Preauthorization Leniency Program 

What is the Preauthorization Leniency Program? 

Select Health has initiated the PLP using Cave Consulting Group software to:

• Analyze practice patterns around various condition-specifc care measures against national benchmarks. 
• Offer preauthorization leniency (gold carding) for providers who most closely meet these benchmarks. 
• Develop specialty-specifc physician effectiveness scores based on this analysis. These scores will compare individual physician effectiveness against the effectiveness of a peer group and relevant best-practice guidelines for their specialty.

There are two goals for adding this program:

• Use a process that is far more relevant to patient care than the current one. Select Health will now be able to review specifc procedures related to prior authorizations in a clinically based process. 
• Identify providers who can be rewarded with a more lenient preauthorization process when specifc procedures apply to a given practice, using a more global process via a broader range of procedures. 

Measuring Effectiveness

The software assigns nearly all claim lines to a medical condition episode of care, resulting in accurate capture and assignment of costs. Episode is assigned to the provider with >20% of professional allowed charges. These episodes are grouped by medical condition associated with a clinical measure, which will then be compared with protocol ranges as defned by the vendor’s National Specialist Panels based on nationwide utilization and published evidence-based care models. The performance is measured on a group level based on a provider’s primary clinic in our records.

What changes can providers expect over time? 

Select Health will continue to prioritize utilization review/utilization management (UR/UM) resources by potential savings using vetted, approved, clinically appropriate thresholds. In addition to preauthorization leniency for costeffcient practice patterns, we will focus additional efforts on those providers who are outside the benchmark thresholds. This data will be reviewed at least twice a year with changes made to the preauthorization leniency list yearly. In some cases, the current threshold for preauthorization leniency is still inconsistent with national standards; thus, these thresholds will be adjusted over time to become more consistent with the benchmarks. Select Health will provide ongoing feedback on medical condition practice patterns in comparison to peers within the region and nationally. 

Continued qualifcation may be subject to post service audits.

Exclusions

There are a few exclusions that you need to be aware of: 

• This only applies to otherwise covered services. Some services are excluded by specifc plans and would still not be covered. 
• Cosmetic procedures will continue to be denied as a plan exclusion, and unspecifed codes will continue to be reviewed.
• There is a great deal of nuance to this information including: 
  • Attribution if you are in multiple clinics 
  • Severity of illness 
  • Defnition of diagnosis 
  • Attribution of tests