Louisville Medicine Volume 71, Issue 5 | Page 11

A DAY IN THE LIFE

A Day in the Life on the “ Dark Side ”

When I was asked to write an article for this issue , there were many things I considered writing about , including my former life as a flight surgeon in the Air Force or as medical director at the Louisville Metro Department of Public Health and Wellness . But , to spare you all from a novella-length project , I narrowed it down to my current role : Plan Performance Medical Director at Elevance Health . This should be interesting - because , well , I ’ m still figuring it out as we speak .

Just over a month ago , I started as the Plan Performance Medical Director for Elevance Health . This is the umbrella company for Anthem Blue Cross Blue Shield in Kentucky , which is one of the largest commercial health insurance plans in Kentucky , and what I now call “ home .” First , the logistics : I am a “ hybrid ” worker , meaning that on average , I am in the office about one day per week , and the rest of the time I work from home . In-office work may mean attending meetings with my local team at our office in the northeast part of Louisville or meeting with a business client someplace in Kentucky . It might also mean representing Anthem in support of a community partner ( for example , a charity event ). At-home work includes online utilization management and case management work and various online meetings throughout the day relating to the various aspects of my job .
My workday is variable . There is no set schedule . The majority of work is sandwiched between 8 a . m . and 6 p . m . Eastern Time , however , I belong to a region that includes Kentucky , Missouri and Wisconsin , which means that we cover both Eastern and Central Time zones . Additionally , the work can go on 24 / 7 in the health insurance world . Our call centers are nearly always open ,
by LORI CALOIA , MD , MPH
and work relating to prior authorizations is going on much later into the evening than my typical work day . Just as an illustration — I received an email at midnight a few days ago about an upcoming peer-to-peer call !
A question I often get is , what types of things do I do on a dayto-day basis ? I have described several of these activities below ; I am sure in a few months , this list will have grown even longer !
Utilization management ( UM )
Before coming to Anthem , I worked as a medical director at Humana Healthy Horizons of Kentucky , one of the Medicaid Managed Care Organizations ( MCOs ) in Kentucky : my first introduction to the “ Dark Side .” This was my introduction to performing utilization reviews . Well-suited to my training in family medicine , I found myself reviewing prior authorizations across the entire continuum of medical care : pharmacy , outpatient procedures , imaging , laboratory tests , durable medical equipment , home health , and inpatient and post-acute admissions . I performed peer-to-peer calls , and processed appeals for health care services to determine medical necessity based on state-approved policies and guidelines .
At Anthem , I still perform utilization reviews across the care continuum , similar to that in my role at Humana . As an experienced reviewer , I am often involved with more complex scenarios , such as transplant requests , those patients who have been in the hospital for a long time due to their serious illnesses or injuries ( sometimes called high length of stay ) or patients with uncommon conditions ( for example , you have probably read about the newly FDA-approved gene therapy for people with hemophilia . I would be the physician who reviews those cases as they arise for patients with Anthem commercial insurance in Kentucky ). I enjoy these reviews , as they keep me in touch with the most up-to-date , evidence-based medicine in a variety of areas ( inpatient , outpatient , ( continued on page 10 ) October 2023 9