Yuzu is working on updating its prior authorization guidelines to provide for quicker decisions with more context and equal cost savings.
Summary
Previously Yuzu had cash pay guidelines available here that guided what services could be approved without MedWatch certification.
Yuzu is now looking to raise the threshold for getting a MedWatch pre-certification from $10k to $50k. This increased limit reflects the maturity of the cash-pay programs operating with Yuzu allowing for increased trust and decreased administrative burden.
By locking in a higher certification threshold, Yuzu and its partners will ensure that we continue to support strategies that work. These strategies need high degrees of trust in order to lock in lower cash-prices.
Proposal
For cases <$10k, the situation remains the same. Care navigator referrals will guide whether a pre-cert is even necessary and a proper referral will waive the need for a certification.
For cases $10k-$50k, the situation changes. The proposed framework requires that:
Medical records such as those required for a pre-cert be sent to Yuzu.
Note: Direct Primary Care (DPC) Plans that Yuzu supports already have the majority or these records due to their trust with patients and role in the referral process.
Note: These records are already generally collected and sent to Yuzu so that Cash Pay Pre-Certs can be collated and sent to MedWatch under the existing pre-cert Regime.
Yuzu be allowed to “approve” a case if the pre-certification team at Yuzu has reviewed relevant records and determines:
The case would be approved under either the Cigna or Aetna open-source guidelines
A senior member of the Yuzu team (Sara or Tracy) has documented specific guideline compliance for the particular case within the Yuzu Case guiding the approval.
For cases >$50k the process would remain the same with MedWatch approval required.
Comparison of proposed versus current strategy
The only difference between current and proposed policy is for cases between $10-50k representing ~10% of cases.
These cases will now be examined by Sara and Tracy at Yuzu before being sent to MedWatch and approved if the Yuzu team believes that the case is obviously an approval.
This will reduce currently stoploss eligible costs for MedWatch case review.
Reasons for change include
Difficulty with current process for what care navigators consider black/white cases
100% of cases in this range that were sent to MedWatch and initially denied were eventually approved after MedWatch after complete records were sent.
Relevant External Guidelines
We know that MedWatch uses MCG guidelines for care. So does Cigna. Aetna uses slightly different but very similar guidelines.
Yuzu will approve claims if they meet the standards of Cigna or Aetna: