NEW Provider Orientation

Transcription

1 NEW Provider Orientation

2 About Golden Shore Medical Group Overview Golden Shore Medical Group (formerly Molina Medical Group) is owned and operated by J. Mario Molina, M.D. Dr. Molina continues his father s legacy. Dr. C. David Molina founded the clinics in 1980 to care for underserved patients California. We are committed to providing access to high quality care through our 17 staff model clinics located in medically underserved areas in Los Angeles, Riverside, Sacramento, and San Bernardino counties. In addition, we contract with other primary care physicians to supplement our staff model clinic network. We currently serve about 120,000 capitated patients insured through Medi-Cal, Medicare, and Covered California in four counties. 2

3 About Golden Shore Medical Group Mission Statement Our mission is to provide high quality and affordable care to our patients. Values We care about our patients and advocate for them. We provide the same quality care that we would want our families to receive. We respect each other and are ethical in our business dealings. We are careful with our financial resources We seek to find better ways to deliver care to our patients. 08/31/2017 3

4 MSO Introduction Golden Shore Medical Group will be managed by Network Medical Management MSO effective January 1, Network Medical Management (NMM) is an innovative and collaborative organization is who lead by physician leaders. Additionally, we provide: Provide comprehensive administrative support to Independent Physicians Associations (IPAs) as well as Medical Group practices Healthcare professionals and financial experts with extensive experiences at Health Plan, DMHC and IPA/Medical Group levels Utilize EZ-Cap system with proprietary software to enhance electronic management of healthcare practices Enable clients to attain their financial goals and achieve organizational success Able to evolve with the health care industry to give up-to-date advice and computer infrastructure support thus allowing groups to achieve profitability and clinical excellence. 08/31/2017 4

5 Health Plan Network & Service Area Affiliated Health Plan Partner: Molina Health Plan Product Lines: Cal MediConnect Covered California Medi-Cal Service Areas Inland Empire Los Angeles Sacramento 5

6 Departments and Functions 08/31/2017 6

7 NMM Departments Finance Customer Service Eligibility and Capitation Contracting Credentialing Customer Service Eligibility & Capitation Utilization Management. Claims Case Management Ambulatory Care Management Quality Management Quality Care Improvement Data Management Web Portal Provider Relations Finance Provider Relations Contracting Marketing & Enrollment Information Technology Claims NMM Credentialing Quality Care Improvement Utilization Management Quality Management Case Management Ambulatory Care Management 08/31/2017 7

8 Provider Contracting 08/31/2017 8

9 Provider Contracting Primary functions of the NMM Contracting team include: Processing Letters of Agreement Completing contract amendments Disbursing contract updates Hours of operation are Monday through Friday 8:30 am to 5:00 pm 08/31/2017 9

10 Provider Contracting Contact Information Existing or General Provider Contracting Inquiries: Winsome Brown, Director of Contracting: New Provider Contracting: Kristina (IE, LA) Asia (Sacramento): 08/31/

11 Credentialing 08/31/

12 Credentialing Functions: Manage credentialing and re-credentialing applications Providers will be re-credentialed every 36 months (notification sent 6 months prior to expiration) Providers must maintain all appropriate certifications, malpractice insurance, and licensures in order to participate with the IPA and health plans 08/31/

13 Credentialing Contact Information Isela Ochoa, Credentialing Manager (877) Ext: 6267 Patrisia Vela, Credentialing Coordinator Ext: Hours of Operation: M-F, 8:30am-5:00pm 08/31/

14 Customer Service 08/31/

15 Customer Service Overview: Customer Service handles members and provider inquiries on authorizations, claims, eligibility, and other general IPA network matters. Contact Information Toll Free: (877) Scope: Authorization assistance Claims assistance Eligibility assistance Patient inquiries Portal inquiries Hours of Operation: M-F, 8:30am-5:00pm 08/31/

16 Eligibility and Capitation 08/31/

17 Eligibility and Capitation Functions: Provider eligibility verification, eligibility updates, capitation payments, health plan eligibility/capitation reconciliation. During patient check in processes, Provider are required to verify eligibility at the time of service through the Health Plan (call or health plan portal). We recommend for proof or evidence be recorded of eligibility data obtained at the time of visit. 08/31/

18 Eligibility Eligible members not found in the NMM database can be added via the following methods: Preferred: Call (877) , eligibility option. Member is added to the web portal within 30 minutes after the provider call. the Eligibility Department at 24 hours turnaround for system to update. Fax the eligibility form [handout] to (626) hours turnaround for system to update. When contacting the Eligibility Department to add members, please provide the following information: Member name (first, last) Member address Member phone number Member DOB Health plan and ID number Eligibility is also available online via the NMM web portal 08/31/

19 Capitation Primary Care Physicians will receive an Explanation of Benefits on a monthly basis containing the following information: Active members Recently added members Recently removed members Health plan adjustments within a 3 month period (when applicable) Note: Primary Care Physicians receive data on newly added patients every month. PCP s need to monitor new patient assignments monthly to scheduled preventive and/or initial health assessment appointments. 08/31/

20 Eligibility and Capitation Contact Information Phone: (877) eligibility option Fax: (626) Hours of Operation: M-F, 8:30 am - 5:00 pm 08/31/

21 Utilization Management 08/31/

22 Utilization Management Functions: Conducts reviews of referrals made by providers and makes a determination to authorize, modify, defer or deny. The assessments are based on consistent application of UM criteria (e.g., MCG, health plan guidelines, Medicare/Medicaid guidelines) The Medical Director and/or designee(s) will regularly monitor and assess the decision-making performance of the UM team participants (e.g., Medical Director, UM/QM Members, Case Managers) 08/31/

23 Utilization Management Submission Process Preferred: Web Portal Then select the IPA Golden Shore Medical Group Web portal features: Submission Authorization status Authorization Extension Modification Requests Denial Letter Extraction Faxes Routine Authorizations: Urgent Authorizations: /31/

24 Utilization Management Referral review timeframes: Routine: 5 business days Urgent: 3 business days (72 hours) - Please use the urgent designation only as appropriate - If a case needs to be expedited, call customer service after submitting your request Web Portal UM functions Request extensions Request modifications Print denial letters 08/31/

25 STATUS Utilization Management OUTCOME Approved Once a request is reviewed and approved, an approval letter will be mailed to the member. A fax will also be sent to the requesting provider and the requested specialist. Deferred A deferred status means the authorization requires additional information such a progress notes or test results. Requested notes need to be send within 14 days for a routine request and 24 hours for any urgent requests. Denied Request for services can be denied if the request does not meet certain guidelines or if not medically indicated. It is important to send pertaining medical records when applicable. Any second request with the same CPT code and same medical records as the original request will subsequently be denied as a duplicate. If a request is redirected to another provider, the original request will be denied and a new authorization to the requested provider will be generated. A denial letter is mailed to the member and faxed to the requesting provider as well as the requested provider. Cancelled A request for treatment can be canceled for any of the following reasons; - member no longer active with IPA - duplicate request - service requested is covered under the health plans carve out benefit. 08/31/

26 Claims 08/31/

27 Claims The primary functions of our claim department is to ensure the accurate and timely processing of claims and encounter data. Provider can submit claims though Office Ally (clearing house) using NMM03 payer ID or our preferred method via the NMM web portal, Office Ally Payor ID: NMM03 Address: 1680 S. Garfield Ave. #200, Alhambra, Ca Functions offered on our web portal include: Single claim submission Batch claim submission Claim status 08/31/

28 Claims Filing Timely Filing From Date of Service Medi-Cal 12 months / 365 days Commercial, POS 90 days Medicare 12 months / 365 days Claims Processing Clean claims; from date received Medi-Cal - 30 Calendar days Commercial, POS - 60 Calendar days Medicare - 60 Calendar days Provider Dispute Resolution Use the Provider Dispute Resolution form [handout] or send request in writing. 08/31/

29 Encounters All contracted Primary Care providers must send in claims and encounter data. Encounter data must be submitted within 60 days from date of service. Encounter Data Submission Benchmarks Benchmark LOB PCP (E&M) Enc PCP & SPC (E&M) Enc All Encounters Commercial Medi-Cal Medicare PCP s will receive encounter data reports on a quarterly basis. 08/31/

30 Case Management 08/31/

31 Case Management Functions: Responsible for managing the transition of patients to lower levels of care Concurrent reviews Retrospective reviews Discharge planning Inpatient authorization reviews Transfers to SNFs Out of area transfers Hospital Admission Notices, Fax: (626) /31/

32 Case Management Contact Information Mitch Agorrilla Phone: (877) ext Hours of Operation: 24 hours a day, 7 days a week After regular business hours, the answering service will page the on-call Case Manager to coordinate admission 08/31/

33 Ambulatory Case Management 08/31/

34 Ambulatory Care Management (ACM) The main function and goal of the ACM team is to emphasize prevention, continuity and coordination of care, which advocates for and links members to services as necessary across providers and settings. Provide access to timely, appropriate, accessible and member centered health care. Reduce Emergency Room visits and avoidable hospitalizations Promote effective and ongoing health education and disease prevention activities Provider cost-effective care Promote information sharing and transparency 08/31/

35 ACM Program Model of Care (Dual eligible) High risk/complex Care Management Chronic Disease Management Transition of Care (post acute follow up) 6. Modify Plan based on analysis 7. Monitor Outcome 1. Member Identification 2. Assessment member care needs 3. Develop Care Plan 5. Analyze Plan effectiveness 4. Implement Care Plan 08/31/

36 Chronic Care Management Team Improve Member Health Access to specialized programs Chronic Disease Management Palliative Care HEDIS/Star Measure improvements Referrals to community resources COMMUNITY AGENCIES HEATLH COACH CLINICAL PHARMACIST CAREGIVER MEMBER SOCIAL WORKER PCP/SCP NMM INTER- DISCIPLINARY CARE TEAM 08/31/

37 Ambulatory Care Management (ACM) Annually, NMM care management and QM collects and analyze member satisfaction survey outcome and member complaints to improve satisfaction of care management program. 08/31/

38 Quality Management 08/31/

39 Quality Management Functions: Reviews quality of covered services furnished by provider to members on inpatient and outpatient basis Grievance Procedure - Member Complaints Notification of member complaints within five (5) business days Appeals Access Monitoring Health Education Cultural and Linguistic Services 08/31/

40 Quality HEDIS/STAR Measures 08/31/

41 Healthcare Effectiveness Data and Information Set HEDIS is a tool created by NCQA, used by Health Plans and CMS to measure quality care performance Impacts Membership growth Contracts Potential health outcomes Member satisfaction 08/31/

42 HEDIS/Star Program Management PCP & Office Staff Support Comprehensive HEDIS reference guide GAPs in Care report PCP HEDIS Report Card Performance Rate vs Benchmark HEDIS training (office visits, dinners, etc.) Office Staff Instructions per Quality Measures Identify barriers to measure performance Apply best practices Identify low performing PCPs Create action plan Data Reconciliation of HEDIS/Star Measures Resource allocation i.e., Urgent Care, Radiologist, Senior Wellness Center Member outreach Live calls, auto-outbound calls, letters 08/31/

43 HEDIS/Star Reference List Adult MBI (1) Weight Assessment & Counseling for Nutrition & Physical Activity (3) Childhood Immunization Status Immunizations for Adolescents Lead Screening in Children Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening for Women Colorectal Cancer Screening Care for Older Adults (1) Appropriate Testing for Children with Pharyngitis Spirometry Testing Controlling High Blood Pressure (3) Comprehensive Diabetes Care (1) Annual Monitoring for Patients on Persistent Medication Disease-Modifying for Rheumatoid Arthritis (1) Medication Reconciliation Post- Discharge (1) Women who suffered a fracture and were treated for Osteoporosis (1) Prenatal and Postpartum Care Pharmacotherapy Management of COPD Exacerbation Medication Management for People with Asthma * (#) indicates Start Measure Weight 08/31/

44 Sample PCP Report 08/31/

45 Sample Gaps in Care 08/31/

46 Sample of HEDIS Benchmarks Measure Commercial Benchmark Medi-Cal Benchmark Medicare Benchmark Breast Cancer Screening (BCS) Rate 71.0% 80.0% 76.0% Cervical Cancer Screening (CCS) Rate 76.0% 73.0% N/A Comprehensive Diabetes Care (CDC) Eye Rate 51.0% 68.0% 81.0% Comprehensive Diabetes Care (CDC) HbA1c Test Rate 90.0% 92.0% 84.0% Comprehensive Diabetes Care (CDC) Nephropathy Rate 83.0% 88.0% 98.0% Colorectal Cancer Screening (COL) Rate 60.0% N/A 81.0% PPC Prenatal Rate 92.0% 92.0% N/A PPC PostPartum Rate 84.0% 72.0% N/A 08/31/2017

47 HEDIS/STAR PCP Web Portal Created to help providers track their patients quality measures Complete history of care gap report/member Member list of incomplete HEDIS measures Ability to upload documents for historical data Accurate lists of required CPT/ICD 10 codes - based on HEDIS technical specification User friendly interface 08/31/

48 Sample HEDIS Web Portal 08/31/

49 Quality Care Improvement Provider Relations Representative will distribute the following reports as follows: January, March, June, August, October, December. PCP REPORT PROGRAM DISCRIPTION HEDIS - Gaps In Care Reports PCPs will be provided with a list of patients due for cervical cancer screening, diabetic patients (eye exam, Hba1c, nephropathy), prenatal & post-partum care, breast cancer screening, well child visits, etc. We urge PCP s to review the gap reports to appropriately recall patients. Members Without Office Visit PCPs will be provided with a list of members who have no record of a PCP visit. Providers are to call member and schedule the member to go in for their annual health assessment. ER Frequent Visitors Encounter Data Summary Providers will receive a list of members who have visited the emergency room more than 4 times during a 3 month time frame. PCP is to call those members and coordinate care to avoid frequent visits to the ER. Providers will receive a report with their encounter submission details along with expected benchmarks. 08/31/

50 Web Portal 08/31/

51 Web Portal Functions: Assistance with new accounts and troubleshooting Contact Information Phone: (626) Hours of Operation: M-F, 8:30am-5:00pm 08/31/

52 Provider Relations 08/31/

53 Provider Relations Functions: The primary point of contact for all providers whose responsibilities include the following: Provider orientations Issue resolution involving authorizations, claims, eligibility, capitation, contracting Provider education/training Disseminating network updates, including health plan policy changes/updates Health education material distribution Member enrollment issues Provider complaints Assistance with grievances 08/31/

54 Provider Relations NMM REPRESENTATIVES Rafael Zepeda, Director of Network Development Office: (626) Fax: (626) Asia Stuck-White, Sacramento Business Dev. Mgr Kristina Hlebo, IE & LA Business Development Manager Cell: (909) Marybell Esquivel, Provider Network Supervisor Office: (626) Cell: (626) Catherine Sanchez, Provider Network Specialist Office: (626) Cell: (626) Mimi Nguyen, Provider Network Coordinator Office: (626) /31/

55 Questions? 08/31/