Fall 2015 Partners in Care Newsletter

Transcription

1 Fall 2015 Partners in Care Newsletter Molina Healthcare s 2015 HEDIS and CAHPS Results The Consumer Assessment of Healthcare Providers and Systems (CAHPS ) is a survey that assesses Molina members satisfaction with their health care. It allows us to better serve our members. Molina Healthcare has received results of how our members scored our providers and our services. In 2015, Molina Healthcare showed improvement on customer service. We also improved in making it easier to see a specialist or get tests and treatments for our members. We still need to improve on how well our doctors communicate with members as well as getting our members access to care as soon as needed. Another tool used to improve member care is the Healthcare Effectiveness Data Information Set or HEDIS. HEDIS scores allow Molina Healthcare to monitor how many members are receiving the services they need. Measures include immunizations, well-child exams, Pap tests and mammograms. There are also scores for diabetes care, and prenatal and after-delivery care. In 2015, Molina improved on the HEDIS measures related to shots for adolescents, breast cancer screening and assessing body mass index (for measuring body fat). We need to improve on making sure our members receive timely prenatal care. We also need to improve on helping members control high blood pressure and asthma. In This Issue HEDIS and CAHPS Results... 1 Answers about Drug Benefits... 2 Featured at... 2 Important Reminders About ID Cards... 3 Molina Healthcare is ICD-10 ready... 3 ICD-10 and Risk Adjustments... 4 Abuse-Deterant Opioids Hospital National Patient Safety Goals... 6 Provider Availability... 7 Leapfrog Hospital Safety Data Flu Season... 8 Translation Services... 8 You can look at the progress related to the goals that Molina Healthcare has set for the annual CAHPS survey results and the annual HEDIS measures in more detail on the Molina Website. You can also view information about the QI Program and print a copy if you would like one. Please visit the provider page on Molina s website at DM0715

2 Where to Find Answers about Drug Benefits As a Molina provider, we encourage you to talk to your members about the medications they need. Information about the pharmacy benefits and formulary medications is on the provider page of the Molina website at On the website, you can find: A list of generic and brand name medications that we cover and do not cover (drug formulary) Limits on covered medications Changes and updates to the prescription drug list made during the year The process to ask for prior authorization or exception requests for medications not on Molina s formulary The process to change a drug to generic medication The process for using different medications that have the same effects, like a brand name or a generic medication Rules to try certain drugs first before we cover another medication for the same condition How you can ask us for approval of certain medications How you can ask for the amount of a medication the member may need Information needed by Molina Healthcare to get approval for medications Featured at www. Clinical Practice and Preventive Health Guidelines Disease Management Programs for Asthma, Diabetes, Hypertension, CAD, CHF & Pregnancy Complex Case Management Information Quality Improvement Programs Member Rights & Responsibilities Privacy Notices Claims/Denials Decision Information Provider Manual Current Formulary & Updates Pharmaceutical Management Procedures UM Affirmative Statement (re: non-incentive for under-utilization) How to Obtain Copies of UM Criteria How to Contact UM Staff & Medical Reviewer New Technology ICD-10 Updates If you would like to receive any of the information posted on our website in hard copy, please call toll-free (888) PARTNERS IN CARE NEWSLETTER

3 Important Reminder about Member ID Cards Most members have Molina Medicare in addition to Medicaid coverage. For this reason, it s important to always ask the member to show you both ID Cards at the time of service. Advantages: Shows that the member is dually eligible Identifies who to bill; primary and secondary insurance Avoids member complaints about incorrect member billing which is prohibited by CMS/Medicare Tells you who to contact if prior authorization is required Molina Healthcare is ICD-10 ready! MEDICARE Molina Healthcare is excited to announce the implementation of ICD-10. The date for ICD-10 implementation has been set and confirmed for October 1, 2015 and Molina Healthcare is ready. Below are a few reminders to help expedite your claims and authorization requests. In accordance with CMS guidelines, claims with incorrect coding will be rejected and returned to the submitter along with instructions on how to resubmit. The guidelines are as follows: For dates of service prior to October 1, 2015, claims must have the appropriate ICD-9 diagnosis code For dates of service on or after October 1, 2015, claims must have the appropriate ICD-10 diagnosis code For outpatient services that span October 1, 2015, the claim must be split between dates, and dateappropriate coding used. Generally, inpatient claims should use the code in effect on the date of discharge For submission guidelines on claim types not covered above, please refer to the detailed guidelines publicly available at the CMS website, CMS.gov. The appeals process will not change upon ICD-10 implementation. Please continue to file appeals with the same method you ve been using. If you have any questions or issues, your Provider Services Representative can assist you. As of October 1, 2015, please make sure all prior-authorization requests include ICD-10 codes. We offer providers three options for submitting prior-authorization requests. You may: 1) Fax prior-authorization forms, 2) Make requests via the provider portal or 3) Submit Clear Coverage applications. For any questions about prior-authorizations, please contact Molina Healthcare s prior-authorization department. For general ICD-10 questions, please refer to the updated FAQs on Molina s website. If you still have questions, please molina.icd10@molinahealthcare.com. PARTNERS IN CARE NEWSLETTER 3

4 ICD-10 and Risk Adjustment On October 1st, Molina will be making the transition to ICD-10. This change has a significant impact on the entire organization, but especially departments like Risk Adjustment. The primary reason for the change to ICD- 10 is to improve clinical communication and documentation. This will lead to greater quality and outcomes of care for our members. ICD-10 will also provide a higher level of accuracy and specificity to assess a member s condition with over 69,000 codes compared to only 14,000 in ICD-9. In Risk Adjustment, it s especially crucial to have an increased level of coding accuracy because it helps us identify members who may benefit from clinical coordination and medical management services. ICD-10 will help make sure that we are able to better understand the health care needs of our members to match them with the appropriate levels of care. It s important to maintain good working relationships with all of our providers and make Risk Adjustment an agenda item on every visit. Without the proper and complete documentation by the provider, there is a high risk for a negative impact to accurately capturing a member s health status, and the resources necessary to meet his or her needs. Risk Adjustment is an ongoing essential component of ensuring our members always have access to the quality health care services they deserve. It takes more than one team or department to drive its success. Learn more about Molina s resources for ICD-10 and your role in Risk Adjustment. It s everyone s responsibility! 4 PARTNERS IN CARE NEWSLETTER

5 Abuse-Deterrent Opioids The death rate for prescription drug overdose has more than tripled since According to the Trust for America s Health, in 2013, Utah has the eighth highest drug overdose mortality rate in the United States, with 16.9 per 100,000 people suffering drug overdose fatalities. Primary care doctors are the highest prescribers of painkillers. According to survey results published in the Clinical Journal of Pain, nearly half of primary care doctors thought abuse-deterrent opioids were not as addictive as regular prescription painkillers. This misconception can lead to over prescription and abuse. Data shows most abusers take the opioid pills by mouth, not by crushing, snorting or injecting the drug. How can you help reduce drug abuse? Some doctors are creating contracts where patients agree to use the medicine as directed and not sell or give the drug to someone else. Doctors also support urine tests for chronic painkiller users. This can help to monitor the patients drug use. Additional steps in helping reduce drug abuse are medication reconciliation and coordination of care activities. The Joint Commission has established Using Medicines Safely as a 2015 National Patient Safety Goal for Ambulatory Care. This goal includes specific recommendations for comprehensive medication reconciliation. Likewise, coordination of care activities particularly during transitions of care are crucial to efforts aimed at reducing the risk of abuse. Ask your patient about other providers they have. Be sure your patient completes a release of information for each provider. Confirm current medications and significant medication history with those providers. Furthermore, coordinating care with your patient s Behavioral Health Specialist is an essential step in treatment planning and monitoring for signs of abuse. The Center for Studying Health System Change (HSC) also offers strategies for improving coordination of care in the primary care setting. Do not underestimate the risk of abuse-deterrent opioids. They are not less addictive than standard narcotic pain killers. References: The Joint Commission: 2015 Ambulatory Care National Patient Safety Goals: Center for Studying Health System Change: Coordination of Care by Primary Care Practices: Strategies, Lessons and Implications (HSC Research Brief No. 12), April 2009: PARTNERS IN CARE NEWSLETTER 5

6 2015 Hospital National Patient Safety Goals The Joint Commission establishes annual goals for patient safety in various health care settings. The goals for hospitals in 2015 are outlined below: Identify Patients Correctly. Use at least two ways to identify patients. For example, use the patient s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Make sure that the correct patient gets the correct blood when they get a blood transfusion. Improve Staff Communication. Get important test results to the right staff person on time. Use Medicines safely. Before a procedure, label medicines that are not labeled. Some examples include medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up. Take extra care with patients who take medicines to thin their blood. Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Prevent Infection. Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the proven goals to: improve hand cleaning prevent infections that are difficult to treat prevent infection of the blood from central lines prevent infection after surgery prevent infection of the blood from central lines or infections of the urinary tract that are caused by catheters Use Alarms Safely. Make improvements to ensure that alarms on medical equipment are heard and responded to on time. Check Patient Medicines. Find out what medicines each patient is taking. Make sure that it is OK for the patient to take any new medicines with their current medicines. Give a list of the patient s medicines to their next caregiver. Give the list to the patient s regular doctor before the patient goes home. Give a list of the patient s medicines to the patient and their family before they go home. Explain the list. Some patients may get medicine in small amounts or for a short time. Make sure that it is OK for those patients to take those medicines with their current medicines. Identify Patient Safety Risks. Find out which patients are most likely to commit suicide. Prevent Mistakes in Surgery. Make sure that the correct surgery is done on the correct patient and at the correct place on the patient s body. Mark the correct place on the patient s body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made. For further information, visit 6 PARTNERS IN CARE NEWSLETTER

7 Provider Availability A Contracted Primary Care Provider must ensure that he/she will be available or accessible, or arrange to have another qualified medical professional available or accessible twenty four (24) hours a day, seven (7) days a week. Provider shall meet the applicable standards for timely access to care and services, taking into account the urgency of the need for the services. The following are acceptable and unacceptable telephone arrangements for contracted PCPs after their normal business hours: Acceptable after-hours coverage The office telephone is answered after-hours by an answering service, which meets language requirements of the major population groups served and which can contact the PCP or another designated medical practitioner. The office telephone is answered after normal business hours by a recording in the language of each of the major population groups served, directing the patient to a.) leave a message and their call will be returned within 30 minutes; b.) call another telephone number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider s telephone. Another recording is not acceptable. The office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or another designated medical practitioner, who can return the call within 30 minutes. Calls answered by an answering service must be returned within 30 minutes. Unacceptable after-hours coverage No answering service or the option to leave a message Providing the option to leave a message, but not returning the calls within 30 minutes An automated message with a referral to the ER for afterhours care For more information on after-hours coverage contact Provider Services at Access to Care All providers should follow the Access to Care Standards listed below. These standards are based on regulatory and accreditation standards. Molina Healthcare monitors compliance to these standards. PCP and SCP Appointment Availability Standards: Routine exams should be provided within 21 days of request. Preventive health services for children within 60 days. Preventive health services for adults within 90 days. Urgent care should be received within 48 hours of the request. Emergency care should be received immediately. Referrals to a specialist should be seen within 30 days of a request. Behavioral Health Provider Appointment Availability Standards: Routine visits should be provided within 10 days of request. Urgent care should be received within 48 hours of the request. Care for Non-Life Threatening Emergencies should occur within 6 hours. PARTNERS IN CARE NEWSLETTER 7

8 Leapfrog Hospital Safety Data A patient safety program helps to reduce accidental injury or medical errors to patients while in the hospital. Leapfrog is the name of a patient safety program. All network hospitals are part of the Leapfrog program. The Leapfrog process gives hospitals one to four stars. One star is for submitting data. Two stars are for making progress toward meeting patient safety standards. Three stars are for making the most progress meeting patient safety standards. Four stars are for meeting all patient safety standards. Molina would like to congratulate the following hospitals on meeting Leapfrog hospital safety standards: American Fork Hospital Ogden Regional Medical Center Brigham City Community Hospital Lakeview Hospital McKay Dee Hospital Mountain View Hospital St. Marks Hospital Timpanogos Regional Hospital Utah Valley Regional All hospitals met the Leapfrog standard for managing serious errors. All facilities are doing well with managing normal deliveries and reducing hospital acquired injuries. For more information, see Flu Season The Advisory Committee on Immunization Practices (ACIP) continues to recommend annual influenza vaccinations for everyone who is at least 6 months of age and older. It s especially important that certain people get vaccinated, either because they are at high risk of having serious flu-related complications or because they live with or care for people at high risk for developing flu-related complications. For a complete copy of the ACIP recommendations and updates or for information on the flu vaccine options for the 2015 flu season, please visit the Centers for Disease Control and Prevention at Translation Services We can provide information in our members primary language. We can arrange for an interpreter to help you speak with our members in almost any language. We also provide written materials in different languages and formats. If you need an interpreter or written materials in a language other than English, please contact Molina s Member Services Department. You can also call TDD/TTY: 711, if a member has a hearing or speech disability. 8 PARTNERS IN CARE NEWSLETTER