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Medical Policy Innovation

How we do things differently

Medical policy has an enormous impact on patients and the physicians and clinicians who serve them because medical policy determines what care the insurance plan will pay for. In fact, 90% of physicians and clinicians surveyed in 2021 told us that it is important to them that those who provide care to patients greatly influence the medical policy of the health plan.   

Physicians guide our medical policy in a way that is unmatched by any other prepaid health plan in North Carolina. We strive to have policies that are provider-friendly and give the best care to patients.

We do this in two ways. First, Carolina Complete Health Network organizes groups of medical experts to vet the plan’s medical policy. Second, physicians sit on the plan’s board of directors, and they endorse any recommended changes to the policy. 

Here are three examples of how we lead the way in medical policy:

 

Pay Emergency Room visits for the care that was provided. We removed a policy that retrospectively paid some Emergency Room procedures at a rate that was lower than what providers expected. 


Adopt payment policies that favor in-office laboratory tests. Continuity of care is greatly helped by providers performing laboratory tests in the office. For this reason, we both leveled-up payments for in-office lab tests and added ten in-office laboratory tests to the current medical policy.

Make sure patients have options that include emerging technology. Thanks to the input of a standing expert workgroup and a pediatric ear nose and throat specialist, we added Sound Arc coverage to the Soft Band and Implantable Bone Conduction policy. Technology changes rapidly. Having communication channels directly with those who provide care ensures we have the most up to date information regarding options for patient care

Current Medical Policy Workgroups: Accomplishments and Priority Areas

2022 Priority Areas:

  1. Recognition and payment for independent practices (vaccinations, testing, etc.).
  2. Review options for a unified database to improve continuity of care.

2021 Accomplishment:

  • Instrumental in advocating for and assisting with providing feedback regarding additional coverage for the In-Office Physician Lab Policy. 

2022 Priority Areas:

  1. Expansion of after-hours access (urgent care, telehealth, etc.).
  2. Addition of emergency department telehealth CPT codes to Medicaid approved list.

2021 Accomplishment:

  • Emergency Medicine: Instrumental in advocating for and providing feedback that led to CCH not adopting or attesting to the Emergency Room Code Leveling policy that was traditionally in place for Medicaid.

2022 Priority Areas:

  1. Easier Access to available therapists
  2. Review options for one EMR for patient data to improve continuity of care.

2021 Accomplishment:

  • Instrumental in advocating for provider education regarding Tailored Plans.

2022 Priority Areas:

  1. No PA on highly approved codes.
  2. Provider education for pediatric complex coding.

2021 Accomplishment:

  • Collaborative efforts with the Emergency Medicine and Primary Care workgroups to decrease inappropriate/preventative emergency room visits.

2022 Priority Areas:

  1. Provider and member education regarding expansion of Medicaid coverage for postpartum mothers.
  2. NIPT coverage for all women regardless of risk.

2021 Accomplishment:

  • Instrumental in advocating for postpartum coverage extension from 90 days to 12 months.

Any physician (MD, DO, NP, PA) or behavioral health clinician can participate in their specialty-matched Medical Policy workgroup as long as they are a participating CCH provider. For more information on getting involved with Medical Policy, please email us at ProviderVoice@cch-network.com