S000000390 Managed Care for Workers Compensation Q and A Additional Question II.pdf
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- Attached to
- Managed Care for Workers' Compensation
- Solicitation number
- S000000390
- Issued by
- Arkansas
About this file
This Q&A document is part of a solicitation (S000000390) from the Arkansas Department of Transformation and Shared Services regarding Managed Care for Workers' Compensation services. The document specifically addresses questions about Pre-Certification and Utilization Review services, clarifying that Pre-Certification is considered a subset of Utilization Review that involves approving procedures or hospitalizations prior to service provision based on evidence-based medicine principles.
The Q&A clarifies important pricing and operational details, including that the state will not accept a percentage of savings model for Out-of-Network negotiations, preferring an hourly rate structure. However, the state is willing to accept a flat rate for both prospective Pre-Certification and retrospective Utilization Review services when performed by the same team. The document also explains that Utilization Review encompasses both pre-certification and retrospective reviews for issues such as inappropriate bundling/unbundling, upcharging, services not meeting evidence-based medicine principles, and inappropriate "By Report" charges.
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Text version
QUESTION NUMBER QUESTION SUBJECT QUESTION TEXT ANSWER TEXT
2.1 Pre-Certification
Based on the State's responses to questions #20 and #22 in the first
Q&A round, it appears that you are using the terms "Utilization Review" and Pre-Certification" interchangeably. Is that correct?
We consider Pre-Certification a subset of Utilization Review. Pre-Certification involves approving procedures or hospitalizations prior to providing the services based on evidenced-based medicine principles. Utilization Review that is not Pre-Certification involves retrospective reviews for appropriateness and further potential cost savings. Examples of this are review for inappropriate "bundling" and "unbundling;"
upcharging for services; services that do not meet evidence-based medicine principles; and inappropriate "By Report" charges.
2.2 Pre-Certification
If that is not correct, can you help us understand what services beyond
"normal bill review" are in scope with the hourly rate requested on the pricing document?
See answer to 2.1.
2.3 Utilization Review
Our internal Utilization Review department is separate from our Bill
Review department and is staffed by RNs that would be responsible for both prospective Pre-Certification of hospital stays and other treatments as directed by AR regulations AND retrospective review of incoming medical bills that are flagged for further review for clinical appropriateness and potential cost savings. Assuming the State desires to have both services as a part of their solution, would you be willing to accept a flat rate for both services since they are similar in scope and are performed by the same team?
Yes.
2.4 Out-of-Network
Negotiations
Out-of-Network negotiations on medical bills is traditionally billed on a percentage of savings basis as opposed to an hourly rate - this allows us to utilize our existing bill structure as well as utilize collected fees to defend our reductions against provider challenges/objections at no cost to the State. Would the State be willing to consider a percentage of savings model for Out-of-Network negotiations?
No.
S000000390 Managed Care for Workers' Compensation Q&A Additional Questions II
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