Feb 28th 2019

Faces of eviCore: Dr. Arnold Wax

eviCore is proud to introduce our next physician in the Faces of eviCore series: Dr. Arnold Wax. Originally from New York, Dr. Wax specialized in oncology but has been performing medical reviews since the 90s, he says, for fun! He has testified in courtrooms, representing as a defense expert in malpractice cases. Dr. Wax has continued to do medical reviews throughout his career, he says, because he likes to see how other people practice, and learn from them. This experience previous to his tenure at eviCore was inherently more retrospective than prospective, but attempting to practice more prospectively has been a welcome challenge for him. 

As he puts it: "Practicing medicine retrospectively is easy; practicing medicine prospectively is very, very difficult."

The Highlights of Peer-to-Peer Calls

The best way to approach a peer-to-peer review, says Dr. Wax, is to remember that you get to build rapport in a peer-to-peer relationship. Speaking with a lot of the same people over and over again means that there is an opportunity to build a relationship of trust. He likes to humanize the nature of the call by asking how they're doing, acknowledging that time differences sometimes mean that it's much later where they are, and mentioning that "I hope I'm not disturbing their lunch break—that usually gets a laugh."

"I really enjoy talking to (nurse practitioners) and (physician's assistants)," says Dr. Wax, "it's not hard to build kind of a personal relationship with them." 

The Challenges of Medical Reviews

A hurdle difficult to overcome, he says, is when people approach these reviews as potentially adversarial. "It's all coverage," he says, "and medical necessity and coverage don't always go hand in hand; unfortunately, we can't overturn a policy, but we can provide alternatives that will be covered." Since eviCore doesn't directly represent a plan, it can be a challenge to describe exactly where we fit into the healthcare system. The best way, according to Dr. Wax, is to describe ourselves as, "indirect advocates for the patients trying to do something that follows the guidelines."

For him, the hard part is when others in the healthcare system don't understand what we are trying to do. Ultimately, we are trying to maintain patient safety, limit radiation exposure, and do the right test the first time around.

Exceptions Are Few and Far Between—and With Good Reason!

In the current state of prior authorization, reviewing medical directors are still able to use their judgment and clinical expertise, and that's a good thing for patients, says Dr. Wax. "If we make an exception for one, the law states it's an exception for all—so unless it's an extenuating circumstance, we often can't make exceptions." Having worked a long time in federal appeals (a 3rd level of review), he's well versed in the legality surrounding exceptions to coverage policies. In addition, with his longtime experience meeting the requirement that he produce two current research references (younger than 5 years) to back up his reasoning and his decision at that level, he is well-versed in the medical literature.

Three important things, he says, should be remembered when dealing with prior authorization and peer-to-peer reviews:

1. Try to provide education on navigating the healthcare system. For example, he explained, Medicare will approve the first scan, but any follow-up PET scans must to go directly through the health plan.

2. If plan policy dictates, then—even if the clinical guidelines say otherwise—we can't force it to be covered. It would require an appeal to the health plan.

3. eviCore is first and foremost a third-party administrative team which reviews the imaging requests and makes a determination about medical coverage based on plan coverage policies and guidelines. Plans requirepeer-to-peers prior to accepting a direct request.

There are exceptions to the rules, he says, and we work hard to make sure that patients get the appropriate and timely care they deserve. For example, if approving a PET scan for someone with an infection means the difference between that person having to endure open heart surgery or a simpler solution, that is a legitimate exception, and the reviewing medical director is fortunately still able to make the call to go ahead with the imaging with the requesting physician. "Saving someone from a highly invasive procedure like that you can make exceptions for the policies."

Ultimately, gaining the trust of the stakeholders is one of the most important factors in performing medical reviews. Dr. Wax sees a lot of value in building rapport with his regular physicians, PAs, and other medical professionals because they can grow to appreciate his expertise—and even come to see him as a committed partner working towards a healthier and more stable healthcare environment.