ICHP : Department of Health Care Policy & Financing Updates

Transcription

1 ICHP : Department of Health Care Policy & Financing Updates Payment Rate for E&M Codes Beginning January 1, 2015, Colorado Medicaid is reimbursing covered office visit (E&M) and vaccine administration procedure codes at a rate equal to 100% of the December 2014 Medicare reimbursement rate. The new rate is available to all enrolled providers that submit fee schedule claims for office visits or vaccine administrations. The new reimbursement rate will remain in place through June 30, Due to a delay in CMS approval of the new rates, the higher rates have not yet been loaded in the Department s claims processing system. The Department does not have an anticipated approval date at this time. The Department will retroactively adjust claims with dates of service on or after January 1, 2015, to reflect the rate increase. April 2015 Provider Workshops Provider Billing Workshop Sessions and Descriptions Provider billing workshops include both Colorado Medical Assistance Program billing instructions and a review of current billing procedures. Who Should Attend? Staff who submit claims, are new to billing Colorado Medicaid services, need a billing refresher course, or administer accounts should consider attending one or more of the following Provider Billing Workshops. Courses are intended to teach, improve, and enhance knowledge of Colorado Medical Assistance Program claim submission. Reservations are required for all workshops. reservations to: workshop.reservations@xerox.com or call extension 5. Include the following information: Colorado Medical Assistance Program provider billing number and the date and time of the workshop. Provider Billing Workshop Sessions Tuesday April 14th: CMS :00AM-11:30AM Web Portal 837P 11:45AM - 12:30PM Transportation 1:00PM - 3:00PM Wednesday April 15th: *WebEx* UB-04 9:00AM - 11:30AM *WebEx* Web Portal :45 AM 12:30PM Hospice 1:00PM - 3:00PM Thursday April 16th: *All classes WebEx* Personal Care 9:00AM - 11:30AM Web Portal 837P 11:45AM - 12:30PM Home Health 1:00PM - 3:00 PM Friday April 17th: Practitioner 9:00AM - 11:00AM FQHC/RHC 1:00PM - 3:00PM

2 P a ge 2 The Facts: Why is Adolescent Health Important? While adolescents (who make up about 21% of the United States population) ages are generally healthy, they have unique health care needs and tend not to seek wellcare services where these needs can be addressed as they emerge. During this transitional period, adolescents face significant challenges. States, families, providers, and educators can use this time to promote behaviors that will improve health in the long term. Adolescents are more likely to engage in activities that risk their overall health, including the use and abuse of alcohol and other substances, unprotected sex, poor eating and exercise habits, and physically-endangering behaviors. In fact, According to Healthy People 2020, behavioral patterns during these developmental periods help determine young people s current health status and their risk of developing chronic diseases in adulthood. Adolescence is also a time when many chronic physical, mental health and substance use conditions first emerge. These conditions often increase risky behaviors which may result in harm to self or others. For example, according to the Centers for Disease Control and Prevention (CDC), 16% of high school students have seriously considered suicide, and 88% of adult daily smokers started smoking before they were 18 years old. Early identification of these conditions and behaviors leads to earlier referral and subsequent treatment. Further, addressing risky behaviors early and promoting positive health behaviors through periodic well-care visits can help adolescents identify and respond to stresses, and make good choices in managing their health. Healthy People 2020 also notes that the leading causes of illness and death among adolescents and young adults are largely preventable. In fact, $700 billion is spent annually on costs directly and indirectly associated with preventable adolescent health problems. Ensuring adolescents have access to a primary care physician who provides an annual, comprehensive well-care visit can: Foster early screening, counseling, and intervention; Reinforce health promotion messages for both adolescents and their parents; Identify adolescents with chronic conditions or who are at-risk for health problems or have initiated health-risk behaviors; Provide the opportunity to monitor growth and development, support psychological and emotional well-being, and encourage healthy lifestyles; and Build confidence in adolescents to effectively and appropriately utilize the health care system. The Adolescent Well-Care Visit The Medicaid Benefit for Children and Adolescents In 1967, Congress introduced the Medicaid benefit for children and adolescents known as Early and Periodic Screening, Diagnostic and Treatment (EPSDT). The goal of EPSDT (referred to in this guide as the Medicaid benefit for children and adolescents ) is to ensure that children receive the health care they need at the time they need it the right care to the right child at the right time in the right setting. This broad scope supports a comprehensive, high-quality health benefit for children and adolescents under age 21 enrolled in Medicaid. States share responsibility for implementing the benefit with the Centers for Medicare & Medicaid Services (CMS). The Medicaid benefit for children and adolescents is more robust than the Medicaid benefit for adults. It is designed to ensure that children and adolescents of all ages receive early detection and preventive care so that health problems are averted or diagnosed and treated as early as possible. It covers all medically necessary services that are included within the categories of mandatory and optional services listed in section 1905(a) of the Social Security Act, regardless of whether such services are covered for adults or included in the state plan. States inform families about the benefit and provide children and adolescents access to the health care ser-

3 P a ge 3 vices they need. Accordingly, states also ensure that there are an adequate number and range of providers to meet the health care needs of the state s enrolled children and adolescents regardless of the type of Medicaid delivery system. The Well-Care Visit Under the Medicaid benefit for children and adolescents, an adolescent well-care visit (also known as a well-child or preventive care visit) includes a comprehensive health history on both physical and mental health development, immunizations, laboratory tests appropriate for age and risk factors, health education, including anticipatory guidance, vision, hearing, and dental services. A well-care visit for adolescents, ages 12 to 21, can provide the screening and health counseling necessary to address five key areas of adolescent health: Mental and behavioral health Tobacco and substance use Violence and injury prevention Sexual behavior Nutritional health Many states have recognized the role of the well-care visit in improving overall adolescent health and have established requirements regarding specific components providers and managed care contractors must include in an adolescent well-care visit. For example, 31 states have established requirements for providers to include a comprehensive health exam as part of their well-care visit that at a minimum addresses [the] five critically important components of adolescent health. Children s Health Care Quality Measures Beginning in 2011, CMS has partnered with states on the voluntary collection of health care quality measures for children and adolescents covered by Medicaid and Children s Health Insurance Program (CHIP). The voluntary collecting and reporting of measures is just one step that states can undertake to help improve the quality of care for children and adolescents. Of the twenty-six measures in the Children s Core Set of Health Care Quality Measures for Medicaid and CHIP (Children s Core Set), twenty-one are appropriate for capturing the quality of care for adolescent health. Examples of the more relevant measures that either include or focus on adolescents are: Human Papillomavirus (HPV) vaccine for female adolescents; Immunization Status for Adolescents; Weight assessment and counseling for nutrition and physical activity for children/adolescents: Body Mass Index assessment for children/adolescents; Chlamydia screening in women; Child and adolescent access to primary care practitioners; and Adolescent well-care visit. By examining data reported through these measures, CMS, states and other stakeholders can gain insight into the quality of health care provided to Medicaid/CHIPenrolled adolescents and identify areas for improvement. The National Committee for Quality Assurance s (NCQA) adolescent well-care measure (and a CMS Child Core Set measure) defines an adolescent well-care visit as at least one comprehensive [annual checkup] with a primary care physician or OB/GYN practitioner during the measurement year that addresses the physical, emotional, and social aspects of an adolescent s health. Well-care visits typically occur independently from a visit for sickness or injury, and consist of a variety of preventive services, including: one or more immunizations for infectious diseases; screenings for a wide range of health and mental health conditions; and education and counseling on a variety of topics pertinent to adolescence. Cont. on page 9.

4 P a ge 4 FY 2014/15 KPI FAQs Will Duals (ACC:MMP) be included in KPI calculations? No, Dual clients will be excluded from FY 15 ACC KPIs and member month counts. Will the expansion population be included in KPI calculations? No, the expansion population will not be included in FY 15 KPI calculations. The Department will consider using FY 15 for the next baseline year to include the expansion population. Will the Department be moving to regional budgets from statewide with regional adjustments? TBD, the Department is still waiting for comparison data for regional budgets. Will well care checks be counted for eligible members if the WCC occurred during the first 90 days of continuous eligibility? Yes, well-care check in the first 90 days of eligibility will count for members who remain in the denominator at the time of the KPI calculation. Also, the KPI will only focus on well-child checks for children ages 3 to 9, as adolescent well-care visits will be tracked in the shared savings program. The post-partum measure is listed as hybrid, which is in the HEDIS methodology. Will HCPF really be doing chart reviews for this measure? The Department will be collecting an administrative only version of this claim. The KPI spec sheet does refer to the HEDIS measure that this measure was based on but the Department will be using only claims data to calculate the KPI. Please refer to the spec sheet for relevant codes. We also have an FQHC that has an OB clinic, but the patients aren t necessarily attributed to the FQ they only go to that clinic while pregnant. Can you help us understand how that will impact the KPI for post-partum care there, too? KPIs are calculated at the regional level, not by individual PCMP. We do not do any Obstetrics here. No prenatal visits, no post-partum visits. All women who become pregnant are referred elsewhere. How is that going to affect our KPI? KPIs are calculated at the regional level, not by individual PCMP.

5 P a ge 5 In addition, here are the current Metric Sheets on how KPIs are being calculated.

6 P a ge 6

7 P a ge 7 Well Child Checks Ages 3-9

8 P a ge 8 Care Coordination Corner The Care Coordinators have recently completed the Health Services Advisory Group (HSAG) Audit. This is an annual review of policies/procedures and the activities of the Care Coordinators. It includes significant chart reviews and interviews with the Care Coordinators who provide the hands-on services to our Members. The ICHP Care Coordinators demonstrated excellence in their documentation and in their interviews. Last year ICHP achieved a 100% and we are hopeful for a repeat performance this year. Be sure to check our next newsletter for the final results. During the HSAG Audit, the Care Coordinators continued to complete the Service Coordination Plans (SCP) for our Full-Benefit Medicare-Medicaid Program (FBMMP) with the strong assistance of our Providers and community partners. The SCP process allows ICHP Care Coordinators to speak with our FBMMP Members to identify who is providing services to the Member and any gaps in care. When a gap in care is identified, the Care Coordinator makes the referral for those services and ensures that the Member receives necessary services. ICHP has identified that the great majority of our FBMMP Members are already well connected with services. The specific services where ICHP sees a gap includes dental, vision and transportation. ICHP Care Coordinators continue to work within the Medicaid Network of Providers and the community resources to fill these gaps in service for Members. ICHP Care Coordinators would like the thank our Primary Care Providers and all of the wonderful community resources for your information, collaboration and support as we strive to serve such a vulnerable population. We couldn t do it without you! Meet Becky Eniczo, ICHP s New Performance Improvement Director Hi, I m Rebecca Eniczo, the new Performance Improvement Director for ICHP. I joined the ICHP team January 5 th, 2015 after five years of managing the Quality Management department for Value Options in Tennessee. I have wanted to live in Colorado for many years to pursue my outdoor passions of snowboarding, backpacking, cycling, and white water paddling so when the opportunity arose to transfer here and work with the awesome ICHP team I couldn t get packed fast enough. For several years I have heard about the forward thinking, innovative work being done in Colorado through partnerships such as ICHP and after 58 days of being here and learning about the amazing work being done in RCCO 4 I understand why your reputation extends all the way to Tennessee. The first 18 years of my career were spent working as a behavioral health provider before transitioning to managed care in March of Having worked in both arenas, which are generally considered antithetical to one another, I have hopefully developed a well-rounded picture of health care that enables me to see common ground. I have a Master s degree in Social Work from the University of Georgia, and as a social worker at heart, I get very passionate about working in an environment where projects bring together multiple and sometimes very disparate entities for the purpose of positively impacting the lives of individuals who are vulnerable and at risk. I am looking forward to meeting and working with all our partners and continuing the great work that was started by my predecessor, Mona Allen. She has left big shoes to fill but I think together, we can keep the growth and momentum going. Thanks for bringing me along for the ride!

9 P a ge North Main Street, Suite 202 Pueblo, Colorado Phone: Fax: info@ichpcolorado.com We re on the web: ICHP; Providing the right services at the right place, at the right time. ICHP is looking for community members and providers to serve on our Performance Advisory Committee or our Stakeholder Advisory Committee. These committees help us by offering feedback about the program and making suggestions for improvements. If you are a Medicaid Member, have a family member who is Medicaid eligible, work for an agency or a provider who serves Medicaid members, we want to hear from you. To learn more about our Committees visit our website or call The Facts: Why is Adolescent Health Important? Continued from page: 3 Each year, CMS, on behalf of the Secretary of HHS, publishes an Annual Report on the Quality of Care for Children in Medicaid and CHIP (Secretary s Report) which includes information about how states reported on the child core measures. According to the 2013 Secretary s Report, on average, states performance on adolescent preventive care measures specifically, well-care visits and immunization status were lower than their performance on the similar measures for younger children. Adolescents (ages 12 21) had a considerably lower median well-care visit rate (46%) than the other age groups, suggesting that only about half of adolescents, on average, are receiving recommended well-child care visits. These lower rates likely reflect the challenges of reaching and engaging adolescents in preventive and primary health care, the clinical and psycho-social needs of this group, and the barriers to serving this population. Resource: Program-Information/By- Topics/Benefits/Downloads/Paving-the-Road-to-Good- Health.pdf Please join us for our upcoming Practice Managers Meeting on July1st. We will be meeting in Pueblo at 503 North Main St. Suite #202 to discuss State Medicaid, ACC: MMP and ICHP updates. Please RSVP via to jessicaprovost@valueoptions.com or by calling 719/ with the number of attendees.