I just completed a training course with CoreCare National, the third party provider who will be managing this process and let me tell you - it isn't going to be fun. It isn't difficult and one of the benefits of CoreCare is that they guarantee that if your case needs to be reviewed for any reason, your request for authorization will be reviewed by a peer in your field AND if you need to talk to to someone about next steps you will talk to a peer as well, but this is a big barrier to treatment that we are all just going to have to deal with.
Here are some highlights of the training to help you navigate these new waters.
CoreCare National - What's to Know
Beyond that, you must submit a Treatment Request that documents medical necessity for additional treatments. That means you need the following:
- Valid Diagnosis Code (there are guidelines and lists on the CoreCare Website, but choose something that includes PAIN and you're more likely to be approved)
- Documentation of Measurable Improvement - i.e. orthopedic tests, ROM percentages, disability scores, pain scale notation
- Proof via Measurable Data (above) that the patient is improving but still requires treatment
- NOTE that NEW CONDITIONS are validation for additional treatment so if you're treating 5 things for a patient, you might consider billing for only one, and then adding additional ones as new conditions over the course of the year.
CareCore also really emphasizes home care so be sure you are giving your patients homework to improve and that you are charting what you are giving them and how you are counseling them on continuing home care activities.
From the webinar I just attended, one of the best codes you can use for female patients is Dysmenorrhea - because it is expected that the patient is going to have this pain every month, and if Acupuncture is sufficient to help relieve it without pursuing additional expensive western therapies (such as laparoscopy for endometriosis) they are going to count that as a bonus and a good reason to continue covering Acupuncture treatment.
Most pregnancy related issues such as induction and breach baby presentation are not covered, and if you're treating anxiety and depression you better find a physical manifestation of pain associated with the condition or they most likely are not going to fund it.
FEP or Federal Employee Program members are exempt from the new CareCore National program (phew!) so no changes there, and no changes have been made in treatment codes covered, so any treatment code that was paid previously on any given plan will still be paid now through this system.
The Good News?
If you work with Health Net or American Specialty Health, this process will be relatively old hat - it is much the same. They made mention of a "tier status" much like ASH uses, but there were so many basic questions in the webinar they couldn't get to explaining it. Presumably, it will be much like ASH - the longer you are connected to CareCore, the higher your tier status and the more treatments will be approved with any given request.
At any rate, we don't have a choice - working with CareCore for authorization is required for all of starting in just two weeks time so buck up, get registered and run a few test patients through the system this week to make sure you're up to speed and can add this into your workflow without too much difficulty sooner rather than later.
CareCore's provider relations team is very friendly too, so don't hesitate to call. And good luck!!
Until Next Time,