New Musculoskeletal Surgical Quality and Safety Management program

Date: 09/27/19

To Our Valued Providers,

Ambetter from Peach State Health Plan is pleased to announce a new Musculoskeletal Surgical Quality and Safety Management program for Ambetter members.  Ambetter from Peach State Health Plan has contracted with Turning Point Healthcare Solutions, LLC (TurningPoint) to work collaboratively with physicians to promote patient safety through the practice of high-quality and cost-effective care for members undergoing musculoskeletal surgical procedures. As part of this program, Ambetter from Peach State Health Plan has delegated its utilization management function to TurningPoint for a limited scope of orthopedic and spine surgical procedures.

Our comprehensive solution integrates evidence-based utilization management guidelines with clinical best practices, site of service optimization, specialized peer to peer engagement, device and recall management, claims review and management, innovative quality programs, and advanced reporting and analytics to promote the overall health management of each member. This program will utilize clinical guidelines that are based upon nationally recognized, evidence-based criteria for determining medical necessity in musculoskeletal surgical procedures.

Program highlights include:

• Administrative tools to support an efficient, user friendly authorization process for procedures requiring precertification, in addition to recommended medical necessity determinations for procedures which do not require precertification. Easy and efficient post-procedural documentation submission which will be shared with Peach State to facilitate timely claims payment.
• Specialized peer-to-peer engagement where a TurningPoint physician (from the same specialty) engages the provider regarding authorization requests that require additional clinical discussion to validate the clinical appropriateness of the procedure specific to the patient’s needs and current condition.
  
• Clinical support tools to assist in the tracking and monitoring of patient outcomes and education around patient risks and preventive measures to better coordinate care for the member and reduce infection rates and complications due to patient comorbidities.
• Provider performance reporting and analytics that give physicians and practice administrators greater visibility and transparency into their performance compared to the practice and similar peer Specialty practices, as well as the rest of the market.
• FDA recall tracking and monitoring to facilitate timely and consistent notification to the physician, patient and to Peach State when a member has received or needs a revision surgery due to a Class I or II FDA device recall.

This correspondence serves as notice under your Participating Ambetter from Peach State Health Plan Provider Agreement of these program changes, effective November 1st, 2019. Physicians must begin submitting requests to TurningPoint for Prior Authorization beginning on October 1st, 2019 for dates of service on or after November 1st, 2019. While it is the responsibility of the rendering physician to obtain prior authorization, facility providers are encouraged to contact TurningPoint to verify the prior authorization has been complete for Peach State members prior to admission.

Prior authorization for medical necessity and targeted length of stay, when applicable, has been delegated to TurningPoint and will be required for the following surgical procedures in both inpatient and outpatient settings:

MUSCULOSKELETAL

Orthopedic Surgical Procedures

Including all associated partial, total and revision surgeries  

• Knee arthroplasty
• Unicompartmental/bicompartmental
  knee replacement
• Hip arthroplasty
• Shoulder arthroplasty
• Ankle arthroplasty
• Wrist arthroplasty
• Acromioplasty and rotator cuff repair
• Anterior cruciate ligament repair
• Knee arthroscopy
• Hip resurfacing
• Meniscal repair
• Hip arthroscopy
• Femoroacetabular arthroscopy
• Ankle fusion
• Shoulder fusion
• Wrist fusion
• Osteochondral defect repair

Spinal Surgical Procedures

Including all associated partial, total and revision surgeries

• Spinal fusion surgeries
• Cervical
• Lumbar
• Thoracic
• Sacral
• Scoliosis
• Disc replacement
• Laminectomy/discectomy
• Kyphoplasty/vertebroplasty
• Sacroiliac joint fusion
• Implantable pain pumps
• Spinal cord neurostimulator
• Spinal decompression     
• Osteochondral defect repair

Key provisions:

• Emergency-related procedures do not require authorization.
• It is the responsibility of the ordering physician to obtain authorization.
• Providers rendering the above services should verify that the necessary authorization has been obtained; failure to do so may result in non-payment of your claims.
• Clinical policies are available by contacting TurningPoint at 1-855-444-0303 for access to digital copies

Training:

Information webinars are available! Please register at attendee.gotowebinar.com/rt/15432042808764162.

We appreciate your support and look forward to your cooperation in assuring that Peach State members receive high quality, cost-effective care for these surgical procedures.

We will provide additional information and training opportunities as we get closer to the effective date of the program. If you have any questions, please contact Ambetter from Peach State Health Plan Provider Services at 1-855-444-0303.

Sincerely,

Steve Dziabis, MD

SVP, Medical Affairs

Peach State Health Plan