connections A Newsletter for MIPA Network Providers

Transcription

1 CMO MONTEFIORE CARE MANAGEMENT connections A Newsletter for MIPA Network Providers SPRING 2013 Medicaid Long-Term Care Program Changes All MLTC plans arrange and pay for the following health and long-term care services (as long as they are medically necessary). These services include: The Medicaid program is changing for your patients who are receiving long-term care services. Most Medicaid and Medicare (dual) eligible consumers who are 21 years of age or older and currently receive home care, adult day health care and other longterm care services must now enroll in a managed long-term care plan within 60 days of receiving an enrollment packet from New York Medicaid Choice. This requirement will also apply for patients new to service. If you have a patient you would like to refer to the Managed Long Term Care Program, please contact the Provider Relations Department at , and we will coordinate the referral and enrollment to a plan that works with Montefiore and the CMO. New York Medicaid Choice has been serving as the Enrollment Broker for the State of New York since 1998, helping Medicaid clients to make informed healthcare decisions, including the selection of a Plan. New York Medicaid Choice can be reached at (TTY: ), Monday through Friday from 8:30 am 8:00 pm and Saturdays from 10:00 am 6:00 pm. Care Management Home Care including Nursing; Home Health Aides; Occupational, Physical and Speech Therapies Optometry/Eyeglasses Dental Services Rehabilitation Therapies Audiology/Hearing Aids Respiratory Therapy Nutrition Medical Social Services Personal Care (such as assistance with bathing, eating, dressing etc.) Podiatry Non-emergency transportation to receive medically necessary services Home-delivered meals and in a group setting (such as a day center) Medical Equipment Social Day Care Prostheses and Orthotics Social/Environmental Supports (such as chore services or home modifications) Personal Emergency Response System Adult Day Healthcare Nursing Home Care Inside: 2 Health Home 4 Obesity in Adults 5 Preventing Falls 6 Workshops 7 Claims Corner 7 Post-N-Track Your patients will receive their other benefits using their Medicaid and/or Medicare cards. Your patients will not lose any benefits by enrolling in a MLTC.

2 2 MEDICAID HEALTH HOME PROGRAM February 2013 marked the end of the first year of beneficiary attribution to the Bronx Accountable Healthcare Network (BAHN) Health Home. To date, Montefiore and its other Health Home care coordination partners have enrolled approximately 1,700 beneficiaries in the State-sponsored care coordination program for Medicaid beneficiaries, and outreach to another 2,000 beneficiaries is in progress. Approximately 85 percent of the enrollees are members of a Medicaid managed care plan. Medicaid managed care plans are expected to attribute the majority of members to Health Homes, given the ongoing efforts to transition many Medicaid feefor-service beneficiaries to Medicaid managed care plans. Montefiore is the lead agency of a Health Home partnership of Acacia Network, Albert Einstein College of Medicine, Morris Heights Health Center, St. Barnabas Hospital and Union Community Health Center. In addition to the six governance partners, there is a referral/treatment network of over 30 mental health, chemical dependency, social support, HIV and housing providers. A few of these, primarily HIV and mental healthtargeted case management providers, also provide care coordination services for BAHN beneficiaries. The BAHN works collaboratively with the New York State Department of Health, healthcare providers, health plans and community-based organizations to address the cost, quality and health outcomes for chronically ill Medicaid beneficiaries in the Bronx. The mission of the BAHN is to provide expert, comprehensive and evidencebased care coordination; work with key stakeholders in the areas of program design, monitoring, evaluation and cost; and promote integration and shared use of health information technology. A Health Home is a care management model in which a care manager/coordinator oversees, provides access to and coordinates care designed to improve health outcomes. The model builds upon the patient-centered medical home (PCMH) concept, a team-based approach to providing comprehensive care that integrates the physical and mental health needs of patients. To qualify for Health Home services, Medicaid beneficiaries must have two or more chronic conditions, HIV/AIDS, or one serious and persistent mental health condition. Beneficiaries are attributed to a Health Home based on their connection with a particular provider as determined by claims analysis of the individual s historical utilization of services. Enrollment in the program is voluntary, and there is no charge to the beneficiary for the services or change in their benefit package. Each Health Home beneficiary is attributed to a specific BAHN care coordination partner and is assigned a care manager who completes a comprehensive medical and psychosocial

3 3 assessment; prepares a care plan in collaboration with the beneficiary and/or the caregiver; and facilitates the beneficiary s access to: primary and specialty care services, crisis intervention, follow-up during post-hospital transitions, and community-based individual social and family support services, including substance abuse treatment and housing. A care manager/coordinator may contact a provider s office to facilitate access to services or to obtain or share information about the beneficiary if the beneficiary has signed a New York State Department of Health Medicaid Health Home Patient Information Sharing Consent (form DOH-5055), a copy of which will be provided upon request. The delivery, referral, payment and authorization of all medically necessary services occurs as usual. If a patient is a Medicaid fee-for-service beneficiary, authorizations and billing should continue with Medicaid directly. If the patient is a Medicaid managed care plan beneficiary, authorization, in-network referrals and billing should continue with the plan directly. Health Home services are provided by the staff of the BAHN care coordination partner organizations. The BAHN is paid a care coordination fee directly by Medicaid or Medicaid managed care plans except for those members transitioned from HIV and mental health targeted case management programs that converted to the Health Home care coordination program (legacy members) the converting care coordination partner organizations are paid directly for legacy members. The Medicaid managed care plans currently contracted with the BAHN are: Affinity, Amerigroup Health Plus, Amida Care, Emblem Health, Fidelis, Healthfirst, Neighborhood Health Partners, VNS Choice (including formerly Select Health) and Wellcare. For more information about the BAHN, including how to make referrals, call the Bronx Accountable Healthcare Network at or The mission of the BAHN is to provide expert, comprehensive and evidence-based care coordination; work with key stakeholders in the areas of program design, monitoring, evaluation and cost; and promote integration and shared use of health information technology.

4 4 TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS The recent focus on obesity among children and young adults has diverted attention from the issue among older adults, where the primary considerations have tended to be malnutrition and weight loss. In fact, several studies have documented both the prevalence and increase in obesity among older adults, and its effect on various chronic conditions, and the Center for Medicare & Medicaid Innovation has made BMI testing and follow-up among the metrics used to measure ACO quality. A BMI should be calculated every 6 months the patient visits your office based on a height and weight measured on site. For patients whose BMI is above range, assess whether weight loss is an appropriate plan. The first step toward reaching that goal is prevention of additional weight gain which usually requires changes in diet and exercise habits accompanied by behavioral support. Weight loss goals vary and may range from 0.5 pound to 1 or 2 pounds per week while a reasonable individual goal is to lose 10 percent of current body weight in 6 months. Dietary Therapy Caloric intake should be reduced by at least 300 calories per day for those attempting modest weight loss, and up to 500 or 1,000 calories per day for those who desire more weight loss. To maintain weight reduction, long-term changes in food choices are recommended. Dietary therapy includes instructions for modifying diets to achieve this goal. Recipes appropriate for patients trying to lose weight can be found on the following Web pages: other/chdblack/cooking.pdf other/sp_recip.pdf Dinners_Cookbook_508-compliant.pdf An interactive menu planner may also help patients choose foods that fit their goals: menu.cgi Frequent contact with your patient during the period of diet adjustment is likely to improve compliance. Physical Activity Physical activity has direct and indirect benefits. Increased physical activity is important in efforts to lose weight because it increases energy expenditure and plays an integral role in weight maintenance. Physical activity also reduces the risk of heart disease more than that achieved by weight loss alone. In addition, increased physical activity may help reduce body fat and prevent the decrease in muscle mass often found during weight loss. For the very sedentary patient, an increase in very light activities may be appropriate. For the obese patient, activity should generally be increased slowly, with care taken to avoid injury. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week. A wide variety of household chores or light activities may help satisfy this goal.

5 5 PREVENTING FALLS IN OLDER ADULTS Falls are a major health problem for adults aged 65 years, resulting in fractures and head injuries, disability, loss of independence, and nursing home placement. In 2010, data from the New York City Department of Health and Mental Hygiene indicated that unintentional falls were the leading cause of injury-related death and hospitalization in this age group in New York City. Each year, hospitals in the city treat and release about 21,000 older adults in their emergency departments and admit another 16,000 for falls. Falls risk assessment and multifactorial prevention strategies are important in maintaining the independence and quality of life of older adults and should be a routine component of care for adults 65. While there are many acceptable fall risk screening tools, two simple questions can help determine whether your patient is at risk for future falls. These questions should be asked at least yearly for older adults: 1. Has your patient had two or more falls in the past year? 2. Has your patient had any falls with injury in the past year? If the answer to either question is yes, this suggests the patient is at risk for future falls and further evaluation may be needed. This will likely include a more detailed history, physical examination, medication review, gaitbalance screening, evaluation of functional limitations and questions about home safety hazards. A complete evaluation may not be possible during one visit, so determine what assessments and interventions you can accomplish in the time you have with the patient. Online training is available to help you improve your skills in assessing risk for falls and choosing the interventions most relevant to your patients. Familiarize yourself with community resources and specialists to whom you can refer patients who need further assessment and interventions. (Adapted from the New York City Department of Health and Mental Hygiene, 2010, Preventing Falls in Older Adults in the Community. City Health Information. 29(4): Available for free downloading at: Falls Risk Assessment and Prevention Tools The American Geriatrics Society Clinical Practice Guideline: Prevention of Falls in Older Persons: recommendations/prevention_of_falls_summary_of_recommendations Centers for Disease Control and Prevention (CDC) Home and Recreational Safety: National Council on Aging, Fall Prevention Center: National Institute on Aging. AgePage. Free print brochures for waiting room on fall and fracture prevention and physical activity and exercise can be ordered at Osteoporosis/Fracture/prevent_falls.asp#d 21,000 Approximate number of older adults in New York City that were treated and then released from emergency departments. 16,000 Approximate number of older adults in New York City hospitals that were admitted for fall-related injuries.

6 6 UPCOMING DISEASE MANAGEMENT WORKSHOPS CMO offers pre-diabetes, diabetes, congestive heart failure and respiratory (asthma/copd) disease management (DM) programs to all members. The CMO Disease Management team supports primary care and specialty providers by educating eligible patients on the importance of health maintenance, self-management techniques and the prevention of disease complications. DM also offers individual consultations with RNs at various primary care sites, group classes, telephonic outreach, telemonitoring programs and coordination of services. DIABETES WORKSHOPS MMG Bronx East 2300 Westchester Avenue, Bronx Tuesday, June 25, 2013, 2:00 4:00 pm (Spanish) Tuesday, June 25, 2013, 4:00 6:00 pm Yonkers Public Library 1500 Central Park Avenue, Story Room Friday, June 21, 2013, 1:00 3:00 pm MMG Grand Concourse 2532 Grand Concourse, Bronx Thursday, June 20, 2013, 4:00 6:00 pm Co-op City Community Center 177 Dreiser Loop, 2nd Fl. Room 8, Bronx Tuesday, June 18, 2013, 4:00 6:00 pm ASTHMA/COPD WORKSHOPS MMG Bronx East 2300 Westchester Avenue, Bronx, Conference Room, Lower Level Thursday, June 20, 2013, 3:00 4:00 pm (Spanish/English) MMG Grand Concourse 2532 Grand Concourse, Bronx, Lower Level Conference Room Wednesday, June 12, 2013, 9:00 10:00 am (Spanish/English) Co-op City Community Center 177 Dreiser Loop, Bronx, 2nd Fl, Room 8 Tuesday, June 4, 2013, 10:00 11:00 am (Spanish/English)? INFORMATION and REGISTRATION For more information regarding disease management workshops, visit us at: Heart failure and diabetes guidelines have been updated and are located at: To register your patients to participate in one of the free disease management workshops, call CMO Disease Management at

7 PHOTO 7 CMO S POST-N-TRACK Post-N-Track (PNT) allows you to : View member eligibility Check claim status, including date paid, check number and amounts paid Create and view authorizations and hospital admissions online Attach additional information to existing authorization when requested Complete clinical certification request forms All participating independent practice association (IPA) providers, including Emblem/HIP Health Plan participating providers, are eligible to use Post-N- Track and are encouraged to register today! Register: We encourage everyone to begin using these features and some new enhancements that will ensure authorizations are not held up awaiting additional paperwork. If you have any questions or require additional training, please contact Horace McFarlane, CMO Post-N-Track/EDI Coordinator, at CLAIMS CORNER: CLAIM DENIALS HELPFUL HINTS The CMO processes an average of 133,000 claims per month, over 99 percent within 30 days. We are always looking for ways to improve our overall performance and minimize our claim denials. The CMO denies approximately 10 percent of all claims received. The highest volume of denials are Timely Filing and Duplicate Submissions. These two alone account for 59 percent of all denials. Our goal is to process claims as promptly as possible and we ask that claims be submitted within the timely filing guidelines. In addition, always allow for adequate processing time to avoid a duplicate submission denial. 133,000 The average number of claims the CMO processes in one month. 99% The percentage of claims processed within 30 days. CMO, THE CARE MANAGEMENT COMPANY, LLC STATEMENT REGARDING APPROPRIATE SERVICES AND COVERAGE FOR HEALTH PLAN DELEGATED MEMBERS CMO is dedicated to ensuring the delivery of appropriate care to Health Plan delegated members. This statement affirms the CMO s policy regarding utilization management (UM) decision making when conducted by Clinical Peer Reviewers and CMO staff. All UM decisions are based on the member s eligibility, the benefits covered under the member s certificate of coverage, and the appropriateness of care and services. CMO does not specifically reward UM decision makers for issuing denials of coverage or services and encourages the use of medically necessary and appropriate care and services to prevent and/or treat medical conditions. CMO does not compensate UM decision makers for noncertification of service or offer incentives to encourage noncertification or underutilization of healthcare services.

8 8 MIPA INSIDER CLASSIFIEDS Let us help you communicate to all MIPA members. If you are interested in advertising in our newsletter free of charge, please or call CMO MONTEFIORE CARE MANAGEMENT MEDICAL SPACE FOR RENT LOCATION: 3220 Fairfield Avenue, Riverdale (one block east of the Henry Hudson Parkway). 800 sq. ft. fully furnished includes: separate ground floor entrance from the street, reception area and waiting room, consultation room, two exam rooms and a small office. If interested, please call Dr. Norman Sas at MEDICAL SPACE AVAILABLE FOR RENT LOCATION: White Plains Road (Rte. 22), Eastchester, New York. Available for part-time sublet. Fully furnished medical space with designated parking spots includes: two treatment rooms, and consultant room. Available Immediately. Flexible schedule/ arrangements. Specialist welcomed. For more information, please call MEDICAL SPACE AVAILABLE FOR SUBLET LOCATION: 18 Ashford Avenue., Dobbs Ferry, New York. Fully furnished medical space in medical office building includes: two treatment rooms and a consultation room. Available Immediately for 3-4 day practice schedule. Specialist welcomed. If interested, please call Dr. Sanford Proner at MEDICAL OFFICE BUILDING FOR SALE OR LEASE LOCATION: Pelham Parkway 4000 sq. ft. / 2 levels Can be used as 1 or 2 suite area If interested, call Dr. Melnick at OFFICE FOR RENT Fully furnished. Pelham Parkway area, near Einstein, Jacobi and public transportation. Ideal for social worker/psychologist. If interested, call Dr. Adam Lyn at MIPA Newsletter Contact Information CMO Connections is published quarterly by the CMO Provider Relations Department, 1 Executive Boulevard., 3rd Floor, Yonkers, New York CMOProviderRelations@montefiore.org