Health Plans | Utilization Management Musculoskeletal

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.

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.

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.

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.

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.

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.

One goal of eviCore’s musculoskeletal solution is to help reduce chronic pain the health plan members suffer. eviCore employs a holistic approach and includes a behavioral health component to assist in mitigating pain. A telehealth program helps health plan members develop skills to change negative thoughts and behaviors related to pain. Members will learn to identify fear-avoidance behaviors and utilize pain management techniques to enhance their coping skills, increase their confidence, and support their goals.

Interventional pain procedures are an important component of our comprehensive pain treatment program. Statistics continue to show the broad and rapid increase in the prevalence of chronic pain, accompanied by significant increases in utilization and associated healthcare costs. Our philosophy for pain management services is to facilitate health plan members’ access to coordinated interdisciplinary care from appropriately trained specialists. Our efficient and timely prior authorization and utilization services are grounded in our use of evidence-based clinical guidelines to help reduce unexplained variation as well as unnecessary or duplicative care.

A recent complement to eviCore’s pain management solution was the development of our advanced and innovative Opioid Management program. This program is a highly configurable set of provider and patient activities and services designed to avoid opioid deaths, addiction, and abuse—and related healthcare costs—by reducing the number of new opioid users at the point of prescription. This is accomplished by screening patients for the potential of abuse in the context of their complete medical and pharmaceutical history, providing the latest evidence-based prescribing guidelines, and leveraging conservative care principles. The program delivers clinical tools for providers to deliver the most appropriate level of pain relief for their patients without unnecessarily exposing them to the risks of opioid overuse and abuse. 

For more than 30 years, eviCore has expanded its breadth and depth of knowledge within the musculoskeletal management space and established superior client partnerships with each health plan client. The 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 realize healthier patient outcomes. Through our portfolio of musculoskeletal services we also collaborate with our health plan clients to maximize the value of their network by promoting clinically appropriate, evidence-based guidelines and cost-effective care.

eviCore supports our nation’s triad of healthcare goals: to improve the patient experience of care, improve the health of the population, and reduce the per capita cost of healthcare. Regarding the first, we help patients gain more knowledge and understanding about their healthcare as one of the surest ways to spark patient activation. Patients who are more knowledgeable about their health are more likely to use self-management techniques, adhere to treatment plans, and actively engage providers about their care.

Our integrated Claims Studio system encompasses appropriate edit checks that are necessary to ensure musculoskeletal services are rendered in accordance with the health plan benefits, authorizations, and network contracts.

To better address product variation and the high costs related to implantable devices in surgical procedures such as total knee and hip replacements, eviCore developed an innovative solution that uses evidence-based clinical guidelines to detect safety and quality gaps in implant usage, and a thorough claims review process to identify and recoup potential and actual overpayments. Our expertise in promoting transparency and predictability into implantable device spend helps reduce medical expenditures for our clients. In short, eviCore’s implant management solution leads to better outcomes and more affordable healthcare.