|PR Newswire Association LLC|
Inappropriate utilization associated with physical medicine services represents a significant cost to Highmark group customers and members. Because of these utilization trends, more employer groups are requesting outpatient prior authorization programs for their members as a means to help control costs.
Highmark has contracted with Healthways (www.healthways.com) on this initiative. Healthways has a great deal of experience in this area working with other insurers, including
This program applies to Highmark members in insured groups in
"This program is one of a number of efforts that Highmark is tracking to help reduce unwarranted variations in the delivery of healthcare and to help manage rising health care costs," said
Dr. Calega also noted that Highmark is protecting members from overutilization because overuse errors can cause harm and waste health care resources. Ultimately, quality care drives cost efficiency.
"This prior authorization requirement only takes effect after the first eight visits," said Dr. Calega. "If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place." Highmark data also shows that nearly two-thirds of members have their needs met and resolved within eight visits.
In addition, a review of Highmark claims data for some practices during the past two years shows chiropractic care is the second highest paid service for members, second only to cardiac care.
"Analysis of data highlighted that nearly a third of member claims may not represent optimal utilization," said Dr. Calega. "We want to ensure that the services are medically appropriate."
Highmark paid more than
"Healthways' analysis of initial claims data indicates a high frequency of visits overall with a handful of members receiving more than 100 visits over the course of a calendar year," said
Highmark is also forming a provider advisory group specifically for this program to help make certain that the highest quality of care is being provided to members in the most efficient manner. The company has a number of other external physician committees that advise the company on a variety of issues. Highmark believes collaboration with health care providers is another important step in the process.
While health care reform law currently does not address the issue of rising health
care costs, initiatives like this one engage providers, insurers and members to more closely address the cost issue in health care.