Preauthorization Leniency Program (PLP)

Select Health PLP uses Cave Consulting Group software to:

• Analyze practice patterns against national benchmarks for various condition-specific care measures. 
• 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 peer group effectiveness and relevant best-practice guidelines for their specialty.

Currently, the PLP focuses on diagnoses of:

• Endometriosis or benign tumor (fibroid), resulting in a hysterectomy
• Tonsillar hypertrophy/recurrent infection, resulting in a tonsillectomy

Program Goals

1. Review specific procedures related to preauthorization in a clinically based process, which is far more relevant to patient care. 
2. Identify providers who can be rewarded with a more lenient preauthorization process when specific procedures apply to a given practice. 

Measurement

To measure effectiveness, the Cave software assigns nearly all claim lines to a medical condition episode of care, resulting in accurate capture and assignment of costs. These episodes are:

• Assigned to providers with >20% of professional allowed charges
• Grouped by medical condition associated with a clinical measure
• Compared with protocol ranges based on nationwide utilization and published evidence-based care models

We measure performance on a group level based on a provider’s primary clinic in our records. There is a great deal of nuance to this information including: 

• Attribution if a provider practices in multiple clinics 
• Severity of illness 
• Definition of diagnosis 
• Attribution of tests 

Program Evolution

Select Health will continue to prioritize potential savings via utilization review/utilization management (UR/UM) using vetted, approved, clinically appropriate thresholds. In addition to preauthorization leniency for cost-efficient 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 national benchmarks. Select Health will provide ongoing feedback on medical condition practice patterns in comparison to peers within the region and nationally. 

Continued qualification may be subject to post-service audits. Providers can also expect random chart audits over the year of leniency to ensure that the physician performed procedures meet the policy criteria for the procedure.

Important Exclusions

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

• PLP 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.

Communication

Select Health sends email updates of your provider group’s mid-cycle and year-end status and supports providers seeking to improve performance and program participation.