Save time when you submit Referral Requests

Transcription

1 Staff Newsletter #16 Flu Season Reminders Page 2 Help Improve Preventive Care Page 3 Key Healthcare Changes in California Page 5 Save time when you submit Referral Requests Referral Request Winter 2012 Saving time means you work smarter, so how can you save time when you submit referral authorization requests? By knowing which referrals are unneeded and which ones will be denied because the service is not covered or can be cared for without a referral. To help you avoid submitting incorrect referrals, we've put together a list of five common inappropriate specialty referrals. 1. Ophthalmology: When an IEHP patient with diabetes needs a Dilated Retinal Exam (DRE) or reports a change in vision, PCPs often submit a referral to an ophthalmologist. But in most cases, IEHP s vision network can provide these services. If an IEHP patient sees a vision provider and a referral to an ophthalmologist is necessary, the vision provider will submit the referral directly to the patient s IPA. 2. Optometry: No referral is needed. IEHP offers authorizations directly to our vision providers. If your IEHP patient needs a vision provider, refer him or her to their IEHP Doctor Directory, visit or call IEHP Member Services. Continued on Page

2 Flu Season Reminders The recommendations for the flu season remain unchanged from last season. Here are a few helpful reminders: Routine influenza vaccine is recommended for everyone ages 6 months and older. Children ages 6 months to 8 years need two doses of the vaccine (administered a minimum of 4 weeks apart) during their first season of vaccination to optimize immune response. Reimbursement: VFC (Vaccines for Children) - eligible children ages 6 months to 18 years should receive flu vaccinations through the VFC program. IEHP will reimburse providers the cost of the influenza vaccine for IEHP patients with Medi-Cal (over 18 years old), Healthy Families, Healthy Kids or Medicare DualChoice (HMO SNP). Submit your completed CMS1500 claim form with the correct CPT code to: IEHP Claims Dept. P.O. Box San Bernardino, CA And remember to submit your PM160 through IEHP s P4P Program to report the administration of the flu vaccine to your IEHP patients up to 18 years of age. For more information, please visit our website, Click on Providers and Flu Updates to view more information on vaccine allergies, billing codes, and more. Referral Requests... continued from page 1 3. Chiropractic: These services are not a covered benefit for IEHP patients in Medi-Cal, Healthy Families or Healthy Kids. If an authorization is requested for a patient covered in these programs, it will be denied. Only IEHP Medicare DualChoice offers chiropractic coverage for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). 4. Acupuncture: Acupuncture services are not a covered benefit for IEHP patients under any IEHP program. 5. Podiatry: When medically necessary, podiatric services are a covered benefit up to age 21 for IEHP Medi-Cal patients. This includes treatment of infections of the foot (gangrene) and medically necessary surgical correction. Adult Medi-Cal patients over age 21 are approved for podiatry services only to prevent hospitalization and/or serious medical complications. Routine foot care (e.g. trimming nails) is not included. Help your provider better manage referrals by reminding him or her not to submit referrals for these specialty areas. If you have any questions about the authorization process, call the IEHP Provider Relations Team at. 2

3 The Power of Preventive Care Rosters When you remind your IEHP patients that their preventive care is due, you help improve their health. To help track preventive care visits, IEHP offers preventive care rosters. Find them under the Eligibility and Rosters option on the secure IEHP provider website at When verifying eligibility for an IEHP patient, check their Member Health Record. The Member Health Record will also remind you to provide IEHP patients with any necessary immunizations, well child visits or other preventive services. You can print a copy of the Member Health Record to place in the patient s chart. The rosters include the following preventive care information: - Childhood immunizations - Well care visits (ages 0 15 months, 3 6 years and adolescent) - Breast cancer screenings - Cervical cancer screenings - Diabetes care - ADHD medication (follow-up care) The rosters also include IEHP Member IDs and phone numbers. For IEHP patients who need preventive services, IEHP encourages you to call them to setup a visit. IEHP appreciates your partnership in making sure your IEHP patients get the preventive care they need. Holiday Re-Gifting Are you thinking about giving someone a holiday gift you received last year but didn t like and never used? Here are some tips on re-gifting. 1. Make sure the person will like it. Gifts are supposed to be special. Never re-gift just to save money. 2. Only re-gift if the item is brand new and in its original packaging. Never re-gift anything used. 3. Keep track of who gave you what. You don t want to give your relative a gift that someone else in the family gave you and might recognize. 4. Rewrap the Gift. Rewrap the gift with new wrapping paper and make sure the old gift tag or card is replaced with a new one. 5. Never Re-gift Food. It expires and gets stale. It might even be harmful after eating. 3

4 Are you following the Claim Submission Requirements? In November of 2011, the Office of Civil Rights (OCR) began random Health Insurance Portability and Accountability (HIPAA) compliance audits of both small and large groups of providers. Eventually, every provider will face an audit. When you do, it's vital to show that you are committed to protecting personal health information (PHI) of all your patients. Use this checklist to create a "culture of privacy" and prepare for a smooth audit. TASK 1. You have a HIPAA training program in place for all staff. 2. All staff have signed an acknowledgement of training on initial hire and annually thereafter. 3. Within the past 12 months you ve documented and reviewed confidentiality policies/procedures, including verbal and phone precautions. 4. You have policies in place for the security of all computerized data systems and paper medical records containing PHI, and you ve updated them within the past 12 months. 5. Your waiting room is arranged so PHI cannot be overheard by other patients. 6. Computer monitors are arranged so screens can only be viewed by office staff. 7. Computer equipment is secure after hours, (i.e. you have an office monitored alarm system). 8. HIPAA Business Associate agreements are in place with all vendors responsible for PHI (for example your computer or software support company). 9. You ve selected a Privacy-Security Officer for the office and shared this person s role with the office staff. Date Completed If you have completed all of the above, your office is prepared for a potential audit. IEHP provides on-site HIPAA training for you and your staff. For more information, call Lori at (909)

5 California forges ahead with key healthcare changes Recent changes at the state level will directly impact healthcare in the Inland Empire. Here is a preview of two that will impact you and your patients. Transition of Healthy Families Program Members into Medi-Cal Starting January 1, 2013, the state will begin transitioning members of the Healthy Families Program to Medi-Cal. This shift impacting 137,000 children in the Inland Empire will occur in four phases. Transition Phases How it impacts you How it impacts your IEHP patient PHASE 1: January 1, 2013 Members of Molina and IEHP s Healthy Families Program will stay with their current health plan but will move to Medi-Cal. PHASE II: April 1, 2013 Members of Kaiser s Healthy Families Program will transition into IEHP s Medi-Cal plan and can still keep Kaiser. PHASE III: August 1, 2013 Healthy Families Program members (who are enrolled in Blue Cross or Community Health Group) must choose either IEHP or Molina for their Medi-Cal. PHASE IV: September 1, 2013 Members of the Healthy Families Program (who live in a county without Medi-Cal managed care) will move into the Medi-Cal fee-for-service system. You will continue to see your IEHP Healthy Families Program patients under the Medi-Cal program (through IEHP). Monthly premium Most of your patients will pay a reduced premium while some patients will no longer pay a premium for their healthcare. Copayments Instead of the current Healthy Families Program copayments, patients will have Medi-Cal copayments (currently at $0). Benefit change Your patients will have Medi-Cal benefits, and some will be accessed differently. Here are some examples: Vision Accessed directly through IEHP (instead of vision plans) Behavioral Health Accessed through both counties behavioral health departments (instead of the IEHP Behavioral Health network) Dental Accessed through Denti-Cal (instead of dental plans) Immunizations Now available through the VFC Care Coordination Initiative (CCI) In June of 2012 the state officially passed the CCI. This initiative will integrate Medicare and Medi-Cal benefits and long-term care services by requiring Medi-Medis to enroll in a managed care plan (with mandatory enrollment for their Medi-Cal coverage and passive enrollment for their Medicare coverage). Final participating counties include: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. CCI Implementation Timelines How it impacts you How it impacts your patient JUNE 2013: Mandatory enrollment for Once your Medi-Medi patients choose Medi-Medis who join IEHP Medi-Cal will start (based on the IEHP (for both their Medi-Cal and (for both their Medi-Cal and Medicare) beneficiary s birth month). Medicare) you must have an IEHP will receive better coordinated care for Medicare contract to continue seeing all their benefits including, long-term JUNE 2013: Medi-Medis can choose to them. If your patient chooses to opt-out care services. enroll their Medicare coverage in a managed to FFS Medicare, you can continue care plan or opt-out to the Medicare to see him/her just as you do today. fee-for-service (FFS) system prior to their For information on obtaining a enrollment date. Medi-Medis who do not Medicare DualChoice contract, choose a plan will be passively enrolled in call the Provider Relations Team a plan. at. 5

6 IEHP Scrub of the Month The office hums along smoothly with the attentive work of Doreen Geiser, the Scrub of the Month. As the office manager for pediatrician Carolyne Lim, MD in Chino, Geiser oversees a busy office, paying Doreen Geiser close attention to detail, and keeping charts organized. I can really trust Doreen with handling the office, said Dr. Lim, who nominated her. The two have worked together since Dr. Lim started her practice 15 years ago. What makes Doreen stand out? Her honesty, trustworthiness, and loyalty. Congratulations Doreen! Nominate a co-worker Do you work with a winner? A hard worker who brightens your office with kindness, inspiring your team to do its best? Tell us why: Write your reason why you think this person should be Scrub of the Month. Keep it under 500 words. If you give us the best reason, we ll give you and your co-worker a $50 Target gift card. Send your name, office location and work phone number. Fax, mail or your entry: Fax: (909) On the cover sheet, write ScrubTalk - Scrub of the Month Nomination. Mail: IEHP ScrubTalk - Scrub of the Month Nomination, P.O. Box 19026, San Bernardino, CA providerservices@iehp.org Q. A. ASK Susie A couple of our IEHP patients were in Adult Day Health Care (ADHC) facilities. I understand that effective October 1, 2012, IEHP began offering this benefit, now called Community Based Adult Services (CBAS). What does this mean to our office? CBAS replaced ADHC. In order for Medi-Cal patients to get the CBAS benefit, they must be enrolled in a Medi-Cal managed care plan, such as IEHP. CBAS eligibility is determined through an assessment process involving the health plan and a CBAS facility. Your office should follow normal protocols and continue to see IEHP patients who are in CBAS. Authorizations will be issued to CBAS facilities that serve IEHP patients. CBAS facilities will then bill IEHP. CBAS services include: Skilled Nursing Care Social Services Meals (one per day) Physical therapy Speech therapy Occupational therapy CBAS will help your IEHP patients: Maintain health Avoid injury Reduce their risk of depression and avoidable visits to a PCP or ER Receive better care coordination Continued on Page 7 6

7 Is Your Patient's Health a Family Affair? Did you ever ask a patient a question, but one of his or her relatives answered you instead? We focus so much on how we should deliver care that we forget one thing: many cultures see a person s health problem differently than we do. It may be a family affair and the decision maker could be someone other than the patient. Key: Involve the right relative. You may get more details for an accurate health history or elicit better treatment compliance. Here are some examples: Perinatal Care In western medicine, doctors involve only the father-to-be in discussions and care for the pregnant woman. But in other cultures, pregnancy, birth, and baby care are a woman s domain. Key: Foster better perinatal care and birth outcomes by including the right female relative, like a mother or aunt. Food and Culture Other cultures have food taboos or beliefs for specific health conditions. When a patient s treatment plan includes a specific diet, ask which foods his or her culture uses to treat the condition. Consider including foods common in the culture. Key: Work closely with the family. Create a culturallyacceptable diet, aiming to increase the patient s compliance to his or her treatment plan. Alternative Medicine/Treatment While taking doctor prescribed medications, patients might also use home remedies some with unknown effects when mixed with these medications. Key: Be respectful. Ask patients if they use home remedies or other non-prescribed medications to treat their conditions. Ask Susie... continued from page 6 IEHP patients who are part of CBAS benefit from greater care coordination. They also maintain better health, avoid injuries and ER visits, and have a reduced risk of depression. If you have any questions about CBAS, please call the IEHP Provider Relations Team. Ask Susie about IEHP procedures or programs: Call. Fax to Ask Susie at (909) providerservices@iehp.org 7

8 P.O. Box San Bernardino, CA Staff Newsletter 2012 Inland Empire Health Plan. All Rights Reserved. PS Add this dish to your holiday menu Twice-baked Garlic Potatoes (Makes 8 servings) 4 large russet potatoes, washed well 1 garlic bulb ½ cup low-sodium chicken broth ½ cup nonfat sour cream ½ teaspoon ground black pepper ¼ cup grated Parmesan cheese Paprika Preheat oven to 425 F. Stick the potatoes with a fork several times and place on a baking sheet. Wrap the garlic in foil and put it next to the potatoes on the baking sheet. Bake until the potatoes are tender and the garlic is browned and softened, minutes. Let the potatoes and garlic cool until comfortable to handle, about 15 minutes. Then cut the potatoes in half end-to-end (lengthwise) and scoop the insides into a large bowl, leaving the skins in one piece. Cut the garlic bulb in half. Squeeze out the garlic and add it to the potatoes. Then add the chicken broth, sour cream and pepper; stir and mash with a fork. Then spoon the mixture back into the potato skins and sprinkle with Parmesan cheese and paprika. Put the stuffed potato skins back on the baking sheet and bake until heated thoroughly and lightly browned, about 15 minutes. Check out the new redesigned IEHP website! Coming this winter. Questions? Ideas? Reach Your Provider Relations Team at Fax: (909)