Agenda. 1. Reduction of Medi-Cal Benefits. 2. STAT Line. 3. Top Authorization and Claim Mistakes. 4. CapConnect. 5. Encounter Data Submissions

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1 Agenda 1. Reduction of Medi-Cal Benefits 2. STAT Line 3. Top Authorization and Claim Mistakes 4. CapConnect 5. Encounter Data Submissions 6. Electronic Claim Submissions 7. HEDIS 8. Risk-Adjustment Coding (HCC) 9. Senior Enrollment

2 Reduction of Medi-cal Benefits Speech Therapy Podiatry Audiology Chiropractor Acupuncture Optometric and optician services (ophthalmology [doctor services for the eyes] will continue to be covered) Incontinence creams and washes Psychology services (psychiatry services services will continue to be covered through county mental health programs ) Dental services

3 Reduction of Medi-cal Benefits Benefits & services will NOT change for beneficiaries who are: Under the age of 21; or Living in a skilled nursing facility (Level A or B; this includes subacute care facilities); or Pregnant; or Receiving benefits through the California Children s Services (CCS) program

4 STAT Line (818) Hours of Operation 9:00 am to 5:00 pm All requests for STAT services are initiated by calling: Designed to handle emergent calls only. Do NOT fax any documents to (714) All calls regarding the status of your other referrals should be directed to the Customer Service Department at (818)

5 Authorizations Top 5 Mistakes 1. Missing ICD9 (diagnosis) code. 2. Missing CPT/HCPC/NDC code. 3. Missing specialist information (no name or specialty). 4. Diagnosis codes and specialist or services requested do not match. For example: request to see a psychiatrist for a diagnosis of lumbago (back pain). 5. Auths requested without medical records (specialized tests, out of network, experimental procedures).

6 Claims Top 4 Mistakes Missing diagnosis code digits 4th or 5th digit is required if indicated in the ICD9CM book. ICD-9 code not listed at the line item level. Invalid CPT code for the year in which the service is performed. Invalid CPT code for the line of business being billed (i.e. Medi-Cal vs. Commercial).

7 Cap Connect CMS Provider portal available at Some of the functions available on CapConnect: Online Referral Submission Provider Search Check the status of your Referrals and Claims Provider Reports ER, HEDIS, New Members, Recent Hospitalizations (My Documents) Forms and Documents (Re-Credentialing applications, Direct Referral)

8 Cap Connect - Registration Steps 1) Log onto 2) Click Register

9 3) Complete all required fields with Provider s information (Be sure to provide an address, as this is where account information is sent)

10 4) Complete all fields for staff members requiring access 5) Click Submit Request

11 Encounter Data Submission You need to submit it even if you are capitated for the service Important for gathering Quality, Compliance Data and HEDIS data every year Tells the health plans how well we take care of our patients Mandated by the health plans and your IPA agreement. Minimum submission requirements are: 3.5 encounters per member per year (all member average) Submitted within 30 days from the date of service

12 Encounter Data Submission Encounter data can be submitted on: HCFA 1500 form HCFA 1500 format on blank sheet of paper Electronically (DDD) For CHDP Visits: Send PM160 directly to the health plan you do not need to submit PM160 s to the IPA.

13 Electronic Claim Submission FREE to you. We pay for it. Faster submission of claims = faster payment to you Faster processing of claims = faster payment to you No wasted paper or postage You can see what you have sent and whether it was received. If there is a problem, you know about it right away.

14 Electronic Claim Submission-DDD Change from Office Ally to Diversified Data Designs (DDD) Greater control over data and improved encounter scores and HEDIS collection Ability to submit attachments Improved visibility throughout the data submission process Better explanations for reject reasons

15 HEDIS - Clinical Measures Program Examples of clinical measures 1. Childhood Immunizations 2. Breast Cancer Screenings 3. Cervical Cancer Screenings 4. Asthma Management 5. Diabetes Management 6. Cholesterol Management 7. Chlamydia screening For more details on these measures visit or refer to the HEDIS Toolkit included in your packet.

16 HEDIS - Clinical Measures Program HEDIS evaluates your performance and looks to improve the health of your members. Compliance with HEDIS measures is mandated by State insurance regulators and contracted health plans. Health Plans pay bonuses according to performance.

17 Improving HEDIS Performance Review Target List A report of members that are eligible to receive screenings for HEDIS is sent to the Physician's office on a quarterly basis. Also available on Schedule Member for Screening Contact members identified on this report and schedule an appointment for the clinical screening within the calendar year. Member Notice A notice is mailed to the member to advise them to schedule an appointment for the recommended clinical screening. Submit Encounter Data Compliance with HEDIS is based on timely encounter data submission from the PCP and other providers. Once screening is performed a claim (HCFA 1500) must be submitted.

18 Risk-Adjustment Coding Seniors The new risk adjustment (RA) model is called HCC - Hierarchal Condition Categories. 1. Code diagnoses (ICD-9 codes) for all conditions and to the highest level of specificity. 2. Submit data to the IPA.

19 Coding Specificity EXAMPLE: Diabetes mellitus without mention of complications INCORRECT (Four digits): CORRECT (Five digits): or or or

20 The Importance of Physician Data 80 percent of all diagnoses reported is from the physician s data. Not accurately coding diagnosis has an impact on the reimbursements levels.

21 Example of Additional Dollars that Specificity of Diagnosis Can Bring*: All conditions coded appropriately Some conditions coded poor specificity No conditions coded 76 year old female year old female year old female.483 Medicaid eligible.183 Medicaid eligible.183 Medicaid eligible.183 Diabetes w PVD manifestations (HCC 15) Vascular disease w/complications (HCC 104).585 Diabetes w/o complications (HCC 19).620 Vascular disease w/o complications (HCC 105).174 No diabetes coded.312 No vascular disease coded CHF (HCC 80).380 CHF not coded CHF not coded Disease Interaction (DM + CHF).253 No Disease Interaction No Disease Interaction Total RAF Total RAF 1.15 Total RAF.666 PMPM Payment $2191 PMPM Payment $1,006 PMPM Payment $583 Annual Payment $26,288 Annual Payment $12,073 Annual Payment $6,996

22 Coding Guidelines Always code to the highest level of specificity for all conditions at the time of the visit. Specificity determines the severity of the case.

23 Seniors Open Enrollment Open Enrollment Period is November 15 through December 31, Your senior patients can select a health plan with PPN. Steven Ashby is a licensed independent broker who can help your senior patients pick a plan. Steven Ashby (323)

24 Seniors Age-in Process at age 65 Three months before their 65th birthday, the Medicare Program informs your members about their Medicare options. The member can select to enroll with you under Premier Physician Network by completing the Medicare Advantage HMO enrollment packet. Every month, PPN will send you a list of your members who will be eligible for Medicare within the next 3 months. This list will alert you to enroll these members with you through PPN and help you avoid losing them to another primary care provider or IPA.

25 Thank you for participating!

26 ADDITIONAL REFERENCE The following slides are included for your benefit to provide you with more in-depth information regarding some of the topics already discussed during the group presentation.

27 Medi-Cal Re-Determination: What is it? Annual Re-Determination Date is the deadline by which the Medi- Cal members must submit their renewal paperwork in order to keep their Medi-Cal benefits. Most members are not aware that they are about to lose their benefits because they did not receive their renewal paperwork. If your member does not complete the renewal paperwork by the Annual Re-Determination Date, he/she will lose Medi-Cal benefits, and you will lose your member. Every month, your medical group will fax you a list of your Medi-Cal members who are 60 days away from their Annual Re- Determination Date.

28 Re-Determination: What can you do? Your office may have most current contact information for the member. Please verify the contact information you have on file for your member against the list that you received from us. Someone from your office should call your patients on this list and remind them to call their Eligibility Worker. The Eligibility Worker can tell the member what renewal paperwork they need to complete and where to send it. This is a courtesy call from your office to help members keep their Medi-Cal benefits.

29 Re-Determination: Phone call talking points Remind the member that their Re-Determination date is less than 60 days away. Ask the member if they have received their renewal paperwork and submitted it to their Eligibility Worker. If not, they must contact their Eligibility Worker to find out what renewal paperwork they need to complete. If the member has already called their Eligibility Worker, tell them you called just as a courtesy. If the member does not know what they should do or who to call, tell them to call their District Health Worker or the Department of Public Social Services Health Line at (877) Remind members that they should always update any address or phone number changes with their Eligibility Worker and with your office. Otherwise, they will not receive the renewal documents and risk losing their health coverage.

30 California Children Services (CCS) CCS is a statewide program that coordinates and pays for medical care and therapy services for children under 21 years of age with certain health care needs. Only certain conditions are covered by CCS. In general, CCS covers medical conditions that are physically disabling or require medical, surgical, or rehabilitative services.

31 What are CCS-eligible conditions? Conditions involving the heart (congenital heart disease, rheumatic heart disease) Neoplasms (cancers, tumors) Diseases of the blood (hemophilia, sickle cell anemia) Diseases of the respiratory system (cystic fibrosis, chronic lung disease) Endocrine, nutritional, and metabolic diseases (thyroid problems, PKU, or diabetes that is hard to control) Diseases of the genito-urinary system (serious kidney problems) Diseases of the gastrointestinal system (liver problems such as biliary atresia) Serious birth defects (cleft lip/palate, spina bifida) Diseases of the sense organs (eye problems leading to loss of vision such as glaucoma and cataracts, and hearing loss) Diseases of the nervous system (cerebral palsy, uncontrolled epilepsy/seizures) Diseases of the muscoloskeletal system and connective tissue (rheumatoid arthritis, muscular dystrophy) Severe disorders of the immune system (HIV infection) Disabling injuries and poisonings requiring intensive care or rehabilitation (severe head, brain, or spinal cord injuries, and severe burns) Complications of premature birth requiring an intensive level of care Diseases of the skin and subcutaneous tissue (severe hemangioma) Medically handicapping malocclusion (severely crooked teeth)

32 Who qualifies for CCS? A child gets CCS services if the child meets all four CCS eligibility rules: 1. The child is under 21 years old. 2. The child has a disability or medical condition that is covered by CCS. 3. The child is a resident of California 4. Financially eligible. The child has: Medi-Cal OR Healthy Families OR The family's adjusted gross income is less than $40,000 (if a family earns less than $40,000 but 200% above the federal poverty level, they will need to apply to Medi-Cal and Healthy Families) OR The family earns more than $40,000, but would spend 20% or more on medical services for the child's CCS eligible condition without CCS.

33 What Services are provided by CCS? Treatment: doctor services, hospital and surgical care, physical therapy and occupational therapy, laboratory tests, X-rays, orthopedic appliances and medical equipment. Medical case management: helps get appropriate providers and care for the child when medically necessary, referrals to other agencies, including public health nursing and regional centers. Medical Therapy Program (MTP): provides physical therapy and/or occupational therapy in public schools for children who are medically eligible.

34 Who can refer to the CCS Program? Anyone, including family member, school, or public health nurse, PCP or specialist. It is important that referral requests be made to CCS as early as possible since CCS sometimes does not pay for medical care that is provided before the date of referral.

35 Who provides CCS services? CCS assures that eligible children receive appropriate high quality care by referring patients only to physicians, dentists, audiologists, speech pathologists and other health care providers who have documented training and experience in pediatrics or one of its subspecialties or experience in providing services to children with CCSeligible conditions. Providers are paneled by the state. CCS only authorizes CCS paneled providers and hospitals.

36 How do I refer to CCS? Send a signed CCS Program Application with the initial referral for services. Send current medical reports in order for CCS to establish eligibility. Encourage the family to apply for Medi-Cal or Healthy Families. If a child is already on full scope Medi-Cal or enrolled in Healthy families, CCS will case manage and authorize services for CCS eligible conditions. Routine well baby care and immunization are not covered by CCS and should be obtained through CHDP.

37 Where do I get more info regarding CCS? California Department of Health Services Website Los Angeles County CCS Or Call (800) Orange County CCS Or Call (714) Application (English): Application (Spanish):

38 Background on Risk Adjustment for Medicare Advantage Before risk adjustment payment policy was implemented Centers for Medicare & Medicaid Services (CMS) paid Medicare Advantage Organizations (Medicare health plans) solely based on patient demographic data. Since health status was not considered, managed care plans received the same capitation whether a member was healthy or severely ill (which requires more health care services) Balanced Budget Act mandated CMS to begin paying Medicare Advantage based on payment methods linked to severity of illness of the member, or risk adjustment (RA). This helps to ensure that Medicare Advantage Organizations are paid more accurately for the health cost expenditures of their members.

39 Risk Adjustment for Medicare Advantage (Medicare HMO plans) Under this method of payment the quantity and quality of diagnosis data physicians provide plays a key role in how much the health plan is paid by CMS. As a result, the IPA is evaluating a new payment methodology to reimburse you higher rates for sicker patients and coding appropriately based on Risk Adjustments.

40 Hierarchical Condition Categories (HCC) The new risk adjustment (RA) model is called CMS- Hierarchal Condition Categories. Approximately 3,100 chronic diseases are grouped into HCCs and weighted to determine additional payment. Under RA, physicians and billing staff must put an emphasis on the ICD-9 diagnosis coding, as well as the CPT procedural coding.

41 Ways Physicians Can Impact Reimbursement Physicians should report all diagnosis codes that are generated as a result of a face to face visit in accordance with your established physician office practices. Exceptions-Pathology and Radiology since they don t see patients face to face.

42 Physician Data Process for Risk Adjustment 1. Appropriate medical record documentation 2. ICD-9-CM coding based on medical record documentation 3. Reporting of the ICD-9-CM diagnostic data to the IPA using the HCFA 1500

43 Medi-Cal Managed Care Requirements- CPSP Services All pregnant members must have access to Comprehensive Perinatal Services that integrate health education, nutrition and psychosocial services with obstetrical care Services must be provided from conception through 60 days following delivery Initial prenatal exam must occur within seven(7) days of the initial referral or request for pregnancy related services All pregnant members must be offered CPSP services by her OB Provider. The OB must Complete the Pregnancy Notification Form Complete the referral for CPSP Services noting clearly that CPSP as the requested service Fax Forms to the UM Department at (818)

44 Medi-Cal Managed Care Requirements- CPSP Services If the member declines the offer for CPSP services, documentation must be made in the member s medical record to include any particular reason the member gives for declining services Included in your packet are copies of: CPSP forms Pregnancy Notification Form (PNR)

45 Medi-Cal Managed Care Requirements- IHEBHA All Medi-Cal managed care patients are required to have Individual Health Educational Behavioral Assessment (IHEBHA) conducted by their assigned physician within 120 days of enrollment Purpose to highlight health education interventions in promoting optimum health and reducing the risk for disease, injury and disability. Goals are to help physicians to identify high-risk behaviors of individual plan members; prioritize the educational needs of their assigned patients related to lifestyle, behavior, environment and cultural linguistic background and assist in initiating and documenting focused health education interventions and followup. Physicians of Medi-Cal managed care patients are required to use updated Staying Healthy Assessment forms for IHEBA.

46 Medi-Cal Managed Care Requirements- IHEBHA Forms are available to all providers in a variety of languages to include English, Spanish Chinese, Lao, Russian and Vietnamese Forms can be downloaded from CapConnect in English. Other languages can be obtained from L.A. Care s website at Provider section.

47 Medi-Cal Managed Care Requirements- Carve Out Services The services provided through carve out programs are not covered by the health plans; however, IPA Utilization Management department coordinates these services with the provider or appropriate health agency or program. Members receiving these services remain enrolled in the Medi-Cal Managed Care Program, except for transplant patients. These services include: CCS Services Regional Centers Mental Health Services Substance Abuse

48 Medi-Cal Managed Care Requirements C&L Interpreter Services Telephone interpretation is recommended when the member is already present at the provider office to avoid any delay in service. Face-to-face interpretation is recommended to explain complex medical consultation or education or when the LEP or hearing-impaired member requests it, and should be requested at least 7 days in advance of the appointment.

49 Medi-Cal Managed Care Requirements C&L- Interpreter Services By calling toll-free at (888) , our Member Services Department can connect you and the member to appropriate interpretative services directly Be prepared to provide the following information to the health network representative: Member s Name Member ID# Language in which services are needed Case History of the Member (i.e. gender, age, reason for visit, type of procedure Date and time of appointment

50 Medi-Cal Managed Care Requirements C&L Interpreter Services Record the member s requests or refusals for interpretative services in the member s chart. Evidence of this is monitored during any Facility Site Review or Medical Records Review audit. Providers should not require or suggest that members use family members or friends as interpreters. The use of such persons may compromise the reliability of medical information and could result in a breach of confidentiality or reluctance on the part of the member to reveal personal information critical to their situation. Family members or friends may be used only if requested by the member, after free interpretative services have been offered and declined. The law prohibits the use of minors as interpreters, except in life-threatening or emergency situations.

51 Health Education Services Health Education Classes Referrals are handled by Customer Services and Utilization Management Customer Service: Referral forms are also on the web at Health Education Materials Variety of health education brochures and handouts are made available to providers at no cost and are available in English, Spanish and Vietnamese.

52 Health Education Services Breastfeeding Benefits Easily digested and always available Protects baby from infections Baby has less vomiting, fewer allergies, less diarrhea Helps mom s uterus return to normal size Saves money and time Gives mom time to relax and enjoy being with the baby Breastfeeding Barriers Baby may not latch properly causing pain and mom is unable to obtain lactation consultation Early return to work Lifestyle issues

53 Health Education Services MMCD Policy Letter prohibits providers from distributing educational and promotional materials containing formula company logos.