Wellmark Enhancing Some of Its Business Practices in Conjunction With Love Settlement

As part of the settlement, the Plans agreed to make business practice enhancements to their claims payment systems and administrative processes. The final order date had not been determined when this publication went to the printer, but it could be as early as November 14, 2007, when the settlement hearing is scheduled. Once the final order date is set, Plans will have a timeframe to fully implement the terms of the settlement. Various timeframes are allowed for implementation.

Here is a synopsis of some of the key changes that Wellmark is in the process of implementing or has implemented:

Precertification Programs

• Post routine precertification requirements on www.wellmark.com and update when changes occur
• If a self-funded group chooses customized precertification requirements, those unique requirements, with the approval of the group, will be posted on www.wellmark.com

Medical Necessity Determination/Experimental or Investigational Treatment

• Update medical necessity definition in member and provider contract language
• Update member contract language to advise members that they cannot be billed for services that were denied as not medically necessary, experimental, or investigational, unless the member has signed a waiver prior to receiving services
• Formalize an internal and external provider appeal process for adverse determinations relating to medical necessity, or experimental or investigational services

Medical Necessity Language

• The settlement recommends Plans encourage self-funded groups to use the medical necessity definition that is outlined in the settlement: “Medically Necessary” or “Medical Necessity” means Covered Services that a physician, exercising prudent clinical judgment, would provide to a Covered Person for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Person’s illness, injury or disease; and (c) not primarily for the convenience of the Covered Person, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered Person’s illness, injury or disease.

Billing and Payment

• Providers must have at least 180 days to file claims from the date of service; Wellmark’s claims filing guidelines give providers 365 days to file claims from the date of service
• To align member claim-filing guidelines with provider claim-filing guidelines, timeframes for member-filed claims will also be 365 days from the date of service; currently, most members have the entire following calendar year to file a claim (i.e., for any service in 2006, members have until December 31, 2007, to file a claim)
• Formalize a dispute resolution process for
  physician billing disputes

Overpayment Recovery Process

• Wellmark will not initiate overpayment recovery efforts more than 18 months after the payment is received by the physician
• If a physician requests an appeal within 30 days of receiving a request to repay an overpayment, the physician is not required to repay the alleged overpayment until the appeal takes place

Wellmark Health Plan of Iowa Receives NCQA Excellent Rating

• Access and Service
• Qualified Providers
• Staying Healthy
• Getting Better
• Living with Illness

Wellmark Health Plan of Iowa received four stars (the highest rating possible) in all five categories.

Are "New Drugs Really New or Simply More Expensive?

When a drug is developed, it typically has two isomers.  For example, even though your hands both have four fingers and a thumb they aren’t exactly alike, but are mirror images of each other.  However, your hands perform the same functions.  The same analogy holds true with an isomer in the drug world.  Isomers are simply molecules (hands) with the same chemical formula but arranged differently. 

Many common drugs are often first marketed by pharmaceutical companies as a combination of two isomers.  When the patent expires for the original drug, the manufacturer advertises a single isomer formulation under a new patent and new brand name.

Prilosec vs. Nexium
For example, Prilosec was the first proton pump inhibitor introduced to the market.  When Prilosec lost its patent, omeprazole (generic form of Prilosec) and Prilosec OTC became available.  Chemically, Prilosec, Prilosec OTC, and omeprazole are exactly the same. 

But as the chart shows, the price is different.

To maintain market share, the manufacturer of Prilosec introduced Nexium (esomeprazole) to the market.  Nexium costs nearly $160 for a 30-day supply.

While Nexium may be marketed as the “healing purple pill” and lead you to believe it is different, it is actually the same molecule as Prilosec/omeprazole with the same chemical formula – simply arranged differently.  Studies have shown it does not provide a therapeutic benefit at similar doses over the lower cost alternatives.

Prior Authorization Strategy
Because Nexium and omeprazole have the same chemical formula arranged differently but with a four-fold price difference, Wellmark implemented a prior authorization program in May 2007 that requires your employees to try Prilosec OTC or omeprazole first.  If either of these options do not work, the next step is to try Prevacid, a second tier drug, before moving to Nexium and other options on the third tier.

These strategies are helping Wellmark deliver a pharmacy program that supports the most clinically effective drug therapy at the lowest total net spend.

Isomeric Drug Examples
Here are some examples of popular isomeric drugs and their lower cost generic or over-the-counter (OTC) alternative:

References:
www.drugstore.com, 9-10-2007
www.pharmacistsletter.com
www.ti.ubc.ca/node/5

Smart Enrollment Strategies for Your Employees

What You Can Do
Order our worksite promotion materials to help promote online registration at www.wellmark.com. Your employees will find convenient self-serve tools and information that can make it easier to find health plan answers.

Be on the lookout!
Wellmark is implementing exciting changes for your employees’ online experience at www.wellmark.com. Early next year, members will have instant access to online tools such as health management tools, pharmacy benefits, and eligibility verification and benefits information. Wellmark is currently developing worksite educational materials to help educate your employees on these changes. Stay tuned for more details in future issues of NEWS FROM BLUE!

Send Us Your Thoughts

We are constantly striving to improve the way we communicate. Tell us what you think about News From Blue by filling out the survey inserted in this month’s publication. Your comments are valuable to us in better serving your needs throughout future issues of NEWS FROM BLUE.

Are You Ready for Flu Season?

Wellmark Blue Cross and Blue Shield is making it easy for employers to conduct a successful flu shot clinic with a free implementation guide (M-23253) and promotional materials, including a table tent (M-20230) and poster (M-20231).

Iowa employers can contact Visiting Nurse Services (VNS) of Des Moines about conducting a flu shot clinic. An interest form (M-23252) is available for Iowa employers to complete and return to VNS.

Schedule flu shots today to help protect your employees and business tomorrow!