October/November 2008


Inside this Issue:

Turn on the Knowledge and Turn on the Business

D2ExplorerTM is ideal for TPAs seeking to manage healthcare spending, utilization, disease prevalence and quality of care. D2Explorer can be used across the entire organization, by TPA executives, care managers and financial managers with a minimum of training to assess plan needs, develop strategies, implement programs, and measure outcomes.

Remember, Sun Life Financial subsidizes 100% of the cost of D2Hawkeye's D2Explorer product for qualifying TPAs. With D2Hawkeye®, you can:

See Data from Multiple Data Sources in One Place: D2 integrates eligibility, medical claims, Rx claims, and other healthcare data into a single record.

Understand Current Spending: D2Hawkeye examines plan experience in terms of dollars, utilization, network, diagnosis, provider, procedure, member demographics, disease prevalence, and quality.

Mitigate Future Risk: D2Hawkeye predictive models identify tomorrow?s risk today, allowing for proactive planning and medical management.

Allocate Resources Effectively: D2 positions TPAs to make need-based decisions about deploying medical management resources, like:

  • Which care management programs are most advantageous?
  • Who are the right members for care management and in what priority?
  • Where are the Rx savings opportunities?
  • How does the quality of care delivered compare with industry norms?

Measure Performance: D2Hawkeye reporting allows TPAs to measure results based on cost, quality and prevalence.

So, equip your business with the knowledge to thrive in a self-insured environment.  Turn on the knowledge and turn on the business.

For more information on D2Hawkeye, or to schedule a demo for your office, please contact Paul Gatanti at paul.gatanti@sunlife.com.

D2ExplorerTM is a trademark of D2Hawkeye®. D2Hawkeye is solely responsible for its product and the information it provides.

What to Know About Eligible Fees

Please remember that when you contract with a third party vendor to provide certain services, you should review the fees charged by the vendor to determine if those fees are eligible expenses under your client's Stop-Loss policy and the underlying plan document.

Sun Life Financial's Stop-Loss Policy provides for reimbursement of certain fees as an eligible expense. Eligible fees include:

  • Hourly case management
  • Hospital bill audits
  • Access to non-directed provider networks
  • Negotiation of out-of-network bills

Fees associated with medical reviews, reasonable and customary determinations, consultant fees, PPO access fees and cost-containment administrative fees are not considered eligible expenses under our Stop-Loss policy.

We may ask for additional documentation as part of our process to determine the eligibility of the fees submitted.

SunResources Spotlight

American Health Holding

American Health Holding (AHH) is a Sun Life Financial preferred vendor for disease management, case management, utilization review, wellness programs, maternity management, and 24/7 nurse line.

Sun Life and AHH have worked together on the management of high dollar claims, in conjunction with TPAs, since 2002. Our case managers have online access to view AHH's case management reports of Sun Life's Stop-Loss policyholders, with permission from the TPA.

Here are other highlights about AHH:

  • National, privately owned company founded in 1993
  • Serves over three million lives
  • Based in Worthington, OH
  • URAC-accredited for Utilization Management, Case Management, and Disease Management
  • Single-source provider of medical management services that span the health care continuum
  • Dedicated to balancing patient needs and cost-effectiveness
  • Licensed in all 28 required states
  • Uses cutting-edge predictive modeling tools
  • Staffed by a blend of health care, business, and medical information systems professionals
  • Website: www.americanhealthholding.com

For more information, please contact Paul Gatanti at SLF (paul.gatanti@sunlife.com or (800) 432-1102, ext. 3920) or Cynthia Hom at AHH (chom@ahhinc.com or (877) 734-3112, ext. 1030

Claims Spotlight

Transplant Claims: Why Do We Need Protocols and Consent Forms?

by Linda McCarthy, Sr. Manager, Case Management Services

One of the questions most asked of Case Management is why we request copies of the protocol and signed consent form for bone marrow and stem cell transplants when we do our medical reviews of these treatments.

First and foremost, we want to make sure that we have all of the necessary information available to do an appropriate review. Both the protocol and signed consent form give Sun Life the crucial information we need to make a determination in accordance with our Stop-Loss policy.
We review the protocol and signed consent form in order to:

  • verify that the titles of the treatment described in the protocol and described in the signed consent form match one another
  • verify that the treatment descriptions match
  • determine whether the treatment is a phase I, II, or III clinical trial
  • determine whether or not it is an experimental/investigational treatment as defined in our Stop-Loss policy:

     

    Section I
    Definitions

    Experimental or Investigational Treatment: For the purpose of determining Eligible Expenses under this Policy, a Treatment (other than covered Off-Label Drug Use) will be considered by Us to be experimental or investigational if:

    1. The Treatment is governed by the United States Food and Drug Administration ( FDA ) and the FDA has not approved the Treatment for the particular condition at the time the Treatment is provided; or
    2. The Treatment is provided as part of an ongoing Phase I, II, or III clinical trials as defined by the National Institute of Health, National Cancer Institute or the FDA; or
    3. There is documentation in published U.S. peer-reviewed medical literature that states that further research, studies, or clinical trials are necessary to determine the safety, toxicity or efficacy of the Treatment.

    Experimental or Investigational Treatment includes any Treatment or hospital confinement that arises from, relates to, or is provided in connection with, the Experimental or Investigational Treatment whether or not the Treatment or hospital confinement, on their own, are considered standard of care or Medically Appropriate and Necessary.

     

  • determine which drugs the patient received as part of the treatment and whether or not they are approved for the patient's diagnosis
  • determine that any off-label drug use meets the definition of Off-Label Drug Use and is an Eligible Expense under the Stop-Loss Policy

     

    Section I
    Definitions

    Off-Label Drug Use: The use of a drug for a purpose other than that for which it was approved by the FDA.

    Section II
    Benefit Provisions
    Expenses Eligible for Reimbursement
    Off-Label Drug Use

    In addition to satisfying the criteria for Eligible Expenses set forth above, expenses related to Off-Label Drug Use may be considered Eligible Expenses when all of the following additional criteria have been satisfied:

    1. The drug is not excluded under Your Plan; and
    2. The drug has been approved by the FDA; and
    3. You can demonstrate to Our satisfaction that the Off-Label Drug Use is appropriate and generally accepted for the condition being treated; and

    If the drug is used for the treatment of cancer, The American Hospital Formulary Service Drug Information, or The Compendia-Based Drug Bulletin, recognize it as an appropriate treatment for that form of cancer.

     

If you have any questions, please contact Linda McCarthy, Sr. Manager of Case Management Services, Stop-Loss at 1-800-432-1102, ext. 1135, or linda.mccarthy@sunlife.com.

Contact Us

Want to speak to us? Feel free to send any general questions or feedback to: tpa.insight@sunlife.com.

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