During my 32 years in clinical practice I must have submitted thousands of requests to the various Health Plans for prior authorization and for formulary exceptions. The approvals were always welcome, while the denials were annoying at best and downright infuriating at worst. For all I knew, decisions were made by throwing darts at a board or flipping a coin. In February 2010 I crossed over to the “dark side” as one of my former partners intoned. Since joining the Lovelace Health Plan as an Associate Medical director, I have come to learn that there is a lot of light that needs to be shed on the process and how decisions – both approvals and denials are made.
Precertification, also known as a prior authorization is a process to review coverage requests for health care services for member eligibility, benefits, and medical criteria. If the member is lacking eligibility or does not have the benefit requested, then the request is denied by Health Plan staff and does not come to the attention of a Medical Director. Neither the Health Plan nor a Medical Director can “create” a benefit that isn’t there. Health Plan reviewers may approve medical requests for prior auth if the request meets criteria. All medical denials must be reviewed by a Medical Director.
All Health Insurance companies are highly regulated (the State Department of Insurance, CMS, and HSD) and we (the Health Plan and Directors) are bound by those regulations in what we can and can’t deny. Decisions for both approval and denial must be supported by evidence based criteria and are not made arbitrarily. We use guidelines from several different organizations: to include Trailblazer Medicare LCD, Milliman Care Guidelines, Cigna, Anthem Blue Cross, Aetna, Apollo Managed Care Consultants, Medical Assistance Division (Medicaid) guidelines as well as Company developed clinical criteria sets just to name a few. When the evidence base is lacking, we will do a literature search or consult ECRI (an independent evaluator of healthcare technologies and services) for clarification. We also rely on clinicians in the community for their guidance and input as to what is the norm or community standard for a procedure.
Medical Directors also perform concurrent reviews on inpatient stays and rehab. Retrospective reviews are done on emergency room utilization and appeals. The goal of the ER Retro review program is to steer members to their primary care physicians (during office hours) and to Urgent Care Centers for non-emergent problems. A consequence of the program is that a handful of hospitals around the state have attached Urgent Care Centers right next to their ERs and are triaging non-emergent cases there.
Medical Directors meet every 2-3 weeks and are evaluated annually. An Inter-rater reliability review helps to ensure that we are “all on the same page” and consistent in our reviews. We also meet twice a year as a committee to review precertification criterion. In conjunction with Pharmacy staff, Formulary exception criterion are revised throughout the year and meetings are held every 2 months to assess new technology (devices, procedures) and set criteria for their use.
This brief synopsis is by no means all inclusive. There are many meetings that require our presence for NCQA or other accrediting purposes. We hope this sheds some light onto what we do and that when we call or request more information understand that we do so in order to provide every opportunity for approval. The bios and photos below should help to put a face with the caller.
Mark Cohen
Associate Medical Director – Lovelace Health Plan
 | John Cruickshank, DO, MBA, CPE, Board Certified, American Board of Osteopathic Family Practice Board Certified Physician Executive, American College of Physician Executives
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 | John Iacuone, MBA in Medical Management, Fellow American Academy of Pediatrics, American College of Physician Executives, and American College of Health Care Executives
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 | Mark Cohen, MD, Diplomate American Boards of Internal Medicine & Rheumatology, Fellow American College of Rheumatology
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 | Jami Frost, MD, Diplomate American Board of Pediatric Hematology/Oncology Medical Director |
 | Denise A. Leonardi, M.D., MBA, FAAFP |
 | Beth Sanchez, PhD
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