Unison Health Plan Plan of of Delaware

Transcription

1 Unison Health Plan Plan of of Delaware

2 Agenda Healthy First Steps Program Diana Bowman RN, CCM, CCP and Tracey Weifenbaugh RNC-NIC, MSN EFT Website Fraud & Abuse Corrected Claims & Appeals Gold Star Program Re-credentialing campaign Provider Information updates

3 Healthy First Steps Program Pregnancy and NICU Care Management Program

4 Healthy First Steps Program Goals & Objectives: National, Multi-disciplinary Maternal teams National, Multi-disciplinary NICU team Increased program participation Increased high-touch interactions with members Reduced incidence of low-weight births Decreased NICU admissions, lengths of stay, readmissions

5 Team Structure Dedicated Clinical Leadership Team Clinical National Director National OB Senior Medical Director OB/GYN and Neonatologist Medical Directors Multi-Disciplinary Team Structure Clinical Staff high-risk case management by OB and NICU nurses Non-Clinical Outreach Staff Social Workers/Behavioral Health Advocates

6 HFS Clinical Model Continuum of Care A Clinical approach tailored to member s health status throughout pregnancy Healthy With No Risk Factors Health risk assessments Monthly educational information Coaching & education 24/7 Nurse Line Healthy With Low Risk Factors Moderate Risk Factors Assessment Score = 3-9 Multiple gestations risk, high-risk pregnancy history, maternal age Level 2 Health Coaches Care in partnership with OB Physicians Integrated Behavioral Health and Social Work support High Risk Factors Assessment Score = 10+ High-risk maternity or chronic condition management Protocol-driven, peer-topeer physician interaction Care in partnership with OB Physicians Management by OB Case Managers (RNs) Integrated Behavioral Health and Social Work support Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.

7 HFS Program Structure Member Identification Welcome outreach calls identifying pregnant members (HARC) Completion of non-clinical and clinical assessment Risk Stratification OB Care Management Prenatal, Trimester and postpartum educational packets and mailings Referral to OB Case Management as appropriate NICU Management Telephonic and on-site case management of NICU babies Engagement of caregiver/family to promote empowerment and provide educational materials Facilitation of discharge planning needs by coordinating with the hospital and families Assessment of ongoing case management needs

8 HFS Program Standards Member Identification Early Intervention Outbound calling Data analysis to identify pregnant members Provider submission of Risk Assessment forms Provider outreach and relations Community outreach Risk stratification Referrals to Smart Start preventative program

9 HFS Program Standards Case Management Integrated Approach Utilization Management Multi-disciplinary rounds with OB and Neonatology Medical Directors Protocol-driven, peer-to-peer physician interaction Behavioral Health Integration NICU Management with licensed NICU nurses Standard member materials across health plans Quality Management (HEDIS Outreach)

10 Noticeable Changes Program Name Change Phone & Fax # changes Phone Fax Number Three Levels of Pregnancy Case Management Level 1 = MSO Level 2 = Health Coach Level 3 = OB CM Maternity Utilization Ante-partum admission Including medical and surgical admissions Dedicated Social Workers

11 Management Team Contacts Marjorie Gearhart (National Director) Diana Bowman (National Associate Director, OB) Eileen Wilkinson (Regional Manager, OB) Susan Habib (National Associate Director, NICU) Tracey Weifenbaugh (National Manager, NICU)

12 Electronic Funds Transfer Eligibility requirements: Participating Provider Receive 835 ERA format EFT transfers should begin within two weeks of receipt of the form. EFT forms are located on our website under the Provider Forms section. You may mail the request to the address listed on the form.

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16 Fraud & Abuse Fraud is committed when a provider or consumer intentionally submits, or causes someone else to submit, false or misleading information for use in determining the amount of health care benefits. Waste is the over-utilization of services. Abuse is provider practices that are inconsistent with professional standards of care.

17 Fraud & Abuse Examples of Provider fraud, waste and abuse: Billing for services not rendered Upcoding Soliciting, offering or receiving kickbacks Failure to maintain adequate records Examples of Member fraud, waste and abuse: Loaning or using another person s insurance card Forging or selling prescription drugs Providing false information when applying for program benefits. For more information or to report suspected Fraud, Waste, or Abuse, please visit our website, Reimbursement policies are available on our website -

18 Claims & Appeals Electronic Claims Submission Electronic Billing Companion is available online Unison s Payer ID# New Corrected Claims Process New process effective 3/1/2010 Corrected claims can also be resubmitted electronically Appeals Process Include your contact information Who, What, When, Where, and Why? Clinical information, records, test results, etc. Must be submitted within 45 days from the date of the EOB or other denial notice* *Please review your contract and Unison s Provider Manual for more information on claims and appeals.

19 Claims & Appeals Claims Unison Health Plan of Delaware P.O. Box 1147 Monroeville, PA Appeals Unison Health Plan of Delaware Attn: Appeals Department Unison Plaza 1001 Brinton Road Pittsburgh, PA 15221

20 Gold Star Update Gold Star Program Changes July 1, 2010 Stay Tuned...

21 Re-credentialing Campaign Begins 6 months before Provider s credentials expire. Unison will send 4 requests to the Provider - a new one is mailed each month. Unsuccessful attempts will result in Provider termination.

22 Has there been a change to your office? New or closing locations Updated phone or fax numbers Providers joining or leaving the practice Doctor s panel status or patient limitations New office hours Tax ID changes Acquisition of a practice Please contact your Provider Relations Advocate in order to make sure we have updated our records for such changes. Unison s local office: If your practice is part of the PO (Medical Society), please contact Lori Ann Rhoads Manager of MedNet and MSD Operations Phone Fax

23 Questions? Thank you.