Musculoskeletal
EviCore by Evernorth Musculoskeletal (MSK) solution addresses the full spectrum of care, from holistic and conservative approaches to more advanced procedures. We apply the most current evidence-based guidelines and technologies to ensure that the right care is delivered for safe, effective and affordable MSK care.
Interventional pain (non-surgical management)
Interventional pain procedures are an important component of our comprehensive pain management program. Evidence continues to show the broad and rapid increase in the prevalence of chronic pain, accompanied by significant increases in utilization and associated health care costs. Our philosophy for pain management services is to facilitate health plan member access to coordinated interdisciplinary care from appropriately trained specialists. Our efficient and timely utilization management services are grounded in individualized application of evidence-based clinical guidelines to help reduce unexplained variation as well as unnecessary or duplicative care.
Joint/Spine (surgical management)
For more than 30 years, EviCore has expanded its breadth and depth of knowledge within the musculoskeletal management space and established superior partnerships with each health plan client. Our surgical management solutions are designed to collaboratively tailor the appropriate treatment with the right provider at the correct time for the patient. Innovative levers embedded in these solutions bring value beyond traditional utilization management and incorporate facilitated decision-making for implantables, acute level-of-stay management, and proactive discharge planning to ultimately achieve healthier patient outcomes. Through our portfolio of MSK services, we also collaborate with our health plan clients to maximize the value of their network by applying clinically appropriate, evidence-based guidelines and cost-effective care.
Services covered
EviCore’s management of conservative care options for MSK conditions covers the full range of specialized therapies, including chiropractic, physical, occupational and speech therapy. Unlike other medical disciplines where procedures occur at a single point in time, specialized therapy services are typically provided episodically over the course of weeks or months, enabling flexible and tailored application.
Specialized therapy management
EviCore’s specialized therapy management solution is condition-based and considers duration, frequency and intensity when evaluating the necessary number of visits. Avoiding the limitations inherent in authorizing specific modalities, our model allows the provider sufficient autonomy and flexibility to select and perform any one of the allowable procedures deemed medically necessary during the episode—based on the member’s presentation at the time of treatment.
Delivery methods
The delivery methods associated with EviCore’s specialized therapy management solution are comprehensive and adaptable. Program administration options include:
- Application of clinical decision support tools
- Traditional prospective reviews requiring prior authorizations
- Innovative bundled payment, value-based care and network management options
EviCore’s goal is to collaborate with health plan and provider partners who assess varying levels of oversight to deliver optimized care. This customized and concierge-based approach incorporates market dynamics pivotal to utilization review in the therapy space.
Increased value
EviCore currently manages proprietary and regional chiropractic services as well as therapy networks. EviCore continually evaluates the potential for additional development based on client need. From a health plan perspective, a delegated model is advantageous as medical services are more closely managed to achieve healthier outcomes while reducing administrative expenses. EviCore continues to be a market leader and a trusted strategic partner in providing program differentiators such as:
- Value-based care
- Credentialing/re-credentialing
- Advanced and predictive analytics
- Same-specialty expertise
Continuous monitoring
EviCore has developed a validated monitoring and scoring tool to identify high-performing providers within a client’s participating provider network. The opportunity leverages network assessments and analytic dashboards, and supports tiering based on clinical outcomes of same-specialty peer group comparisons. Criteria include utilization, cost and quality, which are used for evaluating expedited authorizations. Providers who demonstrate the highest efficiency and compliance with clinical guidelines and program criteria are recognized as high-performing and subject to a simplified and streamlined UM process. EviCore reassesses providers at six-month intervals to confirm their ongoing compliance and qualification for expedited approvals.
Site of care optimization
EviCore’s musculoskeletal Site of Care program is designed to improve member access to more appropriate and cost-effective sites of care for all MSK-related procedures and treatments, with no reduction in care quality and efficacy. We do this by influencing the location selection for MSK-related procedures, offering redirection support to help providers choose a more cost-effective location, and helping manage the inpatient length of stay, as needed. Patient safety is always our top priority, with financial factors only considered if we have established that a lower-cost facility would be equally (if not more) appropriate for their condition.
MSK corePath
As part of EviCore’s Musculoskeletal solution, we offer a member outreach and engagement program designed to truly connect Radiology and MSK Solutions. Our MSK corePath program encourages conservative care, especially in conjunction with a request to use advanced imaging studies as the first step in a care plan for an uncomplicated pain episode. Our experience shows that patients who start with a scan are 3.5 times more likely to undergo MSK surgery than those whose first service was Chiro/PT. EviCore’s MSK corePath program provides the most comprehensive and member-centric approach to lower back, neck and extremity joint pain management in the industry by coordinating the continuum of care. The program assists members along the path to the right treatment and outcome earlier in the decision-making process, instead of waiting to engage at the point where a treatment decision has already been made. The foundation of EviCore’s MSK corePath program is focused on 1) early detection, 2) patient education by a licensed physical therapist and 3) member empowerment as soon as a patient enters the care continuum for low back, neck and/or extremity joint pain.
Bundled program
EviCore has developed a seamless prior authorization approval enhancement to offer a better experience for patients and providers. We know that conservative care and musculoskeletal condition management/surgeries go hand in hand. The sooner members begin conservative care, the better their potential for optimal health outcomes. That’s why EviCore developed MSK Joint Surgery, Physical/Occupational Therapy and Interventional Pain/Conservative Care bundled solutions. These enhanced offerings simplify prior authorization requests for medically necessary conservative treatment following MSK joint surgery and following non-approvals for interventional pain procedures requested before use of conservative care.
Payment integrity
Accurate payment for MSK care episodes can be challenging due to the complexity of the coding process for the wide variety of diagnoses and services that can be involved. Our integrated system, Claims Studio, delivers incremental savings through an enhanced focus on accurate claims payment, which can be applied as an extension of health plans’ existing claims workflows. In this process, the claim is pended in the host system, then sent to EviCore, where it is adjudicated with EviCore’s proprietary system, then returned to the host system with a recommendation for payment—all within the same day. In addition, Claims Studio encompasses appropriate edit checks that ensure MSK services are rendered in accordance with health plan benefits, authorizations and network contracts.
Frequently Asked Questions
All of EviCore’s clinical guidelines are stored on the musculoskeletal clinical guidelines page.
The health plan has contracted with EviCore by Evernorth to assist with managing and administering benefits for musculoskeletal services, which can include interventional pain procedures, joint surgeries, spinal surgeries, as well as chiropractic services and physical, occupational and speech therapy.
This program manages the following pain management services:
- Interventional pain procedures
- Epidural steroid injections, facet joint injections/medial branch blocks/radiofrequency ablation, sympathetic blocks, spinal cord stimulators and implantable drug pumps.
This program manages the following joint and spinal surgery services:
- Joint surgery [hip, knee, shoulder]: Primary and revision joint replacement/arthroplasty, arthroscopic and open surgical procedure
- Spinal surgery: Decompression including discectomy, instrumented and non-instrumented fusion, disc replacement/arthroplasty and vertebral augmentation
This solution manages the following outpatient services:
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Chiropractic Services
60-year-old Don*, who was in a motor vehicle accident a little over a year ago, is still suffering from persistent back pain. Learn how EviCore helped both Don and his provider leverage clinical expertise through EviCore's utilization management.
The fact that 25%–40% of musculoskeletal (MSK) care spending is wasteful or ineffective is concerning enough. But coupled with the knowledge that more than 50% of U.S. adults over 18 live with an MSK condition, the potential impact of low-value MSK care is staggering.
Alice* is a 50-year-old woman experiencing leg pain from a pinched nerve in her back.
EviCore’s Dr. Robert Westergan on Managing Site of Care and Implants for Musculoskeletal Conditions in EviCore's newest insight for our MSK solution.
Q&A: EviCore’s Chief of Musculoskeletal Programs on the Need for Evidence-Based Care for Muscles, Bones and Joints.
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