PROVIDER NEWSLETTER. Illinois 2016 Issue II DISEASE MANAGEMENT IMPROVING MEMBERS HEALTH IN THIS ISSUE

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1 Illinois 2016 Issue II PROVIDER NEWSLETTER DISEASE MANAGEMENT IMPROVING MEMBERS HEALTH Disease Management is a no-cost, voluntary program to assist members with specific chronic conditions. A member is assigned a disease nurse manager who can help the member with: Education and understanding of his or her specific condition Identification of adherence barriers and ways to overcome them Individualized lifestyle modification suggestions to improve daily life Self-management of the member s condition to improve health outcomes Motivational coaching to encourage members when they face difficulties Improved communication with the member s primary care provider and health care team Disease Management can assist your members with the following conditions: Asthma Chronic obstructive pulmonary disease (COPD) Congestive heart failure (CHF) Coronary artery disease (CAD) Depression Diabetes Hypertension Obesity Smoking cessation For more information, or to refer a member to Disease Management, please call us at IN THIS ISSUE Disease Management Improving Members Health...Page 1 How To Improve Patient Satisfaction and CAHPS Scores, Part 1 of 3...Page 2 Q Provider Formulary Update...Page 3 How Care Management Can Help Your Patients...Page 4 Provider Satisfaction Survey...Page 4 Harmony Offers LA Fitness Membership Discount...Page 4 Updated Clinical Practice Guidelines...Page 4 New Outreach Guidelines For Harmony Providers...Page 5 We Are Building a Website That Works for You...Page 5 Enhanced Customer Service Technology... Page 6 Medicare Quality Overview... Page 6 Harmony Introduces Empower Her Women s Health Campaign...Page 7 Better Quality Is Our Goal...Page 7 Updating Provider Directory Information... Page 8 Provider Resources... Page 8

2 HOW TO IMPROVE PATIENT SATISFACTION AND CAHPS SCORES, PART 1 OF 3 WHAT IS THE CAHPS? The Consumer Assessment of Healthcare Providers and Systems (CAHPS ) survey asks patients to evaluate their health care experiences. Harmony-WellCare conducts an annual Child CAHPS survey, which asks parents or guardians to rate experiences with their children s health care providers and plans. As a Harmony-WellCare provider, you can provide a positive experience on key aspects of their children s care; we ve provided some examples of best practices to help with each of the sections. KNOW WHAT YOU ARE BEING RATED ON: TIPS TO INCREASE PATIENT SATISFACTION: 1. Getting Needed Care Ease of getting care, tests, or treatment child needed Obtained child s appointment with specialist as soon as needed Help patients by coordinating care for tests or treatments, and schedule specialists appointments, or advise when additional care is needed to allow time to obtain appointments. 2. Getting Care Quickly Child obtained needed care right away Child obtained appointment for care as soon as needed Educate your patients on how and where to get care after office hours. Do you have on-call staff? Let your patients know who they are. 3. How Well Doctors Communicate Child s doctor explained things in an understandable way Child s doctor listened carefully Child s doctor showed respect Child s doctor spent enough time with your child The simple act of sitting down while talking to patients can have a profound effect. Ask your patients what is important to them. This helps to increase their satisfaction with your care. 4. Shared Decision Making Doctor/health provider talked about reasons you might want your child to take a medicine Doctor/health provider talked about reasons you might not want your child to take a medicine Doctor/health provider asked what you thought was best for your child when starting or stopping a prescription medicine. Use of office staff other than physicians to distribute decision aids could help more patients learn about the medical decisions they are facing or simply to address medications. innovations.ahrq.gov/qualitytools/informedmedical-decisions-foundation-tools-providers Ask your patients, What should I know about you that may not be on your medical chart? Continued on next page 2

3 Continued from previous page 5. Coordination of Care In the last 6 months, did your child s personal doctor seem informed and up-to-date about the care your child got from other health providers? Your office staff needs to offer to help your patients schedule and coordinate care between providers. 6. Rating of Personal Doctor Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your child s personal doctor? 7. Rating of Specialist Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist? Studies have shown that patients feel better about their doctors when they ask patients, What s important to you? Help your members value their visit to the specialists, be informed of their visit and their advice. Make sure both you and your medical team know the questions your practice is being rated on. Knowledge is power. For more information and research on ways to improve patient satisfaction, see Flipping Health Care: From What s the Matter to What Matters to You? You can access this article and video at the websites below. Sources and References: Christina Gunther-Murphy-What Matters Office Practice Setting IHI Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Q PROVIDER FORMULARY UPDATE MEDICAID: The Harmony Medicaid Preferred Drug List (PDL) has been updated. Visit Medicaid/Pharmacy to view the current PDL and any pharmacy updates. You can also refer to the Provider Manual available at to view more information regarding Harmony s pharmacy Utilization Management (UM) policies and procedures. MEDICARE: The Medicare Formulary has been updated. Find the most up-to-date complete formulary at Illinois/Providers/Medicare/Pharmacy. You can also refer to the Provider Manual available at to view more information regarding Harmony-WellCare s pharmacy UM policies and procedures. 3

4 HOW CARE MANAGEMENT CAN HELP YOUR PATIENTS Care Management helps members with special needs. It pairs a member with a care manager. The care manager is a registered nurse (RN) or licensed clinical social worker (LCSW) who can help the member with issues such as: Complex medical and behavioral health needs Solid organ and tissue transplants Chronic illnesses such as asthma, diabetes, hypertension and heart disease Children with special health care needs Lead poisoning This no-cost program gives access to a registered nurse or licensed clinical social worker Monday Friday, 8 a.m. to 5 p.m. For more information about Care Management, or to refer a member to the program, please call us at We re here to help you! PROVIDER SATISFACTION SURVEY WellCare is conducting the annual Provider Satisfaction Survey, May July, in all WellCare markets. Administered by SPH Analytics, the survey targets health care providers to measure satisfaction with WellCare, as well as support NCQA Standards for Health Plan Accreditation. PCPs, Specialists and Behavioral Health providers are randomly selected and surveyed by mail, internet, and phone. Your participation is encouraged and appreciated. HARMONY OFFERS LA FITNESS MEMBERSHIP DISCOUNT Harmony Health Plan is offering members (your patients) a discount membership to join LA Fitness with no enrollment fee! Members and their family members can enroll for $24.95 a month, and are responsible to pay the first and last month s membership dues to join. For more information on, or to refer a member, contact Harmony Member Services at or visit wellcare.com/illinois. UPDATED CLINICAL PRACTICE GUIDELINES Clinical Practice Guidelines (CPG) related to Adult Preventive Health as well as Diabetes have been updated and added to the Provider website. Visit Illinois/Providers/Clinical-Guidelines to access other CPGs related to Preventive Health and Behavioral Health as well as Chronic Conditions. 4

5 NEW OUTREACH GUIDELINES FOR HARMONY PROVIDERS Effective January 29, 2016, the Department of Healthcare & Family Services (HFS) released the following guidelines for Harmony providers when distributing health plan outreach material to members: PATIENT HEALTH PLAN EDUCATION AT PROVIDER LOCATIONS: Ensure all patients know all of their health plan choices. Only use materials based on HFS-approved provider flyer/letter templates. Display the flyer/letter template(s) in your office, and list all health plans you work with. You may add a paragraph indicating a preference for a specific health plan, as long as it shows a benefit to the member and is written positively and truthfully. Any flyer/letter that includes a preferred health plan paragraph must be submitted through the preferred health plan for HFS approval. All flyer/letter templates must include the following statement: Illinois Client Enrollment Services will send you information about your health plan choices when it is time for you to make a health plan choice and during your Open Enrollment period. Providers are prohibited from giving patients access to the Client Enrollment Services Enrollment Portal in any office-related setting, including all of Harmony s primary care provider offices, health fairs, or other health plan functions where enrollment may be discussed. If a potential member is not currently enrolled in a health plan, the provider may refer them to the IL Client Enrollment Services at for information about their health plan choices. Someone who is not enrolled in a health plan may also be excluded from participating in a managed care program and should be referred to IL Health Connect for help finding providers. Individuals enrolled in a health plan should be referred to their health plan for answers to questions and access to care. If you have questions/concerns, or would like to get copies of these guidelines or the provider templates, please call your Provider Relations representative. WE ARE BUILDING A WEBSITE THAT WORKS FOR YOU Harmony-WellCare recently launched a redesigned public website. Now we re redesigning our secure provider portal, where you can log in to complete tasks such as: Check member eligibility and co-payment information Submit authorization requests and check status Submit claims and check status View open care gaps and access reports Access a personal inbox with direct messages from Harmony-WellCare WHAT S NEXT? We are visiting some of you, our providers, to find out how we can improve our website tools. We are planning to talk to people in billing, admissions, care coordination and more. Your feedback will help shape our new portal! Stay tuned for updates on the project. 5

6 ENHANCED CUSTOMER SERVICE TECHNOLOGY WellCare is dedicated to providing customer satisfaction and operational excellence in the communities we serve. We understand patient care is the priority, and your time is important. In order to make it easier for providers to do business with us, we have implemented some major technology improvements designed to make it easier for providers to do business with us. Improvements include: New IVR enhanced features and Self-Service functionality. For additional information on these new improvements, or detailed instructions on using the IVR, see the Provider Phone Access Guide Job Aid. All documents are located on our website at Click on Overview under Medicaid or Medicare. If you wish to reach our EDI team for specific inquiries, you may reach them via at To register, refer to the Provider Resource Guide. To contact Provider Services directly, call the state-specific, toll-free phone number provided on your Quick Reference Guide. MEDICARE MEDICARE QUALITY OVERVIEW QUALITY IMPROVEMENT PROGRAM GOALS WE ACCOMPLISHED IN 2015 INCLUDE: Completed assessments for members who are part of the WellCare D-SNP population Completed individualized care plans for D-SNP members Conducted inter-disciplinary care teams with providers and health plan care managers to ensure that quality care is provided Reviewed data on quality outcomes for diabetes, congestive heart failure, chronic obstructive pulmonary disease, and mental health diagnoses to ensure members receive high quality care Deployed Clinical HEDIS Practice Advisors to assist providers in improving health care outcome rates Enhanced Care and Disease Management Programs by adding health coaches and expanding field-based resources Continued to implement and expand the Community Advocacy Team throughout WellCare markets to ensure all members and provider share access to community resources OUR CONTINUED GOALS FOR 2016 INCLUDE: Improving the WellCare D-SNP Model of Care program to assist with members receiving the right care at the right time in the right setting Reviewing and measuring the quality of care and services that our members receive Working with providers as a team to help meet members health care needs Working with providers to organize care so that together we can coordinate our members health care and improve their quality of service. Contracting with and maintaining High Performance Provider Networks Reviewing and updating our guidelines to ensure that a safe and healthy environment for care is maintained Focusing on performance indicators as an organization to achieve quality excellence WellCare appreciates our providers partnership in ensuring our members receive the best care. To receive a copy of our Medicare Quality Improvement Annual Evaluation and/or the D-SNP Model of Care Evaluation, please call Member Services. 6

7 HARMONY INTRODUCES EMPOWER HER WOMEN S HEALTH CAMPAIGN In May 2016, Harmony will kick off an exciting community women s health campaign called Empower Her. The campaign s purpose is to educate, celebrate, encourage women to take action, and help them make the best healthy lifestyle decisions for themselves and their families. In many communities, women are the primary decision-makers for their families when it comes to health care. The Empower Her campaign, in partnership with community organizations and providers, will bring accessible health resources that support women in living healthier and happier lives. The campaign will address health issues including diabetes, asthma, prenatal/postpartum care wellchild visits, childhood immunizations and breast cancer screenings. The campaign will target Cook County areas where these health issues are prevalent. Stay tuned for activities and information in your community. MEDICAID BETTER QUALITY IS OUR GOAL Our Quality Improvement (QI) program, in collaboration with our providers, is dedicated to improving health outcomes for our members. SOME 2015 QI ACCOMPLISHED PROGRAM GOALS: Development of Provider Scorecards Partnered with providers to accept electronic medical records (EMR) data via secure flat file transfers Onboarded a QI Project Manager for performance measure improvement activities OUR GOALS FOR 2016 INCLUDE: Enhance the Clinical HEDIS Practice Advisors Program to collaborate with providers with enhanced reporting tools (Scorecards) to improve HEDIS performance measure rates Increase partnership with providers to accept EMR data via secure flat file transfers Collaborate with community agencies to perform member outreach efforts for improved health outcomes We look forward to continuing to partner with you to ensure our members get the best care. For more information about the QI program, please contact your Provider Relations representative. 7

8 UPDATING PROVIDER DIRECTORY INFORMATION We rely on our provider network to advise us of demographic changes so we can keep our information current. To ensure our members and Care Management staff have up-to-date provider information, please give us advance notice of changes you make to your office phone number, office address or panel status (open/closed). Thirty-day advance notice is recommended. NEW PHONE NUMBER, OFFICE ADDRESS, CHANGE IN PANEL STATUS, AND ADDING NEW PROVIDERS TO AN EXISTING CONTRACTED GROUP/IPA: MEDICAID Send a letter on your letterhead with the information being updated. Please include contact information if we need to follow up on the update with you. Please send the letter by any of these methods: ILProviderOperations@wellcare.com Fax: MEDICARE Call Mail: WellCare Attention: Provider Operations 29 N Wacker Drive, Suite 300 Chicago, IL, Thank you for helping us maintain up-to-date directory information for your practice. PROVIDER RESOURCES WEB RESOURCES Visit to access our Preventive, Behavioral Health and Clinical Practice Guidelines, Clinical Coverage Guidelines, Pharmacy Guidelines, key forms and other helpful resources. You may also request hard copies of any of the above documents by contacting your Provider Relations representative. For additional information, please refer to your Quick Reference Guide at Medicaid or PROVIDER NEWS Remember to check messages regularly to receive new and updated information. Visit the secure area of to find copies of the latest correspondence. Access the secure portal using the Provider Secure Login area in the Provider drop-down menu on the top of the page. You will see Messages from Harmony located in the right column. ADDITIONAL CRITERIA AVAILABLE Please remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for several medical procedures, devices and tests are available on our website at WE RE JUST A PHONE CALL OR CLICK AWAY! Medicare: Medicaid: IL033243_PRO_NEW_ENG Internal Approved WellCare 2016 IL_03_16 IL6PRONEW74080E_