Health Plans | Utilization Management Musculoskeletal

eviCore healthcare (eviCore) offers proven, diversified medical benefits management solutions that help clients reduce costs while increasing the quality of care for their members. Our teams of specialized medical-professional resources help health plans, providers, and individual patients access and apply tools for identifying conditions and their available treatment options. The eviCore Musculoskeletal solution addresses the full spectrum of potential care and treatment, from holistic and conservative approaches to more advanced and invasive procedures. We then apply up-to-date evidence-based guidelines and advanced technologies to ensure that the right evidence-based care is delivered.

Services Covered

eviCore’s management of conservative care options for musculoskeletal conditions covers the full range of specialized therapy, including massage, acupuncture, 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 authorizing a 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 they deem 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 range from the application of clinical decision support tools; to the more traditional prospective or retrospective utilization reviews requiring prior authorizations and/or claim editing and repricing; to 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.

Network

eviCore currently possesses proprietary and regional chiropractic, acupuncture, and therapy networks in collaboration with various medical professional associations, including comprehensive musculoskeletal care centers. On an ongoing basis eviCore develops and enhances existing networks 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. For example, eviCore continues to be a market leader in providing program differentiators such as:

  • Value-based care
  • Credentialing/re-credentialing
  • Advanced and predictive analytics
  • Risk stratification.

Patient Activation

eviCore’s patient-activation measures focus on education and awareness. By providing educational resources about musculoskeletal conditions and various treatment options, we equip health plan members with the information they need to become to more knowledgeable consumers. In addition, our innovative SmartChoice program serves as a patient outreach service to educate health plan members on the same-quality options that are available for their diagnostic imaging procedure locations, as well as various conservative-care options available to them for the treatment of musculoskeletal pain. By presenting lower-cost, convenient, and high-quality options, eviCore empowers your members to make more informed comparisons and choices.

Payment Integrity

Our integrated system, Claims Studio, delivers incremental savings through an enhanced focus on accurate claims payment, which can be applied as an extension of the client’s existing claims workflow. In this process, the claim is pended in the host system; sent to eviCore, where it is adjudicated with eviCore’s proprietary system; and then returned to the host system for payment—all within the same day. In addition, Claims Studio encompasses appropriate edit checks that ensure specialized therapy services are rendered in accordance with the health plan benefits, authorizations, and network contracts.

Frequently Asked Questions

How can I access the Musculoskeletal solution’s evidence-based clinical guidelines?

All of eviCore’s clinical guidelines are stored on the musculoskeletal clinical guidelines page at (https://www.evicore.com/provider/clinical-guidelines).

What is the relationship between my health plan and eviCore healthcare?
The health plan has contracted with eviCore healthcare to assist with managing and administering benefits for interventional pain procedures; joint surgeries; spinal surgeries; physical, occupational, and speech therapy; chiropractic care; acupuncture; and massage therapy.
What services are managed through the Musculoskeletal Pain Management Solution?

This solution manages member pain-management services in the following areas:

  • Behavioral health
  • Interventional pain procedures
  • Opioids.
What services are managed through the Musculoskeletal Surgical Solution?

This solution manages member joint and spine services for the following:

  • Joint: (limited to shoulder, knee, and hip) replacement/arthroplasty, revision, arthroscopic and open procedures
  • Spine: arthroplasty, discectomy, microdisectomy, fusion, and grafts.

What services are managed through the Musculoskeletal Therapies Solution?

This solution manages outpatient member services for the following:

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Chiropractic Services
  • Acupuncture
  • Massage.

Clinical Expertise

I am responsible and accountable for the rigor associated with the clinical criteria that we use for prior authorization of musculoskeletal procedures. The strong evidence supporting our criteria allows us to make appropriate decisions on patients’ behalf. We are in the business of actually approving medically appropriate procedures, not denying them.

Dr. Robert Westergan

Chief of Musculoskeletal Programs