Evercare of Texas Provider Newsletter for Harris, Travis and Nueces service delivery areas, Spring 2010

Transcription

1 Provider Newsletter for Harris, Travis and Nueces service delivery areas, Spring 2010 Risk Adjustment Coding, Diagnostic Coding for Medicare Advantage 2010 In January 2006, the Centers for Medicare and Medicaid Services (CMS) began to make greater use of ICD-9 codes as a means to assess severity of illness. Just as CMS uses Diagnosis Related Groups (DRG) to reimburse hospitals, CMS groups diagnoses in order to create Hierarchical Condition Categories (HCC). CMS assigns each HCC a risk factor that correlates to specific funding for Medicare Advantage plans. Thus, accurate documentation and ICD-9 coding are essential in order to ensure that each plan has the funds to provide the care each member needs. To ensure that Evercare can continue to provide all the care coordination services that its members need, we look to our contracted primary-care providers and specialists to submit bills using diagnostic codes that are accurate, specific and comprehensive. To help our network physicians achieve high quality knowledge of ICD-9 coding, Evercare has engaged Ingenix, Inc., a UnitedHealth Group company, to assist in our data collection efforts. Ingenix will offer free coding training classes to physicians and their office staff. Please be on the look out for an Ingenix Market Consultant in your service delivery area to schedule your office for one-on-one or a local, mass training throughout The training is primarily for Medicare-certified physicians as the material pertains to Medicare applications. In This Issue: Page(s) Risk Adjustment Coding, 1 Diagnostic Coding for Medicare Advantage 2010 From the Medical Director 2 Notify Network Management 3 with Changes Evercare Measures 4-5 Results, Houston Provider Shines 2010: The Year 6 of Efficiency? Evercare STAR+PLUS 7-8 Member Complaints and Appeals May Affect Providers Quarterly Mailings: 8 Communication is Key Verifying Eligibility Helps 9 with Claims Payments Evercare Updated 9 Documents Are Only a Few Keystrokes Away Medicaid Marketing 10 Guidelines Apply to Providers Important Telephone 11 and Fax Numbers

2 From the Medical Director Revised Clinical Practice Recommendations for Diabetes By Leslie Cortes, MD Medical Director, Central Texas Recently the American Diabetes Association revised its clinical practice recommendations for diabetes. Evercare medical directors and our Medical Advisory Committee will meet next month to discuss these revisions. Until that time, please familiarize yourself with the revisions and watch for more information regarding these revisions in Evercare s next provider newsletter. The revised clinical practice recommendations for diabetes can be reviewed by clicking on the American Diabetes Association s direct link: care.diabetesjournals.org/ content/33/supplement_1/ S3.full. Notify Network Management with Changes To ensure provider directory accuracy, please remember to notify UnitedHealthcare and its subsidiaries if you have recently encountered changes to your office location, billing address, telephone number, tax ID, or closed your business, retired or changed your entity name. Adhering to the following procedure will ensure your provider information is accurate and updated for all of the UnitedHealthcare Products. Providers must notify Evercare in writing on business letterhead or on the Evercare Provider Change Form. To obtain a Provider Change Form from our Web site, please follow these directions: Log on to Click on Physicians and other Health Care Professionals Click on Physicians Click on Texas Physician Forms Click on Request for Address and Tax ID Number Change Form Changes can then be faxed to the following numbers according to provider type. Physicians and Facilities United Health Network Fax: All Other Providers Fax:

3 Evercare Measures Results, Houston Provider Shines Evercare congratulates Dr. Rhonda Barnes-Jordan, a primary-care provider in the Harris service delivery area, and a Medicaid/Medicare provider in our network. Dr. Barnes-Jordan outscored other primary-care providers in the Harris, Nueces and Travis service delivery areas when it came to the provision of comprehensive diabetes care for her patients. The following results illustrate the care and services provided for STAR+PLUS Medicaid members by Dr. Barnes-Jordan s office during the measurement year from July 2008 to June The measures are based on clinically-accepted best practices developed by the American Diabetes Association for type 1 and type 2 diabetics for the prevention and management of complications. Measure Plan average result Diabetes HbA1C Testing 58% 78% Diabetes LDL-C Screening Diabetes Retinal or Dilated Eye Exam Diabetes Urine Microalbumin Testing 62% 100% 89% 100% 29% 78% Dr. Barnes- Jordan s result We interviewed Dr. Barnes-Jordan and asked the secret to her success. Here s what she had to say. Does your office follow particular policies and procedures or strategies as it pertains to diabetes management? I follow the guidelines that are defined by the American Diabetes Association but have implemented several additional strategies within my clinic pertaining to diabetic patients. Does your office use specific processes or systems to help you remember to offer timely clinical services to those patients who are on a diabetic regimen? First and foremost, I have a strong interest in diabetes management. Secondly, when going through my board recertification, I was required to choose a module topic to teach, and I chose diabetes management. In my module, patients were asked to complete a medical questionnaire with 12 questions used by the American Academy of Family Practice. I then implemented this questionnaire into my practice. I read a lot about automated call systems and electronic medical records, and also wanted to implement those processes in my practice to help manage my diabetic patients. The result is a multi-pronged approach. For example, in my clinic, one day a month is strictly devoted to diabetic patients. With the electronic medical record system in place, I look for patients with a red flag, which indicates that at their last visit, their lab results were out of range, or they were categorized as uncontrolled diabetics. An automated call system calls those patients and reminds them that they have not seen their doctor for an appointment and asks them to schedule an appointment to see me. The patient then calls for an appointment, which we schedule on a specific day. Non-compliant patients are called by our staff. On the day they come into the office for their appointment, we have a specific agenda planned for our captive audience. We schedule diabetic educators and nutritionists for that day to come into the office and educate those patients while they wait to see me. Do you use computer or electronic systems to generate reminders for those patients with diabetic diseases? If yes, do you feel that these methods had an effect on your results? It s hard to say. I ve been in practice for 5 years and have always had the automated call system. Other offices use paper charts which make it harder to identify those patients and also difficult for the staff to contact them while also handling other office duties. With the flagging system feature of the electronic medical record, uncontrolled diabetics are easily identifiable and therefore, hard to miss. Are there any systems in place to flag high-risk patients? With the electronic medical record coding system, if a patient does not show for an appointment, then the red flag appears. In addition, if I have noted in the system that the patient had out-of-range lab results that do not meet the ADA guidelines, then I mark them as uncontrolled diabetic patients and the flag appears for those patients. What does your practice do to make adherence to medications/treatments easier for your patients? A: We suggest follow-up appointments and inquire if the patient is taking their medications. If not, we inquire about the side effects of the medications because perhaps there are adverse reactions preventing them from adhering to their medication regimen. We talk with the patient and listen to what they say. When they are in the office for an appointment, we prescribe enough refills until their next scheduled appointment, and if they miss an appointment, then the staff calls them, knowing they should be out of their supply of medication at that point. We continue educating every chance we get. Your practice outperformed all other practices in the screening for LDL-C, conducting Diabetes Eye Exams, and Urine Microalbumin testing. What do you think accounts for that? A: Because we actively try to schedule the uncontrolled diabetics on the same day, we are specifically educating and completing specific lab work or procedures geared for the diabetic patient. The National Committee for Quality Assurance (NCQA), a not-for-profit organization committed to evaluating and publicly reporting on the quality of managed care organizations and preferred provider organizations, supports, sponsors and maintains a performance measurement called HEDIS (Healthcare Effectiveness Data and Information Set.) It is used as the premier tool for monitoring the quality of care in health plans, and designed to ensure that purchasers and consumers can reliably compare the performance of managed care organizations (MCO) and preferred provider organizations (PPO). It also serves as a model for emerging systems of performance measurement in other areas of health care A: Evercare Provider Performance Summaries Rhonda Barnes-Jordan, MD Is there anything else you would like to add? Yes, we are excited about implementing sameday scheduling to begin in March. We have been participating with Baylor in the Medical Center Home project. We ve attended classes once a month and are working towards moving to this concept. We are excited for the March implementation. delivery. The performance measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes. Each year, Evercare conducts Provider Performance Summaries using HEDIS-like measurements so our standards are aligned with national accreditation. In addition, it allows our parent company, UnitedHealthcare, to be compared with other plans on an apples-toapples basis. Results are also used to reveal potential areas for improving the quality of care or costeffectiveness of utilization. continued on page

4 2010: The Year of Efficiency? Evercare STAR+PLUS Member If you do not have a user ID and password, choose click Complaints and Appeals May here and enter your provider information. Affect Providers It s a new and exciting year fixed with resolutions, right? Maybe. Maybe not. But if you made resolutions, they most likely were personal. When a new year comes around, people think of personal resolutions, but how about giving thought to office resolutions? How about this? The year of efficiency. So, if you have wanted to enroll in Electronic Payments and Statements but just haven t done so, this is your friendly reminder! Turn your claims payments and statements into electronic format. Here s how: To register online for this feature, follow these easy steps: Log onto Choose claims and payments. Choose electronic payments and statements. If you already have a user ID and password, enter these in the spaces. After your registration is complete, you will receive an confirmation. You will begin to receive payments electronically in seven to 10 business days. Or by fax: 1. Contact the EPS Help Desk at to request a registration form. 2. Fax the completed enrollment form to EPS is an electronic feature that allows providers to get reimbursed electronically, rather than receiving a physical reimbursement check. The service is available to providers at no cost and helps streamline and simplify the payment process for Evercare and Secure Horizons claims, as well as claims submitted for United Healthcare members. All network and non-network providers are eligible to enroll in EPS. Hospitals Laboratories Evercare STAR+PLUS members have the right to voice their complaints about Evercare and/or their providers. Providers can play an important role in the complaint process either directly or indirectly. Why is this important to me as a provider? Because as the provider, it s important to understand the process and understand what the state of Texas requires. We encourage providers to know the process and educate Evercare STAR+PLUS members on the procedures for filing a complaint. Members can voice a complaint by calling Evercare s Member Services Advocate at A complaint can be filed right away or within a few days. Physicians Long-term services and support providers Other health care professionals Product types EPS is available for the following product platforms: Commercial United Healthcare products Medicare (not available in the Nueces service delivery area) Medicaid STAR+PLUS After the registration process is complete, a Provider Relations Representative will contact you personally to discuss and ensure your satisfaction with this service. While this is not mandatory, we do encourage you to take advantage of the service as it is sure to create efficiencies within your office by reducing the time your staff spends on manual processing and claims payment reconciliation. If we can help with this transition, or if you have additional questions, please do not hesitate to contact the EPS Help Desk at UHC-FAST ( ), Option 5. There is no time limit to filing a complaint with Evercare. Evercare will send the member a letter telling them what we did about the complaint 30 calendar days after the letter was received. STAR+PLUS members can also appeal decisions made about their health care services. STAR+PLUS members can even ask for an expedited appeal if they need an answer right away. Evercare is required to make a decision quickly based on the member s health status when taking the time for a standard appeal could jeopardize the member s life or health. STAR+PLUS members also can ask for a State Fair Hearing. This is important to a provider because according to the Health and Human Services Commission s Uniform Managed Care Manual, providers may be involved in a member s right to receive a State Fair Hearing. STAR+PLUS member s request for a State Fair Hearing If the STAR+PLUS member disagrees with the health plan s decision, the member has the right to ask for a Fair Hearing. The member may appoint, in writing, a representative. A provider may be a member s representative. The member or member representative must ask for the Fair Hearing within 90 calendar days of the date on the health plan s letter. If the member does not ask for the Fair Hearing within 90 calendar days, the member may lose continued on page

5 continued from page 7 his or her right to a Fair Hearing. To request a Fair Hearing, the member or member representative contacts the health plan either in writing or by telephone: Writing: 9702 Bissonnet, Suite 2200W Houston, TX Telephone: The STAR+PLUS member has the right to continue any service he or she is now receiving until the final hearing decision if the member requests the Fair Hearing within ten days from receipt of the hearing notice from the health plan. If a Fair Hearing is not requested within ten calendar days from receipt of the hearing notice, the services being appealed will be discontinued. STAR+PLUS members do not have a right to a Fair Hearing if Medicaid does not cover the service the Provider requested. If the member asks for a Fair Hearing, the member will get a packet of information letting the member know the date, time and location of the hearing. Most Fair Hearings are held by telephone and the member or the member s representative may tell why he or she asked for the service. HHSC will give the member a final decision within 90 calendar days from the date the member asked for the hearing. Quarterly Mailings: Communication is Key Evercare is taking steps to proactively inform our contracted providers about important information your office needs to know. Each quarter you will receive a package via mail from Evercare. This will include some or all of the following: STAR+PLUS Provider Directory (for STAR+PLUS providers only) Quarterly newsletter Evercare in Focus Updates to reference materials such as the Quick Reference Guide New information that helps us to better work together to serve you and your staff, as well as our members This information also can be found on our Web site: Click on Physicians and other health professionals, then Claims forms and manuals. Please watch for these quarterly news packages and be sure to share them with your staff. We hope you find the information and communication pieces beneficial to your practice and your patients. Verifying Eligibility Helps with Claims Payments Verifying Evercare STAR+PLUS membership is an important provider responsibility. It could affect whether or not you get paid for seeing Evercare members. Completing the following steps prior to seeing an Evercare member also will help with claims payments. When a patient identifies himself or herself as an Evercare STAR+PLUS member, providers should verify eligibility through one or more of the following steps: 1. Ask for the member s Medicaid Identification (Form 3087) and their Evercare STAR+PLUS Identification card. 2. Call the Automated Eligibility Line at Visit Evercare s online system at 4. Call the TMHP s Automated Inquiry System (AIS) at Call TexMedNet (TMHP s EDI Helpdesk) at Evercare Updated Documents Are Only a Few Keystrokes Away Evercare s Quick Reference Guide (QRG) is updated often and mailed to your office in our quarterly provider mailing packet. The format is clean, user-friendly, and contains important information about Evercare and its policies and procedures. We also post it online to help your office find needed information quickly and easily. To access the online QRG and other important educational pieces, follow the navigation below on our Web site: Physicians Claims, Forms & Manuals Select Texas from the drop-down box Select Reference Guides from the drop-down box Click on Quick Reference Guide In addition, the latest provider newsletter, Evercare in Focus, also is online. To view a pdf of the newsletter, please follow the navigation below: Physicians Claims, Forms & Manuals Select Texas from the drop-down box Select Physician Newsletters from the drop-down box Click on Texas Physician Newsletter If the patient is not eligible for medical assistance or certain benefits, the patient is treated as a private-pay patient. If the patient is an acute care member and presents with an identification card that says Long Term Care services only, ask to see their Medicare card. Failure to accurately identify a member can result in delays in processing claims, inaccurate claims payments and possibly no provider reimbursement if the patient is not a STAR+PLUS member. For additional questions, contact your provider relations representative at

6 Medicaid Marketing Guidelines Apply to Providers Texas has established specific marketing guidelines and limitations for Medicaid health maintenance organizations. Texas has established specific marketing guidelines and limitations for Medicaid health maintenance organizations. These guidelines are applicable to the managed care organization (MCO), its agents, subcontractors and providers. They ensure that consumers receive accurate and unbiased information. Please familiarize your office with the following Marketing guidelines. 1. Providers are permitted to educate/inform their patients about the CHIP/ Medicaid Managed Care Programs in which they participate. 2. Providers may inform their patients of the benefits, services, and specialty care services offered through the MCOs in which they participate. However, providers may not recommend one MCO over another MCO, offer patients incentives to select one MCO over another MCO, or assist the patient in deciding to select a specific MCO. 3. At the patients request, Providers may give patients the information necessary to contact a particular MCO. 4. Provider must distribute and/or display Health-related Materials for all contracted MCOs or choose not to distribute and/or display for any contracted MCO: Health-related posters cannot be larger than 16 x 24. Children s books, donated by MCOs, must be in Common Areas. Materials may have the MCO s name, logo, and phone number. Providers are not required to distribute and/or display all Health-related Materials provided by each MCO with whom they contract. Providers can choose which items to distribute or display from each contracted MCO, as long as they distribute or display one or more items from each contracted MCO. 5. Providers must display stickers submitted by all contracted MCOs or choose to not display stickers for any contracted MCOs. MCO stickers indicating the provider participates with a particular health plan cannot be larger than 5 x 7 and not indicate anything more than the health plan is accepted or welcomed here. Effective January 1, 2009, the appropriate Program logo must be affixed. 6. Providers may distribute Children s Medicaid/CHIP Applications to families of uninsured children and assist with completing the Application. 7. Providers may direct patients to enroll in the CHIP/Medicaid Managed Care Programs by calling the Administrative Services Contractor. The MCO may conduct Member orientation for its Members, in a private/conference room at a Provider s office, but NOT in Common Areas at Provider s office. Evercare Provider Performance Summaries (continued from page 5) Evercare recently surveyed providers and measured the following measures: Coronary Artery Disease CAD LDL-C Screening Congestive Heart Failure CHF ACEi/ARBs CHF Beta-Blockers CHF LDL-C Screening Diabetes Diabetes HbA1C Testing Diabetes LDL-C Screening Diabetes Retinal or Dilated Eye Exam Diabetes Urine Micro albumin Testing Evercare Important Telephone and Fax Numbers Customer Service Departments Evercare STAR+PLUS (Medicaid) Claims status, eligibility, benefit questions, PCP assignments Plan DH Plan MH Plan IH Claims status, eligibility, benefit questions, PCP assignments Other Numbers Adult Preventive Care Annual Wellness Exam for Men Annual Wellness Exam for Women Cervical Cancer screenings Mammography Asthma Asthma Medication Management Each quarter this year, Evercare will highlight a provider, or providers, whose HEDIS measurements were above the plan average for each measurement. This quarter, we re focusing on Diabetes. (Part 1 of 4-part series) Eligibility Verification Automated line, for all plans Authorizations For all plans: Facility inpatient notifications Press 1 Physician office outpatient notifications Press 2 Provider service coordination Press 3 CBA questions/nursing Home modifications Press 4 Authorizations Fax Numbers Pre-authorization for Physicians/Facilities: Fax: or etx_um_precert@uhc.com DAHS/Provider Services/Other Requests: Fax: etx_ltc_auth_requests@uhc.com Durable Medical Equipment/Supplies: Fax: etx_dme_supply_auth_req@uhc.com Skilled Services (Nursing/PT/OT): Fax: etx_skilled_in_home_auth_req@uhc.com Provider Relations For all Evercare plans

7 9702 Bissonnet, Suite 2200W Houston, TX In This Issue: Risk Adjustment Coding, Diagnostic Coding for Medicare Advantage 2010 From the Medical Director Evercare Measures Results, Houston Provider Shines 2010: The Year of Efficiency? Evercare STAR+PLUS Member Complaints and Appeals May Affect Providers Quarterly Mailings: Communication is Key and more! Locations: Evercare of Texas (Harris Service Area) 9702 Bissonnet Suite 2200W Houston, TX (Dallas/Fort Worth Service Area) 5800 Granite Parkway, Suite 900 Plano, TX (Nueces Service Area) 400 Mann Street, Suite 901 Corpus Christi, TX (Travis Service Area) 1250 Capital of Texas Highway South, Ste. 360 (Bldg. 1) Austin, TX (San Antonio Area) 6200 Northwest Parkway San Antonio, TX UnitedHealthcare Services, Inc. EVTX10MC _000