From the Desk of the Chief Medical Officer

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1 From the Desk of the Chief Officer Welcome to our September 2016 issue, where Premier Health Group (PHG) shares news about upcoming initiatives, and helpful reminders. We are proud to open channels of communication to providers, presenting the information and updates you need to maximize patient care and services. This month, we present information about our Preventative Services Booklet, a guide to providing preventative benefits to Medicare Advantage patients. Find out about HEDIS Alcohol and Other Drug Dependence and HEDIS Osteoporosis Management in Women Who Had a Fracture measures. In this issue, read about NCQA standards and why it matters to be accredited. Finally, learn more about Minute Clinics and where members can find them when they need care. As always, if you have any questions or would like to speak to our Chief Officer or our local Director, please call (937) We look forward to our continued work together. Yours in health, IN THIS ISSUE Network Operations Why is RAF Important? HEDIS: Initiation and Engagement of Alcohol and other Drug Dependence Treatment (IET) HEDIS: Osteoporosis Management in Women Who Had a Fracture NCQA: What are the Benefits to Being Accredited Minute Clinics: Where to Seek Care After Hours Jerry Clark, MD, FACP President and Chief Officer Premier Health Group 1

2 Network Operations Provider Agreement Amendment The deadline for return of the amendment to the Participating Provider Agreement has passed. If you have not returned the amendment, please sign and return as soon as possible. As a reminder, the amendment outlines changes to the participating provider agreement, such as CMS compliance training requirements (i.e. Fraud, Waste and Abuse), the importance of EMR and interoperability and the importance of following PHG policies and procedures. Preventative Services Booklet At PHG, we stand with providers in a shared commitment to preventative care, helping to keep patients well and maintain their highest quality of life. We created a preventative services booklet for serving the preventative care needs for your Medicare Advantage patients. Inside the booklet, you ll find: A list of covered preventative visits Initial Preventative Physical Exam (IPPE) Welcome to Medicare Preventative Visit details; Personalized Prevention Plan Services (PPPS) Annual Wellness Visit details; A list of covered preventative services and screenings, complete with corresponding HCPCS/CPT codes, the beneficiary covered, frequency of the service, and member cost; and A list of covered vaccinations, complete with corresponding HCPCS/CPT codes, the beneficiary covered, and member cost. We are happy to provide these guidelines to help you streamline your reimbursement processes, so you can keep your focus on patient care. You can access the Preventative Services Booklet here. Reminder About Billing DSNP Members We wish to remind providers of CMS regulations regarding some billing matters. Providers may not bill Medicare Dual Special Needs Plan (DSNP) members, which members are dually eligible for Medicare and Medicaid, for Medicare Part A and B cost sharing when the applicable state program is responsible for that reimbursement. Also, providers must either accept the member copayment from a health benefits plan as full payment, or bill the applicable state. Regarding balance billing, providers may not bill, charge, collect a deposit from, seek remuneration or reimbursement from, or have any recourse against a member to whom health care services have been provided. This includes any person or persons acting on behalf of the member. Thank you for helping us comply with these requirements. 2

3 Preventative Care and Screening: Influenza Immunization A reminder to providers about influenza immunization for members. The following members may obtain their influenza immunization in these ways: Vaccines (Brand Drugs) Influenza (injectable) Influenza (intranasal) Qualifications Employee Plan Commercial Plan Medicare > 6 months Rx or > 6 months Rx or $0 $0 Rx = pharmacy only, any participating pharmacy Rx or = any participating pharmacy, physician s office, or retail clinics (Minute Clinics for example) Contact Numbers Please reference the table below for contact information. Department Purpose Contact Number Provider Services Eligibility, claims inquiries (855) and appeals information Management Prior authorization (855) Provider OnLine Technical concerns (855) Pharmacy Services Pharmacy information (855) Medicare Member Member inquiries (855) Services Commercial Member Member inquiries (855) Services Provider Relations Provider questions (937) As always, you can reach out to our Chief Officer or our local Director at (937) Why is RAF Important? Risk Adjustment Factor (RAF) is a Medicare-based program that assesses and predicts the burden of illness for individuals and patient populations. Medicare uses the Hierarchical Condition Categories (HCC) model to understand which chronic conditions providers manage. HCC is tied to the billing of certain acute and chronic medical conditions that are identified, assessed or treated during a patient encounter. There are approximately 8,000 diagnosis codes that impact RAF, many of which are chronic in nature. Submission of these specific ICD-10-CM codes on a claim is the only way to impact the RAF score of your patient panel. RAF is critical because it will provide a clearer understanding of the health status of our members, especially patients exhibiting more complex and serious conditions. 3

4 Premier Health Group s RAF campaign kicked-off in April Our Population Health liaisons will begin to deliver the second round of Patient Assessment Forms (PAF) to the offices at the end of September. We encourage all practices to see our patients as soon as possible in the year for their annual wellness exams. To meet our requirement, each practice must complete these forms by December 31, If you have questions about HCC coding or filling out the PAF, contact: Nini Trayvick, MBA, LPN DTrayvick@PremierHealth.com Phone: Cell: Tanya Jackson, BS TRJackson@PremierHealth.com Phone: Cell: HEDIS: Initiation and Engagement of Alcohol and other Drug Dependence Treatment (IET) Measure HEDIS is a quality and performance assessment tool, required by the Centers for Medicare and Medicaid Services (CMS), which employs standardized measures set by the National Committee for Quality Assurance (NCQA). The review is conducted each January to May 15, and takes a retrospective look at care and services through claims, medical record reviews, and member surveys. The results guide the organization in developing quality initiatives, assessing performance, and building educational programs. One of the assessments used is the Initiation and Engagement of Alcohol and other Drug Dependence Treatment (IET) measure. The HEDIS IET measure monitors whether adolescents and adults with an episode of alcohol and other drug dependence had inpatient or outpatient treatment within 14 days of their initial diagnosis, and two additional treatments within 30 days of the first visit. How providers can help: When giving a diagnosis of alcohol or other drug dependence, arrange follow-up visits over the next four to six weeks, or refer the patient immediately to a behavioral health provider. For example: o Every time a patient receives a primary or secondary diagnosis indicating abuse of alcohol or other drugs, schedule a follow-up visit within 14 days. o During the second visit, schedule two additional visits and/or schedule the patient to see a substance abuse treatment specialist within the next 14 days. o Following a hospital discharge for a patient with an alcohol or other drug dependence diagnosis, schedule two additional visits within 30 days. Involve others who are supportive of the patient to increase participation in treatment. Listen for and work with existing motivation in patients. 4

5 HEDIS: Osteoporosis Management in Women Who Had a Fracture Measure Another area that has opportunity for improvement is the HEDIS measure: Osteoporosis Management in Women Who Had a Fracture. This measure assesses the number of women ages 67 to 85 who suffered a fracture, and who had either a bone mineral density test (BMD) or prescription for a drug to treat osteoporosis in the six months after the fracture. The intent is to prevent secondary fractures resulting from osteoporosis in older women. Fractures of finger, toe, face and skull are not included in this measure. Below you will find a list of medications which fulfill this measure: HEDIS 2016: Osteoporosis Therapies Biphosphates Other Agents Alendronate Alendronate-cholecalciferol Ibandronate Risedronate Zoledronic acid Calcitronin Denosumab Raloxifene Teriparatide Exclusions include: Members who had a BMD test during the 24 months prior to the encounter; Members who had a claim/encounter for osteoporosis therapy during the 12 months prior to the IESD; Members who received a dispensed prescription or had an active prescription to treat osteoporosis during the 12 months prior to the IESD. NCQA: What are the Benefits to Being Accredited? Premier HealthOne (our Individual health insurance product offered on and off the Ohio Healthcare Exchange) is accredited by the NCQA. This accreditation supports the value and quality of our services and provides opportunities for welcoming new business and staying competitive. NCQA accreditation is a thorough, comprehensive assessment based on member experience and clinical performance that meets the demands of: Consumers As more individuals seek coverage through the national marketplace, quality assurance is an important component of their choice; Employers Many businesses and organizations prefer plans that are NCQAaccredited; and 5

6 Regulators Most states recognize NCQA-accreditation as meeting requirements for commercial Medicaid plans, and NCQA-accreditation is accepted by the Federal Employees Health Benefits Program. Minute Clinics: Where to Seek Care After Hours For patients who need care outside regular physician office hours, PHG offers coverage for care at select facilities. They re open during evening and weekend hours and offer urgent care for non-life-threatening illnesses and minor injuries so patients don t have to go to the Emergency Room. Members can choose from these immediate care locations: Retail Clinic/After Hours (PCP Co-pays apply) After Hours Care Troy Englewood After Hours Care First Care After Hours Beavercreek MinuteClinic inside CVS/Pharmacy Stores (Members can go to any clinic nationwide) University Health Clinics (Any university nationwide. The clinic must be located on a campus) Urgent Care (Urgent Care Co-pays apply) Doctor s Urgent Care Hometown Urgent Care AcessMD Urgent Care Community Urgent Care Dayton s Children s Hospital Urgent Care Concentra Urgent Care Fraud, Waste and Abuse Premier Health Plan is committed to building healthier communities in southwest Ohio. In one of our efforts to keep healthcare affordable, we seek to detect, correct and prevent fraud, waste and abuse. If you suspect fraud, waste or abuse please contact us at our toll free number, (855)