Major injuries or multiple trauma with a potential for a prolonged hospitalization and/or acute rehabilitation admission
• Premature infants with one or more of the following:
  • gestational age ≤ 24 weeks / ICD-9: 765.0 
  • severe congenital heart disease, e.g. hypoplastic left heat, Tetralogy of Fallot, etc. / ICD-9: 746.7, 746.01, 746.89, 745.2
  • severe gastrointestinal anomalies, e.g. gastroschisis, omphalocele, necrotizing enterocolitis, short bowel syndrome, etc. / ICD-9: 756.79, 777.5, 777.8, 579.3, 756.79
  • severe bronchopulmonary dysplasia requiring long term ventilator treatment / ICD-9: 770.7

Case Characteristics

• Out of network services with minimal or no negotiated discounts
• Billed charges that greatly exceed reasonable and customary for the services rendered – refer before the claim is paid
• Questionable charges, such as unbundling or experimental treatments
• Cases with the potential to exceed the reinsurance deductible
• Multiple inpatient stays

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Submission Process for Clinical Notices

1. Use the clinical notification triggers list as a guide for completion of clinical notifications submitted to Summit Re.
2. It is recommended that the clinical notices be submitted from the medical management department as they are usually the department first notified of a request for services.
3. Complete the Clinical Notification Form (all sections that apply to your case).
4. Completed forms may be faxed to 260-469-3014, emailed via encrypted software to claims@summit-re.com, or mailed to Summit Reinsurance Services, 7030 Pointe Inverness Way, Suite 350*, Fort Wayne, IN 46804.
5. In lieu of the clinical notification form, you may submit a report containing similar information.

*Address updated when this article was converted to this post in 2014.

Early Intervention Goal of New Clinical Notice Process

To better assist you in managing your risk and to minimize paperwork, Summit Re has significantly revised the notification process for high cost, catastrophic cases. The main goal of the revised process is to help you manage your risk while there is an opportunity to intervene. Under the current HMO reinsurance agreements, clients are required to notify Summit Re of members whose eligible expenses have reached 50% of the deductible. Currently, Summit Re receives the majority of the 50% notices from finance or claims departments. By this time, the claims have already been paid by you, and it is usually too late to implement any additional interventions that may help mitigate costs, as illustrated in the two examples below.

Summit Re will no longer require submission of a 50% notice report from the finance/claims area. Instead, we are requesting clinical notices from the medical management department. The clinical notices will be much more actionable, since services may still be in the pre-service negotiation phase, the case may be undergoing concurrent review and claims have not yet been paid.

As reinsurance agreements are renewed, the language regarding 50% notices will be revised to reflect the new process. The revised referral trigger list (CLICK HERE) keeps the focus on situations where Summit Re may be of assistance to you.

Medicare Revenue Recovery ReSource

Medicare reimbursement is one of the top issues that our clients face, so we’ve identified a unique way to make your Medicare revenue recovery much less of a headache. Beam Partners, LLC specializes in helping healthcare plans recover additional Medicare premium by using custom software that combines your medical claims and pharmacy data to identify the medical records that qualify.

Morbidity-based payments

The Medicare Advantage program operates under a diagnosis-based risk adjustment system that pays higher monthly capitation rates for enrollees with higher morbidity levels. Diagnosis codes extracted from medical claims are submitted to Centers for Medicare and Medicaid Services (CMS). CMS uses these diagnoses to assign enrollees to disease categories. The problem is that medical claims often do not reflect the enrollees’ true morbidity:

• Only a fraction of the diseases and conditions documented in the medical record ever make it to the claim form or record submitted to the health plan.
• New enrollees often have inadequate claims information.
• Inadequate diagnosis coding is common because diagnosis codes rarely factor into the claims adjudication process.

Every disease not submitted to CMS that is included in the CMSHCC (Hierarchical Condition Categories) model represents lost revenue. This lost revenue is most acute for patients with comorbidities, who are likely to require a disproportionate share of your resources.

Lost Opportunity

If you have not reviewed medical records for additional HCCs in the past two years, you may have given up significant revenue. The portion of the capitation payment attributable to medical diagnosis is being phased in by Medicare Revenue Recovery ReSource CMS through 2007, at which time 100% of the premium payment will be risk based. The table gives the transition schedule.

Results

Working closely with your staff, Beam clinical staff assesses data and medical charts to maximize recovery of lost premium. The results can be substantial. Based on its experience, Beam Partners estimates recoveries of about $3 million for every 10,000 members in the Medicare plan. Therefore, for plans with 25,000 members, approximately $7.5 million of additional recoveries is typical.

Contact: Your Summit Re account manager or Brian Fehlhaber, VP, Sales and Marketing at 260-469-3004 or bfehlhaber@summit-re.com.

Information-Based Decisions with TransAdvise

URN’s TransAdvise is a new complimentary service for our clients who have contracts with URN. TransAdvise clinical consultants can assist you and your members by providing information about transplant-related diagnoses and treatment options. A dedicated team of transplant nurse experts who work with more than 12,000 transplants each year are available to provide:

• Transplant program performance information (e.g. annual volumes and outcomes) to help patients make more informed decisions about their transplant care.
• Information about relevant clinical trials and treatment protocols based on diagnosis or underlying condition.
• Assistance in referral to Transplant Centers of Excellence Network programs to maximize clinical and financial outcomes.

These services help you and your members make more informed decisions about transplant care with the goal of better outcomes.

Access to TransAdvise is direct, flexible, easy, and free to our clients. Simply call (800) 343-4305 to speak with a TransAdvise clinical consultant or provide this number directly to your members. TransAdvise clinical consultants are available from 7:00 a.m. to 6:00 p.m. CST, Monday through Friday. Conference calls with a TransAdvise clinical consultant are also available for you and your members.

Summit Re/URN Transplant Program

The Fall (October) 2005 edition of Summit Perspectives detailed Summit Re’s new transplant program features with United Resources Networks (URN). Some key points to keep in mind regarding the program are:

• URN access fees are discounted for transplant services on business reinsured through Summit Re. These discounts are not available by directly contracting with URN or through any other reinsurer.
• URN will extend the Summit Re discount fee arrangements to a new Summit Re client who was using URN through another reinsurer.
• A Summit Re client does not have to use URN exclusively in order to obtain the discounted access fees for transplant services where URN is utilized on business reinsured through Summit Re.
• Zero Access Fees (ZAP) is an exclusive URN arrangement with Summit Re. It provides for alternative transplant facility terms with no access fees. These terms can be elected on a case-by-case basis at the time of each transplant referral.

Please contact Debbie Stubbs RN, MS, CCM at dstubbs@summit-re. com if you have any questions or would like additional information concerning the Summit Re/URN Transplant Program.

Manage Your Transplant Risk More Effectively with New Program

Selecting a Network The most important consideration when choosing a transplant network should always be the quality of care delivered.  A secondary but important consideration is the cost effectiveness of the network.  A network that charges access fees but has greater net savings overall due to more favorable negotiated arrangements with network facilities is preferable to a transplant network that charges no access fees but has less effective contracts.

New Program

Summit Re recently conducted a thorough assessment of three transplant networks. (See table on page 3.)   As a result of that assessment, we concluded that United Resource Networks (U.R.N.)  provided the best overall value.  Therefore, we agreed to enter into an exclusive arrangement with U.R.N. for the provision of transplant services for our clients.  We have been able to negotiate lower access fees because of this exclusive relationship.

Access Fees

Under the new program, our clients will have their access fees for each transplant reduced by 5% due to Summit Re’s exclusivity with U.R.N.  An additional 5% reduction can be realized if clients incorporate certain benefit incentives into their plan designs for the use of U.R.N. facilities and use them exclusively.  A third discount is based on Summit Re’s total volume of business with U.R.N.

Make the Change

This program replaces the previous benefit that Summit Re had negotiated with U.R.N. – namely, a waiver of the 35%-of-savings fee U.R.N. normally charges for cases that access U.R.N. facilities but do not result in transplantation.  The current program is still available to existing Summit Re clients who access U.R.N., but we recommend the new program.  Summit Re will contact current clients to discuss the program in greater detail.

Access Fee Discount	Source
5% discount	Summit Re’s exclusive marketing of U.R.N. for transplant services
5% discount	Client’s exclusivity agreement and benefit differentials
Up to 10%	Summit Re’s total volume of business with U.R.N.*
Total Discount: Up to 20%

*This portion of the discounts will be calculated retrospectively by U.R.N. on an annual basis.  The discount is available to clients who have reinsurance coverage through Summit Re that is in effect on the date of the payment to Summit Re.

Transplant Facts: Costs and Incidence

The cost of transplantation can be staggering and continues to rise as new technology and pharmacology become available.  

Incidence of Transplants

According to the United Organ Sharing Network (UNOS), there are currently over 89,000 patients listed for a transplant.  The breakdown of types of transplants as a percentage of the total is shown in the chart below.  There continues to be a disparity between the number of transplants requested and the number of organs available. Only 40% of the patients waiting for a solid organ transplant will get one. To view the current wait list statistics and the number of transplants completed and organs donated, please go to www.unos.org.

Comparison of Transplant Programs

Summit Re engaged in a stringent due diligence process prior to making the decision to enter into an exclusive agreement with United Resource Networks (U.R.N.) for transplant management. Below you will find a comparison of the type of information we considered:

Size & Scope	U.R.N.	INTERLINK	LifeTrac
Covered lives	46 million	20 million	15 million
Annual transplant referrals	10,000+	900	1,800
Centers available	108+	44	47
Average network discount across all five phases	43%	31%	31%
Dedicated personnel (excluding claims repricing):Licensed medical / clinical staff Support staff Total	86 97 183	2 10 12	3 6 9
Pricing
Per diem for all phases of care in most contracts	Yes	No	No
Organ & bone marrow acquisition included in all case rates	Yes	Some	Some
Access Fees	$3,500 - $20,000	$3,000 - $13,000	None
Services
Complete utilization & financial reporting	Yes	Yes	Unknown
Web access to comprehensive medical center data	Yes	No	Yes
Transplant case-management services available	Yes	No	No
Quality & Credentialing
Physician advisory panels	4	No	No
Education
Annual education conferences	5+, on-line CEUs	On-line CEUs	No
Annual client conference	Yes	No	Unknown
Other Products
Able to take or share economic risk for transplants	Yes	No	No
Specialized pediatric credentialing and network	Yes	No	Yes
Congenital heart disease program and network	Yes	No	No

Disclaimer – Competitor information is based on data available through a variety of sources. Specific detailed information should be sought directly from each competitor to ensure reliable comparison data.

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.