Table 2 Mandate implementation processes by level, EPIS phase and domain, and key actors
Process | Phase | Domain | Key actor(s) |
|---|---|---|---|
Regulator | |||
Monitor proposed legislation | Exploration | Inner | Government relations |
Meet with stakeholders and share draft guidance | Preparation | Bridging — stakeholders/public comment | Stakeholder relations |
Issue guidance | Implementation | Inner | Deputy Director, Office of Plan Licensing |
Conduct independent medical review | Implementation | Bridging — patients, insurer | Independent medical review team; independent doctors |
Review and revise regulator guidance | Sustainment | Bridging — insurer | Deputy Director, Office of Plan Licensing |
Enforcement | Sustainment | Bridging — insurer | Office of Enforcement |
Insurer | |||
Monitor proposed legislation | Exploration | Inner | Government relations |
Compliance of existing benefits/plans with legislation and state regulation | Exploration | Inner | Compliance dept. |
Evaluate network capacity for services | Exploration | Inner | Provider relations |
Evaluate costs of new fertility preservation benefits | Exploration | Inner | Health insurance actuary |
Plan how to comply with SB 600 and regulator guidance | Preparation | Inner | Compliance |
Configure system to incorporate fertility preservation codes for benefit verification, pre-authorization, and claims | Preparation | Inner | Member services, provider relations, claims |
Incorporate fertility preservation benefit into plan handbooks, member online portal, member service scripts | Preparation | Inner | Member services |
Train member services, provider services, claims team on fertility preservation benefit | Preparation | Inner | Member services, provider relations, claims |
Contract with providers and facilities for fertility preservation services | Preparation | Bridging — clinic | Provider relations |
Sell/modify fertility preservation benefits to purchasers | Preparation | Bridging — purchaser | Sales and account management |
Provider/clinic education on fertility preservation benefits | Implementation | Bridging — clinic | Provider services |
Benefit verification | Implementation | Bridging — clinic | Utilization management |
Administer benefit verification, prior authorization, claims processes | Implementation | Bridging — clinic | Utilization management |
Answer member questions | Implementation | Bridging — patient | Member services |
Generate letters of agreement | Implementation | Bridging — clinic | Provider relations |
Evaluate utilization | Sustainment | Inner | Quality |
Clinic | |||
Learn about fertility preservation benefit mandate through clinical societies | Exploration | Bridging — professional clinical society | Clinician |
Advocate for clinic adoption of financial and patient experience processes that enable benefit utilization | Exploration | Inner | Clinician, financial team |
Negotiate contracts with insurers | Preparation | Bridging — insurer | Contracting specialist |
Advocate for fertility preservation benefit reimbursement rates at insurance contracting | Preparation | Bridging — insurer | Medical or clinic director |
Determine patient payment options | Preparation | Inner | Medical director, clinic director, financial team |
Allocate financial resources to staff financial navigation | Preparation | Inner | Medical or clinic director |
Configure or modify processes for financial counseling of and collecting payments from fertility preservation patients. Examples are as follows: • Defer payments if expect success in appeal • Convert visits to no charge because cannot wait for pre-authorization and appeals • Require patients to pay cash costs up front due to uncertainty of reimbursement | Preparation | Inner | Medical or clinic director, physician, financial team |
Train financial counselors • Processes for financial counseling of and collecting payments from fertility preservation patients • Insurer-specific processes | Preparation | Inner | Financial team |
Generate tips, loopholes for financial team specific to insurers to disseminate among financial counselors | Preparation | Inner | Financial team |
Generate tools for patients to interact with insurers • Lists of insurance billing codes (ICD, CPT, NPI, tax ID) for patients to inquire with insurers • Benefit verification, appeal documents | Preparation | Inner | Financial team |
Modify processes to conduct benefit verification before patient arrives, different from infertility patients | Preparation | Inner | Financial team |
Benefit verification (online insurer portal, telephone call, via patients; primary and secondary insurer, fertility benefit carve out plans); assess if subject to SB 600 | Implementation | Bridging — insurer | Financial team |
Submit prior authorization via online insurer portal, request expedited review, outreach to provider relations team for individual cases | Implementation | Bridging — insurer | Financial team |
Submit and process claims to insurer | Implementation | Bridging — insurer | Financial team |
Escalate benefit verification, pre-authorization, appeals, and claims to insurer supervisors | Implementation | Bridging — insurer | Financial team |
Prepare appeals to insurer and regulator for independent medical review | Implementation | Bridging — insurer Bridging — regulator, patient | Financial team, patient navigator |
Counsel patients on out-of-pocket cost estimates, appeal options, maximize benefits, philanthropic resources | Implementation | Bridging – patient | Financial team, patient navigator |
Follow up with patients on insurer processes (claims, appeals) | Implementation | Bridging — patient | Financial team, patient navigator |
Conduct parallel processes for benefit verification, pre-authorization, claims, and appeals for medical and pharmacy benefits | Implementation | Bridging – insurer | Financial team |
Negotiate one-off letters of agreements for patients with benefits but out of network | Implementation | Bridging — insurer | Contracting specialist |
Follow up on why not all plans with an insurer are included in a clinic’s contract with the insurer | Sustainment | Bridging — insurer | Contracting specialist |