General Information. Overview. Purpose. Table of Contents

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1 Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.engage Inovalonto conduct outreach efforts for ouraca individual and small group on and off exchange business FAQs Overview General Information Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. (collectively BCBSGa ) continue to work to adhere quickly and responsively to government guidance as it is issued regarding the Affordable Care Act (ACA).Key provisions of the ACA are intended to extend coverage to millions of uninsured Americans, to implement measures that will help improve system efficiency, and to eliminate industry practices that include rescission and denial of coverage due to pre-existing conditions. As a result of the legislation, consumers now have the opportunity to purchase health care plans in the Health Insurance Marketplace (often called the exchange). Our provider newsletter Network Update shares information about risk management programs associated with the ACA and applicable to plans sold both on and off theexchange, our business relationship with Inovalon (a health care technology company), and Inovalon s outreach efforts on our behalf to members and providers. Purpose BCBSGa is working with Inovalon to help ensure that members who have purchased health care plans on and off the exchange get their diagnoses confirmed, corrected, and updated every year, as well as have potential preventive care gaps addressed. To accomplish this goal, BCBSGanetwork providers may receive letters from Inovalon,asking providers to perform patient outreach. The goal of this document is to address common questions regarding interventions and tools used with our outreach process, as we work to help members resolve their health care gaps. We hope you find this document helpful. Table of Contents Definitions General Questions Personal Health Visits In-Office Visits Paper SOAP Notes Incentives Offered epass Tool Medical Records/Chart Requests Contact Information April 2015 Page 1 of 8

2 Definitions In-Office Visits (also called Encounter Facilitation) An In-Office Visit is a face-to-face encounter conducted by the member s primary care provider (PCP) in the PCP s office. The in-office visit is prompted by letters that Inovalonmails to the member and the provider to encourage the member to see his or her provider related to a certain medical condition(s).inovalon will make additional calls to the member to help ensure the member schedules an appointment with his or her PCP. The provider is asked to complete a SOAP Note (see definition below) following the in-office visit either by completing the paper form and sending to Inovalon or by submitting the information electronically using Inovalon sepass tool. Directions for completing SOAP Notes are included in the provider s mailing. Personal Health Visits (also called Supplemental Member Encounter) A Personal Health Visit is a faceto-face encounter conducted by an Inovalonphysician, physician assistant (PA) or nurse practitioner (NP) in the member s home, at aninovalon member center, or a partnered center such as a retail clinic (e.g., Walgreens). During these visits, the clinical providers may take the member s history and vitals and other information needed for SOAP Note creation. Membersare advised to see their PCPif additional follow-up is required. The goal is to collect additional health information and share results with the member s PCP. SOAP Note (also called Encounter Facilitation Form) The SOAP Note is the standardized documentation format of a medical record. It stands for Subjective, Objective, Assessment, and Plan. General Questions 1. What is Commercial Risk Adjustment? Due to health care reform, health care insurers are no longer allowed to perform medical underwriting on individual and small grouphealth insurance applicants. This new guarantee issue environment allows individuals who have previously been unable to obtain coverage to enter the marketplace. To ensure stability within the markets, the ACA provides for three protective programs: Reinsurance, Risk Adjustment and Risk Corridors (often referred to as the 3Rs ). The overall goal of these programs is to provide certainty and protect against adverse selection(attracting a higher than average risk pool) while stabilizing premiums, as market reforms and enrollment on and off the exchanges began in January As the only permanent program, Risk Adjustment is intended to provide increased payments to health insurers that attract higher-risk populations, such as those with chronic conditions. 2. Who is Inovalon and why did they call me? To comply withthe ACA and requirements of the Risk Adjustment program, specifically,bcbsga is updating health documentation for members in the individual and small group markets who have purchased our health insurance plans on and off the exchange. We engaged Inovalon an independent company that provides secure, clinical documentation services to contact our members and encourage In-Office Visits with their physicians and/or conduct Personal Health Visits in their home, at a retail clinic (such as Walgreens) or other location. April 2015 Page 2 of 10

3 Personal Health Visits (In-home Assessments performed by Inovalon) 1. Why was my patient contacted for a Personal Health Visit? We are working to update health documentation for members in the individual and small group markets who have purchased our health insurance plans on and off the exchange. Claims data was used to selectbcbsga s Commercial health insurance members who have not seen a physician for medical care this year or appear to have some type of gap in care that could be closed by seeing a physician. This voluntary program was developed to encourage members to seek treatment for any conditions that may be identified during the assessment. 2. Will I be compensated for my involvement in this Personal Health Visit? No. We have contracted with Inovalon to perform these visits. Since there are no additional resources required from you or your staff, no compensation will be provided to you. After the examination is complete, the documentation from the exam will be sent to you so you can better coordinate your patient s care. 3. Does the member have to pay for the Personal HealthVisit? No, the Personal Health Visit is free of charge to the member, and there is no copayment.bcbsgais paying Inovalon for these assessments. 4. Will I be penalized if I do not participate? No. There are no penalties if you do not participate, as this is a voluntary program. If the member completes the Personal Health Visit, the records of this evaluation will be provided to you. This is to help you better coordinate your patient s care. 5. How will the outcomes of this assessment impact my reimbursement withbcbsga? This assessment has no influence on your negotiated reimbursement rates withbcbsga.however, the results of the assessment may help you identify services your patient may need and direct the patient to you to seek treatment. 6. What are the qualifications of the medical professional who will be evaluating my patient if they have a Personal Health Visit with someone else? The assessment is limited to a physical exam; treatment will not be provided. The medical professional will be a licensed physician, nurse practitioner, or physician assistant hired to perform this service. It is important to note that this exam is in addition to any regular visits the member has with you and is not a substitute for the member s annual physical examination. (Please see related question number 12.) 7. What kind of assessment is performed? The assessment is a review of the patient s overall health and includes measuring vital signs such as pulse and blood pressure. The medical professional discusses symptoms of any present medical conditions and reviews the patient s medical history. He or she will not order any tests or write any prescriptions. The records of this evaluation will be provided to you. This will help you better coordinate your patient s care. April 2015 Page 3 of 10

4 Please note that this assessment is in addition to any regular visits the member has with you and is not a substitute for the member s annual physical examination. 8. What if this is not a patient of mine? At the time the member was selected for this intervention, you were the member s physician on record. We determine physician on record either by the member s Primary Care Provider (PCP) selection or through claims history. At this time, there is no further action required. 9. What will I (or my staff) be required to do prior to the Personal Health Visit? No additional action is required from you or your staff prior to the Personal Health Visit. 10. How will I be informed of the results of the Personal Health Visit? After the examination is complete, the documentation from the assessment will be sent to you for your patient s record and for you to provide care as you deem appropriate. This is to help you better coordinate your patient s care. 11. How will I be expected to follow up with this patient (such as the next steps )? After you have had a chance to review the results of the Personal Health Visit, you may want to contact this patient to schedule a future follow-up appointment to discuss health care goals and treatment plans. Your patient was also told at the time of the assessment to continue to seek your medical guidance. 12. As the member s primary care provider, I would prefer to evaluate my patient instead of Inovalon s Personal Health Visits option. Is this possible? Yes, as before, we encourage patients to consult with their primary care providers. And as the primary provider, you always have the option to see these patients providing medical recommendations and care and prescribing medications and dosages as you deem appropriate.every day, you have several opportunities to educate your patients on the importance of good health, preventive care and taking medications correctly. We always encourage our members your patients to consult with their physicians if they have questions about their health care or any medications they are taking. If you elect to conduct the evaluation during an In-Office Visit,we will reimburse you at your standardcontracted rate with us for the office visit. Once you conduct the evaluation, please complete the SOAP Note electronically via the epass tool. If you prefer, you can complete a paper SOAP Note and fax it to Inovalonat It is important to note that the member s cost share (deductible, copayment or coinsurance) may apply during this visit. Should your office be unable to schedule an appointment with our member, Inovalon will contact the member on our company s behalf to conduct the Personal Health Visit. April 2015 Page 4 of 10

5 13. Does the Personal Health Visit comply with the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? Yes. The company performing the Personal Health Visits Inovalon and its contractors is a Business Associate ofbcbsgaand as such, Inovalon is legally bound to protect, preserve, and maintain the confidentiality of any Protected Health Information (PHI)the company gleans from clinical records. In-Office Visits (Encouraging Members to see their PCP) 1. Why did I receive this letter and/or my patient s profiles form? Is the documentation in the patient s medical record not sufficient? You received this letter becausebcbsga identified some potential conditions that have not been documented on a claim this year, or the patient may have potential preventive care gaps. We hope the epass /patient profile form attached to the letter assists you in evaluating both the patient s acute and chronic, underlying conditions. This is meant to supplement, not replace, your standard documentation practices for office visits. 2. I just saw this patient for a checkup. Do I need to see them again just to fill out this form? If you have seen the patient within the prior 60* days for the conditions or preventive care gaps that we are asking you to confirm or refute, you can use the information from that encounter to update the SOAP Note. If you did not discuss in that encounter the conditions or preventive care gaps that we are asking you to address, then we will try to get the patient back into your office for another face-to-face encounter. Our goal with this voluntary program is to help ensure that members get their diagnoses confirmed, corrected, and updated every year, as well as have potential preventive care gaps identified and addressed. *IMPORTANT NOTE: The visit within 60 days must be within the current benefit year. 3. I have never seen this patient. Why am I listed as their physician? At the time the member was selected for this intervention, you were the member s physician on record. We determine physician on record either by the member s Primary Care Provider (PCP) selection or through claims history. Please fax the letter back to Inovalon at and indicate the patient is not being seen by your practice. 4. Can I submit a claim for this encounter? Yes, please follow your existing billing processes. We will process the claim according to the member s benefits. 5. Does the member s cost share (such as copayment, deductible, co-insurance) apply to this encounter? Yes, the member s benefits (including cost shares) do apply for this visit. April 2015 Page 5 of 10

6 Paper SOAP Notes 1. Can I fax a paper SOAP Note instead of using epass? Yes. You have the option to fax in a completed paper SOAP Note to Inovalon at To ensure that the paper SOAP Note is fully processed, all required fields must be completed and signed by the patient s physician. 2. What am I supposed to do with this form after I fax it to Inovalon? We request that you place a copy of the form with the patient s other medical records as a supplement to your usual documentation process. 3. Does this form replace my usual encounter notes for the patient s visit? No. The form is meant to supplement your usual documentation process. 4. How often will I be receiving these forms? This will depend on your patient s health status and the frequency of his or her visits. 5. The provider listed on the form either does not see this patient or no longer practices here/is retired. What should I do with this form? Does the patient still seek care within your practice or group and is seen by another provider in your office? If YES: You may have the patient s new provider complete the form and note the changes at the top of the first page. We will update our system with the correct information upon receipt of the completed form. We apologize for any confusion. If NO: Please fax the letter back to Inovalonat and indicate the patient is no longer seen by your practice. 6. The information you have for the patient (address/phone number/gender/date of birth) is incorrect. How can we correct that? Changes to member information must come from the member. Please have the member contact ourmember Services area. 7. What happens if I don t complete the SOAP Note (is there a penalty)? This is a voluntary program, and there are no penalties if you do not participate. However, please note that we believe this process is a vital part of coordinating care for your patients and our members. April 2015 Page 6 of 10

7 8. What are some tips to keep in mind when completing SOAP Notes? We ask that you fully complete the SOAP Notes, addressing all questions as appropriate. Here are some tips for completing SOAP Notes that we hope are helpful. o The exam date for the patient must match the exam date on the completed SOAP Note o A claim must be submitted for the exam and the date of service on the claim must match the exam date on the completed SOAP Note o The provider signature date should be the actual date the SOAP Note is signed o All mandatory fields on the paper SOAP Note must be completed o The exam date must occur between January 1, 2015, and December 31, 2015, for this benefit year o All mandatory fields on the paper SOAP Note must be completed to be eligible for incentive payment (see section on incentives) o Incentives are only paid once for each patient for whom a health assessment was requested (see section on incentives) 9. Can I complete this form without seeing the patient based on the information in their medical records? If you have seen the patient within the prior 60*days for the conditions or preventive care gaps that we are asking you to confirm or refute, you can use the information from that encounter to update the SOAP Note. If you did not address the conditions or preventive care gaps that we are asking you to confirm or refute in that encounter, then Inovalon will encourage your patients via mail and phone calls to schedule an appointment with your office for a face-to-face encounter. Our goal with this program is to help ensure that members get their diagnoses confirmed, corrected, and updated every year, as well as have potential preventive care gaps addressed. *IMPORTANT NOTE: The visit within 60 days must be within the current benefit year. 10. Do you expect me to tell you the condition and the ICD-9/ICD-10 code? No. Please document the condition with the level of specificity needed to accurately capture your diagnoses of the patient. In addition, record this information legibly to ensure that our coders can accurately record the information by then coding the appropriate ICD-9/ICD-10 code. Incentives Offered In addition to the office visit fee, BCBSGa will pay you $ for each electronic SOAP Note properly completed and submitted for patient assessments performed during the current benefit year. You may also submit your patient assessment data for the members we request using paper SOAP Notes and send to Inovalon at the company s secure fax line at , or through the Web-based epass tool. For each paper SOAP Note submitted for patient assessments performed, you will receive $50.00 in addition to your office visit fee. Refer to question 8 in the preceding Soap Notes section for information/tips on properly completing SOAP Notes in order to receive incentives. April 2015 Page 7 of 10

8 epass Tool 1. What is epass? For providers who are caring forbcbsga members, we offer epass an electronic tool called Electronic Patient Assessment Solution Suite to document your patients condition. We understand that many providers do not have the time to document all relevant ICD-9 codes for the many complicated chronic conditions they manage for submitting a claim. epass is an easy-to-use tool that gives you comprehensive information about yourbcbsgapatients, including potential preventive care gaps, and also gives you the tool to completely document your patients conditions. The epass tool is available for use for only members Inovalon identifies and who have purchased our individual and small group health insurance plans on and off the exchange. 2. What am I supposed to do with epass? Inovalon has identified patients who have inconsistent or incomplete healthcare records. For example, if a patient with evidence of Spiriva medication claims does not have medical claims for diagnoses that suggest COPD, an assessment gap would be identified. The epass tool uses the Encounter SOAP Note that you create to confirm or refute that COPD is present in this patient. 3. How do I get started using the epass tool? You will first need to sign up for an account online with Inovalon at the following Web address: Inovalon offers live support via the company s support center to help guide you through completing information onthe epass tool. Inovalon representatives are available toll free at , Monday Friday, 8a.m. 7p.m. EST. In addition, Inovalonis working to create an Introduction to epass tool kit to assist you in completing the required fields necessary and submit the assessment via epass. The kit will be available online soon, and we ll notify you when the tool kit is available. Please note that a more comprehensive manual is currently available online and located on the HELP screen in epass for reference as well as Inovalon s Quick Start Guide and frequently asked questions. Medical Records Chart Reviews 1. Why is BCBSGa requesting records for exchange members? Each year, BCBSGa requests your assistance in our retrospective medical chart review programs. We continue to request members medical records to obtain information required by the Healthcare Effectiveness Data and Information Set (HEDIS ) and the Centers for Medicare & Medicaid Services (CMS). In 2014, we began requesting medical records/charts for members who have purchased our individual and/or small group health plans on or of the exchange as well. This particular effort is part of BCBSGa s compliance with provisions of the Affordable Care Act that require our company to collect and report diagnosis code data that may have not been previously documented for our members who have purchased individual or small group health plans on or off the exchange.our company has engaged Inovalon to contact providers on our behalf to collect and review medical record/chart information. April 2015 Page 8 of 10

9 2. How often will the chart requests occur? Throughout the year, Inovalon, Inc. will schedule the collection or review of medical record/chartinformation for members who have had services rendered by your provider practice or facility. Arepresentative from Inovalon, Inc. will contact your office to coordinate a convenient date and time to review records on our behalf. 3. Do patients have to provide their permission for records to be released to Inovalon? No, patient-authorized information releases are not required in order for you to comply with these requests for medical records. Providers are permitted to disclose Protected Health Information to health plans without authorization from patients when both the provider and health plan had a relationship with the patient and the information relates to the relationship [45 CFR (c)(4)]. For more information regarding privacy rule language, please visit 4. Is this chart collection process HIPAA compliant? Yes. According to HIPAA Privacy Rules (CFR 160, 164), amended August 14, 2002, health care providers can disclose Protected Health Information (PHI) to health plans for the purpose of quality assurance, quality improvement, accreditation activities and approved research studies. As defined by HIPAA, the role of the company performing the chart collection, Inovalon and its contractors, is as a Business Associate of Covered Entities, and as such, Inovalon is ethically and legally bound to protect, preserve, and maintain the confidentiality of any PHI it gleans from clinical records. In this setting, you may rest assured that Inovalon will treat your patients PHI with the highest level of protection and confidentiality. Please know that we consider the confidentiality of patient information to be of the utmost importance. 5. My specialty is not commonly requested for medical record/chart collection, why are you requesting this information? On BCBSGa s behalf, Inovalon targets specific providers for medical records/chart reviews and validates the provider specialty as set forth by the U.S. Department of Health and Human Services (HHS) requirements and standards.it is important to note that our requests do NOT include psychotherapy notes as that term is defined under HIPAA requirements. Under HIPAA, psychotherapy notes are defined as notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual s medical record. (45 CFR ) 6. If I m a behavioral health provider, is BCBSGa requesting that I provide psychotherapy notes as part of the medical record request? No. Inovalon is not requesting psychotherapy notes. Again under HIPAA, psychotherapy notes are defined as notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual s medical record. (45 CFR ) Psychotherapy notes do NOT include: - Medication prescription and monitoring - Counseling session start and stop times - Modalities and frequencies of treatment furnished - Results of clinical tests; and April 2015 Page 9 of 10

10 - Summary of the following: o Diagnosis o Functional status o Treatment plan o Symptoms o Prognosis; and o Progress to date As a result, we are permitted to collect the above information to support our audit, and you should provide, where applicable, pursuant to the request. 7. What is the benefit to providers for participating with these medical record requests? Is the medical record view mandatory? Participation will achieve several benefits. Clinical diagnosis data accuracy leads to improved risk score insight and accurate financial reimbursement for care provided. Additionally, appropriately reimbursed health plans are able to maintain stable member premiums and create new member programs to improve care. It is highly likely that the contractual agreement between BCBSGa and the provider state the participation in providing the requested medical records is mandatory. Please review the contractual agreement with BCBSGa. 8. I am not a network-participating provider with BCBSGa. Why do you need my information? We have identified at least one patient who was seen at your office practice or facility during the requested date of service range. Our records show that a claim was submitted to us for the visit. Contact Information Please contact Inovalon toll free at if you have additional questions about their outreach process or the epass tool. Blue Cross and Blue Shield of Georgia, Inc., and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. April 2015 Page 10 of 10