COMMENTS ON ASH CLINICAL PRACTICE GUIDELINES REFERRED TO IN DENIALS

This is a commentary on the three ASH Clinical Practice Guidelines (CPGs) and the Mercy Guidelines by Haldeman et al referred to in the claims denials sent to you by ASH. If you need to see these ASH CPGs, you can find them at. https://www.ashlink.com/ASH/public/Providers/CQM/CQM.aspx

Standard ASH practice is to allow 5 visits and then to require the doctor to get preauthorization for any additional services. ASH has operated the BCBS HMO since 2000 and, according to the attached 2011 letter from Charles Bassett, BCBS VP Government Relations and Public Policy, the average number of treatments per patient has been 3.6 to 4.7 over the past ten years. This is because when the doctors request precertification, regardless of the severity of the reported subjective and objective findings, very few additional treatments are allowed as medically necessary, often only 2-3.

ASH has even admitted in writing that its goal is to achieve an average of 6.5 visits per episode of care according to the attached document regarding Tier Ratings. Bear this in mind as you read below that ASH Clinical Practice Guidelines (CPGs) referred to as a basis for claims denials today allow 30 days of care of an acute condition, 60 days of treatment for a chronic condition, and up to four months for a condition requiring supportive care. Also attached is the Tier Rating schedule revealing the ASH goal to pressure doctors with rewards into treating patients an average of 6.5 visits per patient episode of care. ASH never allows the 30/60 day/4 month levels of care outlined in the following CPGs.

602-932-8113.