CEO Message
Howard Lee
President & CEO
Celebrating the Nurses That Impact Our Lives
May is national nurses’ month—a time for us to give back and to celebrate the dedicated nurses that make an impact on our community. When I think about the values inspired by our physician founders, I’m reminded of our Registered Nurse (RN) Care Specialists here at UHA—they are compassionate, trustworthy, genuine, ethical, knowledgeable, and fair. Their role here at UHA is essential, and their contributions impact the lives of our members directly. In a world of technology and self-serve models, UHA still believes in human interaction and our RN care specialists are a testament to this. Our values at UHA are expressed through their actions.
Compassionate and trustworthy. Our RN Care Specialists assist members in navigating the healthcare system by answering questions and guiding them through processes. They listen to members and provide a voice for those that need it. They play an important role in our member’s health and well-being - from ensuring medications are picked up, to making the appropriate follow up appointments with their doctors and ensuring they have help at home. They also do in depth reviews of members’ medical records when hospitalized or when related to a prior authorization, to ensure our members are receiving the highest quality care possible.
Genuine and ethical. Our RN Care Specialists care about members and empower them through education, in the form of lunch and learns, educational material, and classes that are disease specific. Our RN care specialists encourage members to learn more about their conditions and how to advocate for themselves.
Knowledgeable and fair. Our RN Care Specialists are broadening their reach to members by connecting with organizations in the community that can provide more education and disease management resources for various conditions, including asthma and diabetes. UHA’s plan going forward is to have our RN Care Specialists assigned to hospital reviews by island, to learn more about the available resources in our communities and make connections with providers to improve care coordination for our members. Most recently they’ve connected with Times Pharmacy to refer members who may need medication reconciliation with a pharmacist. Transparency and communicating updates to members, employers, and providers are important to our RN Care Specialists who strive to provide quality care to all those they serve.
We have been working hard to improve the lives of everyone we touch. Our RN Care Specialists will continue building trusted relationships, educating the community and lend a helping hand for all those we serve. Their dedication and care reflect our values and mission for better health and a better life.
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Dr. George McPheeters, M.D. FACS
Chief Medical Officer
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The Concept and Intent of Medical Necessity
Dr. David Eddy is known as the “father of evidence-based medicine.” He is a physician, has a PhD in mathematics and was a professor of economic engineering systems in addition to serving in a variety of clinical and medical administrative positions in and out of government. He was employed by Kaiser and Blue Cross at different times and in separate capacities. He is an academic with real world experience.
In the mid 1970’s he developed mathematical models for a variety of clinical endeavors including cancer screening. He created analytics for efficacy and value and won the Lanchester Prize for this work which was adopted widely by specialty societies and the American Cancer Society. The prize recognized his contributions to operations research and management science. My point is that he had medical, strong mathematical and engineering backgrounds and an aptitude for exploring decision analysis and value-based care 50 years ago.
Dr. Eddy wrote the language which is adopted almost verbatim in the statutes of many states. In brief, care prescribed by an appropriate provider is “medically necessary and must be covered when it
- will treat an identified medical condition,
- is the most appropriate service considering benefits and harms,
- is KNOWN to be effective, and
- is cost effective for the condition compared to other interventions.”
The precise language is in both UHA’s MBG and the participating provider contract.
This is the foundation for coverage decisions. It is supported internally at UHA by standard clinical guidelines (MCG, InterQual, appropriate use criteria from specialty societies (e.g. American College of Cardiology, American Society of Clinical Oncology, etc.) and independent medical reviewers. It is the job of the doctors at UHA to make careful, ethical and informed decisions and to be open to collaborative discussions, which we will engage in honestly with a willingness to communicate at any time. We work with a large group of registered nurses, data analysts and integrity professionals to keep the needs of the members individually and in the aggregate as our top priority. Any thoughts that we seek to save money for the company’s bottom line are patently false. We are a mutual benefit society with deep roots in the local medical community and Hawaii has always been our home. We invite the opportunity to engage directly with providers and, if necessary, with your patients.
Most physicians in the islands have never heard of Dr. David Eddy, but his contributions have been both scholarly and ethical. It is generally accepted in government, academia and within commercial payers that a third of health care costs in the USA (over a trillion dollars annually) goes to no value or such low value service that it is counterproductive. Some of it contributes to direct patient harm. Waste avoidance is part of the stewardship which we pursue at UHA.
Until recently, every member of the healthcare services department at UHA completed an online business ethics course from Santa Clara University. Because that course is no longer available, we have created a curriculum for our staff. I invite any provider who is interested to receive the compilation with attached notes. We look forward to hearing from you about this or anything else. If you have questions, please contact the Health Care Services department at (808) 532-4006, or toll-free (800) 458-4600, ext. 300.
We wish you a great summer.
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NEW UHA Medical Benefits Plan – UHA One PlanSM
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This year UHA is launching a new medical benefits plan called “UHA One Plan.”
We have rolled this plan out to UHA employees and their dependents first, so you may see this plan as UHA employees visit their doctors.
Previously, UHA employees and their families were covered by UHA 3000. UHA One Plan is very similar to UHA 3000, so there should be minimal disruption to patient coverage.
Below are the key differences between UHA One Plan and UHA 3000.
UHA One Plan
- No annual deductible
- Maximum Out-of-Pocket: $2,500 per person and $7,500 per family
- (Diagnostic, Laboratory and Pathology Services) Laboratory and Pathology - Outpatient: 20% Eligible Charge
- Allergy Testing: 20% Eligible Charge
- Second Opinion: $12 copay
If you have any questions, please contact Customer Services at (808) 532-4000, or toll-free at (800) 458-4600.
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Provider Demographics Updates
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Please verify the accuracy of your demographic’s information (physical address, telephone number, etc.) by visiting our Online Provider Directory at uhahealth.com/providers/search.
If your demographics information is accurate and no changes are needed, no further action is needed. If your demographics information is not accurate, please submit one Online Participating Provider Change Form for each rendering provider within your group practice. If you are a sole proprietor with only one rendering provider in your practice, please submit only one Online Participating Provider Change Form.
A link to the Online Participating Provider Change Form may be found at portal.uhahealth.com/cforms/home/parchangeform.
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Billing Claims to UnitedHealthcare vs. UHA
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As of May 15, 2021, UHA members were given access to the UnitedHealthcare (UHC) Options PPO Network for U.S. mainland services. Providers should only bill claims to UnitedHealthcare if services were rendered out-of-state. If services were rendered within the State of Hawaii, Providers should continue to bill claims to UHA directly at the following mailing address:
UHA Health Insurance
700 Bishop Street, Suite 300
Honolulu, Hawaii 96813
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