How Medical Policy at Regence works and why it matters for your health

A researcher at work in a University of Utah laboratory, Salt Lake City, Utah. Photo credit University of Utah ©Brett Wilhelm

 

Did you know? Coverage at Regence is determined by our Medical Policy.  

Actually, it’s medical policies. About 550 of them. (And counting!)  

Medical Policy is the place where evidence-based medicine and your health insurance meet. 

Regence medical policies ensure that what we cover is based on scientific evidence, clinical research and modern standards of clinical practice. 

Why does Medical Policy matter? 

At Regence, we know it’s important you get the latest, proven treatments your doctor recommends for you. As medical science advances, your health insurance should, too. But just because something is new and shiny doesn’t mean it performs as expected. 

Each day, our team of doctorate-level, biomedical scientists and trained clinicians study the newest medical innovations and interventions. They evaluate FDA approvals. They read medical literature and synthesize the design, conclusions and limitations from individual studies. They review clinical practice guidelines across dozens of medical specialties and sub-specialties. They collect input from all types of doctors outside our company, including 231 providers who volunteer to give us feedback.  

These analysts—with input and oversight from our physician leaders and executive medical directors—look for evidence that procedures, equipment and services are: 

• Medically necessary 
• Clinically effective 
• Supported by peer-reviewed research 

Wait!  Of course, my doctor is going to recommend something that is medically necessary, you say.  

But take, for example, when your doctor orders labs—laboratory testing on a blood draw.  

It’s so easy to order labs, says our Medical Policy team. Sometimes folks don’t think too much. They order big, broad panels for people who just need a narrow screening and don’t have any signs or symptoms. Thousands of people are getting these broad tests unnecessarily. It adds up to a big chunk of money, and those people aren’t getting better care for it. 

So Regence published a medical policy addressing certain lab tests that may be used in screening circumstances to ensure that the blood panels your doctor orders are actionable for your health. 

That’s just one example of how Regence Medical Policy guards against unnecessary medical services and waste, ultimately balancing that with the costs you might pay. 

Validated by science 

Another way is to ensure your premium dollars go to procedures, equipment and services that are supported by science.  

Medical researchers and inventors prove that their advancements work by running rigorous experiments and clinical trials, publishing those results in peer-reviewed medical journals and inviting others to replicate their findings. Once that body of research builds up, there’s scientific evidence the advancement works and is effective for you. 

Recently, Regence published policies declining coverage for emerging treatments in advanced liver cancer and herniated discs. While promising, there isn’t enough research yet to validate that those treatments are effective. 

Every year, our analysts review each policy. As the science improves, we update the policy to cover the advancement.  

Partnering with providers 

Providers have an important voice in our Medical Policy. Before changing a policy, Regence invites providers to give their input. 

Our Medical Policy team reviews the information from providers. If a provider sends us an email that says, “Hey, I don’t think you considered this important study,” we take that especially seriously. We know providers want the best care for their patients. 

For example, recently Regence received feedback from providers treating patients with a rare and serious condition called Nutcracker syndrome, in which the left kidney vein is compressed, causing pain. Based on the feedback, Regence changed its medical policy to cover the treatment for that indication and ensure those members got the care they needed.   

Each of our policy analysts is a strong advocate for evidence-based medicine. They enjoy learning about the research behind these different medical technologies and sometimes the disturbing lack of research. 

“We’ve seen health care costs increase exponentially,” one senior policy analyst said. “It’s rewarding to help people get the care they need while at the same time steering them away from stuff—and their associated costs—that don't help. We need to do everything we can to make health care affordable for us all.”