We wanted to keep you informed of the challenges associated with some insurance plans. There are a number of plans that are moving to require pre-authorization of ALL of your treatment services. If your plan is one that requires pre-authorization your insurance will not cover your treatment unless it is separately approved by eviCore a medical utilization management company. We want you to be aware of the impact on your care with such a program and that you do have the power to change the system. Below you will read a general description of how this program is implemented, what the impact is and what you can do about it.
After your initial treatment and before we provide treatment, we are required to seek approval from eviCore through completion of forms, via their website or by phone. They require extensive information that must be provided in a format different than what you have seen in any of our documents. Due to website issues or call volumes this process may prevent you from being able to schedule appointments immediately after your first visit. If there is a delay, we will stay in touch with you to coordinate future appointments. After we submit the required information, eviCore will tell us how many initial visits are authorized and the duration over which those visits are authorized. Any time there is an authorization decision, you will receive a letter of their decision.
Depending upon your diagnosis, eviCore may authorize as few as 2 initial visits to be provided over the course of a period of perhaps 30 to 90 days. Even if our providers have determined that your child should receive more care more frequently. This initially authorized number of visits includes the evaluation visit. If your providers determine that your child needs additional care at the end of the initial number of visits and time period authorized by eviCore, our team will be required to submit a new request and provide more documentation, again in a format specified by eviCore. Additional requests for treatment authorization can require up 60 to 120 minutes of a therapist’s time, time for which the therapist and the clinic will not be compensated by your insurance.
Unfortunately, and despite our efforts, the process of requesting authorization for additional visits may result in an interruption or delay in your care. If, for example, eviCore initially authorizes only 2 visits over a period of 30 days and you use those visits in, say, one week, we may be able to request additional visits without waiting for the expiration of the 30 days and eviCore may grant those visits over a new specified time period. For any subsequent requests, we are required to wait until 7 days before expiration of the new time period before we can request additional care. This may mean that you will have to wait to receive some of your care in order to have that care covered by your insurance.
In the event that some or all of subsequent requests for authorization of your care are not approved by eviCore, meaning that additional visits will not be covered by your insurance, we will be happy to discuss the differences in the personalized care plan our therapist prepared for your child and what your insurance will cover. Although our contract with your insurance states we are to use our professional judgment to provide you with the care we see is medically necessary, we cannot guarantee that the pre-authorization, coverage or payment decisions will be the same as what we or your doctor see is medically necessary for your child. With your signed consent and agreement to be financially responsible for any specific services that your insurance does not cover, we can proceed to care for you with the goal of achieving the best outcome we can for your child and family.
We want to be very transparent with you regarding the impact on your child’s care with a program like this because it is being promoted as an improvement by your insurance plan. The following is a summary of the issues as well as what you can do.
1) eviCore is limiting the services and care that you are able to receive.
2) The authorizations that are granted by eviCore are not in line with what best practices are for speech, occupational, applied behavior analysis or other therapies for your child’s diagnosis. The authorizations also do not reflect the recommendations of our professionals and will harm your child’s outcome.
3) We have been in touch with both your insurance and eviCore regarding issues with this program but the only way they will change is through your efforts.
4) Many benefit plans can opt out of eviCore. Please contact your HR department about eviCore and the issues you experience