WE WELCOME CARE1ST PROVIDERS TO OUR QUALITY OUTREACH PARTNERSHIP

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1 PROVIDER S U M M E R 1 0 Newsletter WE WELCOME CARE1ST PROVIDERS TO OUR QUALITY OUTREACH PARTNERSHIP Our Quality Outreach Department is delighted to partner with providers by giving you educational tools to use at the point of care. Our Quality Outreach Tool-Kit has essential tools that will improve our HEDIS rates and continually improve the quality of care to our members. This coming fall, our Quality Outreach Teams will be visiting your offices and a priority item will be to provide extensive education regarding Hierarchal Condition Category (HCC). Why is it important? The HCC process consists of collecting accurate diagnosis codes on all our members and we submit this data directly to the Centers for Medicaid and Medicare Services (CMS). This data is used by CMS to determine the cost of care for our members. Welcome to our Quality Outreach Partnership, we look forward to seeing you soon and being a permanent resource to better meet your needs. If you have any questions, please contact the Quality Outreach staff at (877) At Care1st, our Providers and Members come first! Our goal during our visits will be to assist you and your office staff in understanding how specific diagnosis must be documented and submitted to assure we have accurate accounting of our member s conditions. We will also be addressing Healthcare Effectiveness Data and Information Sets (HEDIS), which are annual sets of quality measures. We have developed specific tools that will help in meeting all of these goals that we would like to share with you.

2 in thisissue We Welcome Care1st Providers to Our Quality Outreach Partnership... cover by Rebecca Romo, Quality Improvement Project Manager Care1st Community Health Event Celebrate Good Health... p.2 by Laura Reyes, Provider Network Administrator Health Information Technology for Economic and Clinical Health Act (HITECH)... p.3 by Janet Eisenberg, Compliance Audit Manager Care1stCARES Is In The House... p.4 by Robert Feldman, RN Director - Medical Services Care1stCARES Disease Management Practice Guidelines... p.5 by Robert Feldman, RN Director - Medical Services Sensitivity Critical to the Care of Female Patients... p.5 by Rosa Hernández, Health Education Specialist Language Rights for Care1st Health Plan Members... p.6 by Therese Horth, Cultural & Linguistic Specialist Nurse Rachel Is Too Friendly... p.7 by Alan Bloom, Vice President - Legal & Regulatory Services Care1st Community Health Event Celebrate Good Health Care1st and HealthCare Partners proudly sponsored the Celebrate Good Health community event at the Watts Senior Center on February 26th. Guests included members of the Watts Senior Center, parishioners from St. Lawrence Church, and neighborhood residents. The event s Mardi gras theme greeted attendees with masks, beads, and a tote bag full of information and giveaways. Plenty of healthy refreshments were available through the generous participation of Care1st Health Plan, Costco, and Starbucks. Care1st hosted a hospitality suite to introduce members to Dr. Malone and Dr. Deorosan who are active Care1st / HealthCare Partners providers within the community. Linda Fleischman and Rosa Hernández, from Care1st s Education Department, provided body fat analysis, educational displays, and pamphlets. Dr. Fitzgerald, DDS, Care1st Health Plan s Dental Director of Quality Improvement, furnished a booth presenting the importance of dental hygiene to personal health. A variety of health screenings were offered to guests. Screenings included stroke, glucose, bone density, and blood pressure. Carrie Anne, from SilverSneakers, demonstrated an aerobics workout to inspire seniors to get up and get moving. The event included the participation of a Massage Therapy school who donated their time and skills by providing relaxing and soothing massages. This event was a successful collaboration between Care1st Health Plan and HealthCare Partners. Two organizations dedicated and committed to improving quality of care and healthy living. If you have any questions regarding participation in future educational events, please contact the marketing department at Care1st Health Plan at (800)

3 Health Information Technology for Economic and Clinical Health Act (HITECH) part of the American Recovery and Reinvestment Act of 2009 (ARRA) 1 Chief Privacy Officers are very busy implementing the federal data breach notification requirements spelled out in the new HITECH law. Simply put, HITECH requires health care providers to notify individuals whose data has been breached. The Breach Notice Rule is an interim final regulation issued on August 24, 2009 by the US Department of Health & Human Services (DHHS). It provides guidance on how to comply with HITECH. Details and exclusions of the Breach Notice Rule can be accessed on the Internet at: gov/ocr/privacy/hipaa/understanding/coveredentities/breachnotificationifr.html Breach Notice Requirement Under the new law, when a breach 2 has been identified, a covered entity is to notify each individual whose unsecured protected health information (PHI) has been, or reasonably believed to have been, accessed, acquired, disclosed, or compromised. PHI is compromised when it poses a significant risk of financial, reputational, or other harm to the individual. It does not matter if the breach occurred through the covered entity or a business associate. Business associates must notify the covered entity of the breach. Discovery constitutes the first day the covered entity or business associate knows, or has reason to suspect, that a breach has occurred. Once discovered, any required notifications must occur without unreasonable delay (i.e. no later than 60 calendar days after discovery). If notification is delayed, proper evidence should be prepared to demonstrate the necessity of the delay. Prompt notification to an individual should be written and sent via first class mail unless the individual requests electronic mail delivery. If the individual s contact information is out of date or insufficient, a substitute form of notice should be used. Substitute forms of notice include posting on the covered entity s website, or public notice in major print or broadcast media in the geographic area where the individual most likely resides. Breaches involving 500 or more individuals in State or jurisdiction require the use of State media outlets. Further, when a breach involves 500 or more, the HHS should be immediately notified by visiting the HHS website by filling out and electronically submitting a breach report form. The HHS Breach Reporting Form can be found at: Otherwise (less than 500), a covered entity should maintain a log of breaches and submit it annually to HHS using the breach form and electronic submission to HHS. No matter how a covered entity notifies an individual of a breach, the notification must include: How the breach occurred; Date(s) of breach/discovery; Description of the PHI involved; Description of investigation and mitigation process and future prevention plans; Contact procedures in order to get more information; and How individuals can be protected against potential harm. Examples 1) The Billing Department mistakenly sends the Explanation of Benefits (EOB) notice of a patient who received behavioral health services to the individual s employer. Does this require breach notification? Yes. The Privacy Rule was violated, and there could be substantial reputational or financial harm caused when accidentally disclosing PHI to someone s employer. 2) A hospital laptop was stolen and it contained the medical records information of 30 people. However, the laptop was encrypted. Is breach notification required? No. The PHI was secured by encryption. 3) A hospital discloses PHI that contains the name of patient and the fact that the patient received treatment in the hospital s substance abuse treatment program. Does this require breach notification? Yes. The Privacy Rule was violated, and there could be significant risk of reputational or financial harm to the individual when disclosing treatment at specialized facilities (e.g., oncology, substance abuse, etc.). 4) A laptop was stolen and it contained the medical records information of 30 patients. The laptop was recovered and a forensic analysis shows the laptop was not opened, altered, or accessed. Is breach notification required? No. The Privacy Rule was violated, but the PHI was not compromised, and thus, there is no significant risk of reputational or financial harm to the patients. 5) A provider discloses PHI that contains the name of the patient and the fact that the patient received services (but not what the specific services were) at a hospital or the provider s office. Does this require breach notification? No. Although the Privacy Rule was violated, it is not likely there would be significant risk of reputational or financial harm to the individual. 1 A Quick Guide To Investigating Data Breaches, Frank Riccardi, JD, CHC, CFE, CPHRM Compliance Today, January 2010; and hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/index. html 2 A breach is an unauthorized acquisition, access, use, or disclosure of unsecured PHI which compromises the privacy, security, or integrity of the PHI. To report suspected and/or actual breaches of Care1st members protected health information, call Care1st s Hotline at or call Care1st s Compliance Officer, Brooks Jones at

4 Care1stCARES Is In The House Beginning April 1, 2010, all Disease Management Programs under Care1stCARES have been transitioned from Healthways to Care1st Health Plan. The administration of all Disease Management Programs by Care1st staff allows for improved comprehensive care coordination between our PPGs, physicians, home health agencies, and Care1st internal departments such as Complex Case Management, Transitional Care Case Management, Inpatient Case Management, Social Services and Pharmacy. The current Disease Management Programs include: Medi-Cal Asthma CHF Medicare COPD CHF You can obtain more information about these programs, including how to refer your Care1st patients to Care1stCARES on our website. The link for Care1stCARES site is: care1st-cares.asp The purpose of the Care1stCARES programs is to oversee and manage a defined member population with chronic conditions. To achieve ultimate outcomes, the program consistently applies approved guidelines and criteria and focuses on member self-care efforts. The goals of the Care1stCARES programs include: To reduce the members incidence of condition exacerbation Improve medication adherence and compliance to prescribed medication therapy To improve overall quality of life To improve member s knowledge/understanding of their condition To improve member s self-management skills To improve practitioner adherence to approved treatment guidelines To decrease hospital admissions To decrease Emergency Room visits We look forward to working closely with you in delivering high quality care and improving the quality of life for our members. If you would like to discuss these programs with our Disease Managers, please contact Care1st Health Plan at

5 Care1stCARES Disease Management Practice Guidelines Practice guidelines provide evidence-based recommendations for the assessment and treatment of various disorders. All guidelines used for the Care1stCARES Disease Management Program are nationally recognized and represent appropriate standards of care for each condition. Below are the guidelines utilized by the Care1stCARES programs. Asthma COPD CHF National Heart, Lung, and Blood Institute (NHLBI) National Education and Prevention Program (NAEPP), Expert Panel Report 3 (EPR3): Guidelines for Diagnosis and Management of Asthma Complete guidelines are accessible at: Global Initiative for Chronic Obstructive Lung Disease, Complete guidelines are accessible at: Heart Failure Society of America Comprehensive Heart Failure Practice Guideline, 2006 ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults 2009 Complete guidelines are accessible at: Sensitivity Critical to the Care of Female Patients In a recent focus group study conducted by the health plans that provide services to Medi-Cal Managed Care members in Los Angeles County, female members gave feedback on ways to increase breast and cervical cancer screenings. The following were their suggestions: Provide educational materials and videos in the waiting room explaining what women may expect during the exams and provide materials following the screenings as well. Remind women about the importance and intervals for breast and cervical cancer screenings. Show greater sensitivity about how difficult these screenings can be for women. Refrain from making comments about a woman s body. Inform women how to receive their screening results within a reasonable time frame. Please contact Rosa Hernández at ext or at rhernandez@care1st.com to request a full copy of this report. Care1st Health Plan s website, offers member materials on a variety of topics, including mammograms and cervical cancer screenings. We encourage you to follow the preventive health care guidelines also available on this site.

6 Language Rights for Care1st Health Plan Members Care1st Health Plan members have the right to: Request interpreting services (telephonic, face-to-face & American Sign Language) from Care1st or their PCP at no cost. Receive interpreting services 24 hours a day / 7 days a week (includes after hours) Receive health education brochures and materials in their primary language and /or alternative formats (i.e. Audio, Braille & Large Print etc.) Participate in community programs and services that offer culturally and linguistically appropriate social services. File a grievance if the services provided do not meet their cultural and language needs. Care1st Health Plan provides at NO COST: Interpreting services 24 hours a day / 7 days a week by calling Care1st Member Services at Live Interpreter Services prior to scheduled appointments 24 hours in advance by calling Care1st Member Services at Educational materials and forms in various languages (i.e. Member s Rights, Request or Refusal of Interpreting services forms, IHEBA, etc.), including alternative formats (i.e. audio, Braille, Large Print, etc.). Educational opportunities & resources for providers and staff; including on-site trainings. Referrals to Community Programs and Services Interpreting Services Poster To Contact a Member with Hearing/Speech Impairment: Call California Relay Service at The California Relay Service is a FREE service available 24 hours a day / 365 days a year with no restrictions on call length or number of calls. Interpreting Services Poster: The poster must be placed in visible areas within your office (i.e. reception desk, waiting room, or exam room). It is translated into LA County s ten threshold languages and will inform patients of the availability of interpretation services at no cost. You may obtain free copies of the poster by contacting the Cultural and Linguistic Department. Cultural & Language Related Complaints & Grievances: Provider offices should establish a policy for their office that will assist staff in handling cultural & language related complaints. Grievance forms are available in English, Spanish, Arabic, Armenian, Chinese, Farsi, Khmer (Cambodian), Korean, Russian, Tagalog, and Vietnamese. Please contact the Cultural and Linguistics department to request a copy. You can also visit the Care1st website to access most of the materials available in various languages at If you need any additional information, please contact Therese Horth at (323) ext We also welcome you to send your request via to thorth@care1st.com. Bilingual Providers & Staff: The most current ICE Provider & Staff language capability selfassessment tool has recently been distributed via Fax to providers and facility site review nurses. If you have not received a copy in the last couple of months, please request a copy via to Therese Horth at thorth@care1st.com, or download

7 a copy from the Care1st Health Plan website at com. Furthermore, please maintain certification of language proficiency certifications or interpretive trainings on file for each provider and office staff. Bilingual staff providing medical interpreting services are encouraged to take a language proficiency test by a qualified agency to determine if they are qualified for medical interpreting. Bilingual staff, with limited bilingual capabilities, should not provide interpreting service to members. Other Resources: On-line Cultural Competence Training from DHS Office of Minority at Health Care Interpreting: A short Course for Bilingual Health Care Workers Who Interpreter for Patients www. lacare.org Resource-materials such as videos on how-to work with interpreters and cultural resources at org, (CCHCP), (Francis Curry TB Center) TCE publications such as How to Choose and Use a Language Agency and Health Care Interpreter Training in California at Ensuring Linguistic Access in Health Care Settings and Language Services Action Kit available from National Health Law Program at Department of Health And Human Services-The Office of Minority Health: Nurse Rachel Is Too Friendly Nurse Rachel is the friendliest person in the world. She greets patients to Dr. Tran s office with enthusiasm, always asks after their family members, and proudly shows off the treats her patients bring her to thank her for her kindness as they deal with their own medical problems and those of their family members. One of nurse Rachel s favorite patients, Mary Jones, passed away recently from breast cancer. Nurse Rachel posted on her Facebook a picture she had taken of Mary just before she died with the caption: Mary Jones, a grand lady to end, passed away today. Another victim of breast cancer. Nurse Rachel violated the law in posting the picture and the caption without the permission of Mary Jones. Protected Health Information is not to be released even on a Facebook page paying tribute to a patient. Motive is irrelevant. All health professionals must avoid posting online pictures and names of patients, mentions of the health conditions of patients, and any mention of health status including death. Social networking is just that, SO- CIAL. It is not to be used by friendly professionals to share information about patients, even patients who bring them treats and treat them like friends.

8 Health Care Fraud & Abuse Common Managed Care Fraud Schemes It is in your best interest and that of all citizens to report suspected fraud. Health care fraud, whether against Medicare, Medi-Cal and/or Private Insurers, increases everyone s health care costs. If we are to maintain and sustain our current health care system, we must work together to reduce unnecessary costs. I. Administrative/Financial II. Services/Encounter III. Member Issues Falsifying credentials. Billing fee-for-service [FFS] for capitated services. Double-billing for health care services or goods that were provided. Accepting kickbacks for referring sicker patients to FFS specialists. Conducting improper dis-/enrollment practices. Attracting healthy patients or refusing sicker patients. Persuading sicker patients to dis-enroll. Falsifying medical exemptions. Use of telemarketing/selling as marketing tools. Department Contact Information Provider Relations P: (323) Ext F: (323) Member Services P: (800) F: (323) Authorizations P: (800) F: (323) Pharmacy P: (877) P: (877) RX-CARE1 F: (866) F: (866) R1-CARE1 Claims P: (800) Ext Ext LOS ANGELES ORANGE SAN BERNARDINO RIVERSIDE Care1st Health Plan 601 Potrero Grande Drive Monterey Park, CA Phone (323) Main Fax (323) Falsifying encounter data. Misrepresenting services to meet quality of care standards. Billing for phantom patients who did not receive services. Billing for services/supplies not provided. Upcoding charges and unbundling services. Excluding distinct groups of beneficiaries [e.g. patients with chronic conditions]. Engaging in under-utilization. Regularly denying treatment requests and specialist referrals without regard to proper medical evaluation. Concealing ownership in a related company. On-line: CONTACT INFORMATION BY COUNTY: SAN DIEGO Care1st Health Plan 3131 Camino del Rio North Suite 350 San Diego, CA Phone (619) Main Fax (619) Falsifying eligibility applications. Using another person s health plan identification card to obtain medical care. Doctor shopping to obtain multiple prescriptions for controlled substances/ prescriptions drugs. Misrepresenting medical conditions. Failing to report third party liability. WHAT CAN YOU DO? Review Care1st Provider Manuals. Report potential fraud to the Department of Health Services for Medi-Cal. Report potential fraud to the HHS Office Inspector General for Medicare. Contact Care1st Health Plan s Special Investigations Unit and make aware of potential fraud issue. Establish office policies and procedures to address fraud and abuse issues. Share this important information with your staff. Report potential fraud by calling: Medicare Fraud Hotline of the HHS office Inspector General (800) Medi-Cal Fraud Hotline Department of Health Services (800) Care1st Health Plan Compliance Hotline (877) PNO