The Point THIS ISSUE: Newsletter for Martin s Point Health Care Network Providers

Transcription

1 The Point Newsletter for Martin s Point Health Care Network Providers F A L L 2016 THIS ISSUE: Increase Revenue and RVUs with a Comprehensive Visit...1 Preventing Falls in Older Adults...2 Update Your Info with Provider DataPoint...2 Authorization Process...3 Claims Update: Auxiliary Services Payment Policy...4 Understanding the Donut Hole....5 Annual Updates....6 BP Measurement Getting it Right!...9 Medicare s Annual Wellness Visit Once per CALENDAR YEAR!... 9 Is It Covered? Find Out First! We ve Moved Our Website!...10 Chlamydia and Gonorrhea Screening Recommendations...11 Provider Remittances...11 Please visit for more information on the topics covered in this newsletter and to review the Martin s Point provider manual. You may also call with any questions or to request paper copies of any of the information on our website.

2 Increase Your Revenue and RVUs with a Comprehensive Visit Martin s Point encourages our Generations Advantage members to receive both their annual Medicare Wellness Visit and an Annual Physical Exam each year. While Original Medicare only covers the Wellness Visit, Generations Advantage covers both at a $0 copay! These preventive visits are important because they serve as the primary platform for the annual assessment and documentation of each member s health. This year we are encouraging our members to schedule these two services back-to-back in one longer appointment that we call a Comprehensive Visit. This will provide you more time to examine and develop health goals with your patient and to document the visit. We are offering our Generations Advantage network providers additional support for this effort in two ways: 1) For this combined visit, we will pay for both the Medicare Wellness Visit CPT code AND a Physical Exam CPT code 2) For each patient with applicable chronic conditions, we will pay an additional $100 for the completion of a very simple Comprehensive Visit Form with corresponding documentation Here are three examples of different visit types, showing how a Comprehensive Visit can help you can get MORE REVENUE and RVUs out of 45 minutes of your time AND improve patient experience! Visit Type Total Time with PT(s) Revenue per Visit/ Total RVUs per Visit/Total Revenue per 15 Min. Slot Revenue per 45 Min. Example 1: 3 Acute Visits (15 min. each) 15 min x3 =45 min. $95.72/ $ /8.1 $95.72 $ Example 2: Example 3: 1 Preventive Visit (Original Medicare) 1 Generations Advantage Comprehensive Visit (AWV+ PE) 45 min. $ $42.03 $ min. $ $ $ Visit Billing Codes Medicare Annual Wellness Visit First Visit: G0438, Subsequent Visit(s): G0439 Annual Physical Examination First Visit: 99387, Subsequent Visit(s): If you have questions about the Comprehensive Visit program or would like to learn more about the process for submitting post-visit documentation, please contact us at or send an to Network.Management@martinspoint.org. 2

3 Preventing Falls in Older Adults Approximately one in three older adults falls each year, and the personal and financial toll of these falls is high. Falls and fear of falling contribute to social isolation, disability, and premature death in older adults. The direct medical costs for fall-related injuries total more than $34 billion annually. Falls, however, are not a natural part of the aging process and there are many evidence-based interventions that can reduce the risk of falls in older adults. The CDC s Stopping Elderly Accidents, Deaths & Injuries Program (STEADI) recommends that providers focus on addressing modifiable risk factors for falling including: Lower body weakness Difficulties with gait and balance Use of psychoactive medications Postural dizziness Poor vision Problems with shoes or feet Home hazards Patients are often reluctant to report falls to their health care providers. Proactively asking about fall history and discussing risk factors and how to minimize them is important. If you or your patients have questions about benefits related to reducing fall risk, such as physical or occupational therapy and mobility aids, or are interested in learning about communitybased fall prevention programs, please contact Member Services by calling the number on the back of the member s health plan ID card. References: CDC, STEADI-Older Adult Fall Prevention El-Khoury, F et al (2013). The effect of fall prevention exercise programs on fall induced injuries in community dwelling older adults: systematic review and meta analysis of randomized controlled trials. BMJ 2013, 347:f6234. Available at: Patient Resources CDC: Home and Recreational Safety Available at: falls/adultfalls.html Update Your Info with Provider DataPoint Martin s Point introduces Provider DataPoint, our new web-based provider data management tool. Your use of Provider DataPoint helps us maintain accurate provider directories and process timely claim reimbursements! Reminder: We no longer accept updates and changes by . Please use Provider DataPoint to: 3 Change information about your practice (name, phone numbers, address, billing information, NPI, etc.) Add or delete a location to your already contracted practice/group Change information about a provider (name change, delete/add specialty, change a panel status, add languages, etc.) Add a provider to your practice/group (both credentialed and noncredentialed) Terminate a provider from your practice/ group Check the status of a previously submitted data change request To access Provider DataPoint, go to: martinspoint.org/ Tools/Update-Your-Info If you have questions, see the instructions on our website or speak to your provider representative.

4 Authorization Process Prior Authorizations: Tips for Timely Response To ensure our members are able to get the services they need when they need them, it is important for us to be able to provide accurate and timely processing of your Prior Authorization requests. We want to partner with you to ensure this process is as smooth as possible. Below are some tips to help! 1. Make sure a Prior Authorization is required. Before taking the time to complete a Prior Authorization request, please confirm that an authorization is needed. To see if a prior authorization is required, use the following link: martinspoint.org/ Tools/Preauthorizations 2. Make sure to use our updated Prior Authorization form. You can find it at: martinspoint.org/tools/preauthorizations 3. Make sure the information you provide is legible, clear, and complete. We are unable to process the request without all of the required information. Make sure to include: CPT and ICD-10 codes NPI numbers Service Provider or Facility Begin date of services Once we receive all of the required information, we will be able to begin processing your request. Our turnaround times are listed below: Number of visits requested, if applicable Type of Request Generations Advantage US Family Health Plan Nonurgent Urgent 14 calendar days from the date/time of receipt of the request No longer than 72 hours from time of receipt of the request, depending upon medical exigency Retroactive N/A 30 days from the date/time of the receipt of the request 4

5 Claims Update: Auxiliary Services Payment Policy Martin s Point Generations Advantage and the US Family Health Plan will cover auxiliary services only if the primary service has met medical necessity and is a covered benefit. We have defined auxiliary services as any procedure that is performed as the result of the performance of a primary procedure. Examples would include medical supplies, anesthesia, and lab work. Auxiliary services may exist on the primary procedures claim or on another claim from a different provider on the same day. Liability to the member for auxiliary services will depend on the following: Denied Authorization (prior to service being performed): Auxiliary Services Denied: The Martin s Point Health Management Department will indicate in the determination that auxiliary services are not covered. If the authorization indicates they are not covered, all auxiliary services will default to member responsibility. Auxiliary Services Not Denied: If the auxiliary services are not mentioned in the authorization, the auxiliary services will default to provider liability. Denied Authorization (after the service is performed): The auxiliary services will default to provider liability. Local Coverage Determination (LCD)/ National Coverage Determination (NCD) Denials: Local Coverage Determinations and National Coverage Determinations are Medicare policies which determine coverage criteria of a procedure within a specific carrier region or for all regions of Medicare. Martin s Point may or may not require authorization for these procedures; it is the provider s responsibility to assure that any procedure performed meets the coverage criteria of these Medicare policies. If a service is performed that doesn t meet these criteria, it will be denied regardless of whether Martin s Point requires authorization. It is the provider s responsibility to request an authorization for coverage of the procedure and auxiliary services prior to the service being performed (see liability guidelines above). Exclusions: Auxiliary services will be covered in the following situations Multiple Surgeries Performed: If multiple surgeries are performed on the same day by the same provider and one of the surgeries is covered, auxiliary services not related to the denied surgery will be covered. Office Visits: Office visits, if determined to be unrelated to the procedure. Dispute Process: If the provider submits medical documentation that proves the auxiliary service is unrelated to the primary procedure, the documentation will be subject to Coder and Health Management Department review. If the service is determined to be unrelated to the primary procedure, the claim will be adjusted for payment. 5

6 PHASE 1: Initial Coverage The DONUT HOLE Understanding the Donut Hole The Coverage Gap (sometimes called the donut hole ) refers to a period in the Medicare Part D prescription drug coverage when Medicare patients are responsible for paying more for medications. The Coverage Gap was created by the federal government and went into effect January 1, 2006, at the same time as Medicare prescription drug coverage (Part D). The amounts shown are for They can change each year. PATIENT PLAN Each time a patient fills a prescription for PAYS PAYS a drug that is covered on the formulary (drug list), they pay a COPAYMENT. The plan pays the balance. If PATIENT OTHERS In this phase, PAYS PAY the patient pays a LARGER share of the cost of drugs. Instead of paying a COPAYMENT, they pay a PERCENTAGE of the cost. In 2016 they pay 45% of the cost of brand name drugs (plus a portion of the dispensing fee) and 58% of the price for generic drugs. If PHASE 3: Catastrophic Coverage PATIENT PAYS Total $$ Patient Pays +Total $$ Plan Pays $3,310 PHASE 2: Coverage Gap1 Total $$ Patient Paid in Phase 1 Total $$ Patient Paid in Phase 2 + Total $$ Paid By Drug Manufacturers 2 $4,850 they move into PLAN PAYS Then they move into The DONUT HOLE Then In this phase, the patient pays a SMALLER share of costs. Patient's cost for each prescription is the GREATER of: $2.95 for Generics $7.40 for Brand Name or 5% of Total Cost This phase continues until the end of the year. On January 1, the process begins again and they start back in the Initial Coverage phase. 1 Member cost shares in the Coverage Gap may vary by plan. 2 The drug manufacturer pays 50% of the total cost of brand name medications. 6

7 Annual Updates Martin s Point strives to ensure our members and our network providers are well informed about our health plans. We update our website periodically to provide useful information and tools. Recent updates are listed below: 7 Topic Health Management Registered nurses, social workers, and pharmacists are available to partner with you in the care of your patient by providing case management, disease management, health coaching, and medication adherence support. Clinical Guidelines Clinical guidelines offer an evidence-based framework to assist providers and patients in the diagnosis and treatment of common diseases and conditions. Martin s Point selects and utilizes national clinical guidelines and benchmarks based on: 1) population health needs and care standards in the communities we serve, 2) Healthcare Effectiveness Data and Information Set (HEDIS ) results, and 3) health care quality initiatives and programs. Utilization Management (UM) The UM team is committed to ensuring that patients receive appropriate care for their medical condition(s). UM decisions are based on criteria designed to meet the needs of patients based on their individual medical condition(s). UM decisions are based only on appropriateness of care and existence of coverage. All nurse reviews follow these criteria and there are no incentives (financial or other) to deny care. Evidence of Coverage Document Martin s Point ensures all new and existing members receive communication regarding their rights and responsibilities in their annual Evidence of Coverage document. For more information martinspoint.org/resources/ Health-Management If you have questions, would like to refer a member, or would like additional information, please call us at martinspoint.org/resources/ Health-Management If you have questions or would like a copy of these guidelines, please call us at martinspoint.org/provider- Manual/PreAuthorization Please call us toll-free at , Monday through Friday, 8 am 5 pm EST, to speak with a UM reviewer. UM staff are also available to receive inbound communications regarding UM issues after normal business hours via fax at martinspoint.org/ Tools/Pharmacy For preauthorizations or other questions related to pharmacy benefits, please call us at

8 Topic Martin s Point Quality Management Program (QMP) The QMP provides the structure and formal processes to systematically monitor and evaluate the quality, appropriateness, efficiency, safety, and effectiveness of care and service. Martin s Point adopted the Institute for Healthcare Improvement s (IHI) Triple Aim as our quality framework. The Triple Aim is an approach to optimize health system performance by simultaneously pursuing three dimensions: Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per-capita cost of health care Credentialing The Martin s Point Credentialing team (or its designated qualified agent) reviews facility and provider documentation to determine eligibility for participation in our health plan network. Martin s Point recognizes the provider s right to: Review information submitted in support of their credentialing/recredentialing application (to the extent permitted by law) Correct erroneous information Receive the status of their credentialing/recredentialing application upon request (via phone or mail) Review their credentialing file by scheduling an appointment (via phone or mail) Behavioral Health Martin s Point has partnered with Maine Health and its Behavioral Health Care Program (BHCP) to provide integrated behavioral health services to our members. Our goal is to connect patients with behavioral health professionals who can help make the important connections between their emotional and physical well-being. BHCP is available to members 24 hours a day, seven days a week, for triage and referral, through a toll-free telephone line. US Family Health Plan Members: Generations Advantage Members: For more information martinspoint.org/resources/ Quality-and-Compliance A summary report on progress in meeting quality -improvement goals is available to providers upon request. Please call or us at: quality@martinspoint.org. martinspoint.org/provider- Manual/Credentialing Providers may contact us at: ProviderCred@ martinspoint.org Phone: or Fax: Martin s Point Health Care Attn: Credentialing Department PO Box 9746 Portland, ME Behavioral health providers and facilities may be found at: Providers-and-Pharmacies Benefit coverage requires preauthorization for all services. For more information, please call:

9 Topic Member Experience Martin s Point values and uses all feedback received from our network providers and our members in our improvement efforts. Martin s Point utilizes the Healthcare Effectiveness Data and Information Set (HEDIS ), Consumer Assessment of Health Care Providers and Systems (CAHPS ), and, for Medicare members, the Health Outcomes Survey (HOS) results, along with other data, to evaluate and drive our efforts to provide among the best health plans in the nation. An important part of our job is making sure our health plan members have appropriate access to: Regular and routine care appointments Urgent care appointments After-hours services Member Services telephone service Behavioral health care services We regularly measure our performance in these areas by looking at survey results, member complaints and grievances, and member services telephone records. If we identify any issues with access to specific practitioners, groups, or services, we work to immediately address the issues, and we make site visits as appropriate. We also continually measure the geographic distribution of our members to determine how effectively our provider network meets their needs (as outlined by TRICARE, CMS, and the Maine Bureau of Insurance regulations). Using GeoNetworks software, we routinely generate reports to identify opportunities for network enhancement. Formularies Our health plan formularies are frequently updated to keep pace with new clinical data and evolving drug classes. Our goal is to maintain a clinically sound, broad formulary to help drive generic utilization to reduce pharmacy costs for your patients. We distribute revised formularies to our members on an annual basis and will inform members and providers when changes are made. For more information martinspoint.org/ Provider-Manual If you have questions or would like more detail about these reports, please contact our Provider Inquiry team at These reports will be made available to providers upon request martinspoint.org/ Tools/Pharmacy For preauthorizations or other questions related to pharmacy benefits, please call us at Please visit our website, for a complete list of annual updates on programs such as: Health Management Services for Your Patients, Clinical Guidelines, Utilization Management, Member Rights and Responsibilities, Quality Program, Office Site Standards and Performance Thresholds, Member Access and Network Geography, Credentialing, and Behavioral Health.

10 Blood Pressure Measurement Getting it Right! Though measuring blood pressure is among the most common practitioner activities, getting accurate measures in clinical settings can be challenging. Barriers include: 1) incorrect technique, 2) natural blood pressure variability, and 3) the so-called white coat effect. Regardless of the device used, some simple steps can improve accuracy: Ensure the patient is prepared. Ask if they need to use the bathroom. Confirm no nicotine, caffeine, alcohol, or vigorous exercise in the past minutes. The patient should sit comfortably with legs uncrossed and back and arm support, relaxing for five minutes. Place the cuff on bare skin 1 above the antecubital fossa with the midline of the bladder over the brachial artery (cuff should be at mid-sternum level). Ask the patient not to speak or move while you inflate and deflate the cuff. Follow best practices: Have cuffs that fit your patients. Use validated monitors and avoid finger/wrist devices. Extensive evidence suggests that, for hypertensive patients, measurements taken in a medical setting are consistently higher than those with 24-hour ambulatory monitors. Note the tendency toward terminal digit bias when recording values. References: Ogedegbe, G & Pickering, T. (2010). Principles and techniques of blood pressure measurement. Cardiology Clinics 28(4): Available at: Pickering, T. et al (2005). Recommendations for blood pressure measurement in humans and experimental animals, Part 1. Hypertension 45: Available at: Patient Resources: American Heart Association. Available at: HighBloodPressure/High-Blood-Pressure_UCM_002020_SubHomePage.jsp Medicare s Annual Wellness Visit Once per CALENDAR YEAR! Generations Advantage plan benefits DO NOT follow Original Medicare s rule which limits the ability of a beneficiary to obtain preventive care to a rolling 12-month period. In contrast, Generations Advantage members can receive their Annual Wellness Visits once per calendar year. For example, a Generations Advantage member can have their Annual Wellness Visit in December of one year and schedule their next visit for March of the following year! See the Comprehensive Visit article in this issue of The Point to learn how you can increase your revenue by scheduling your Generations Advantage patients for their Annual Wellness Visit together with their annual physical. That s a win-win for your patients and your practice! 10

11 Is It Covered? Find Out First! Routine Foot Care (including Nail Trimming) Coverage for routine foot care trimming nails, removing calluses, and other hygienic and preventive maintenance care is limited by diagnosis. Martin s Point will only cover routine foot care when there is a secondary diagnosis that would justify the coverage. For more information, please call Provider Inquiry at Genetic Testing Martin s Point requires prior authorization and medical review for genetic testing. To ensure the best experience for your patients, please call the Plan for this authorization before the labs are drawn. References MLN on Routine Foot Care: Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/medicarepodiatryservicesse_factsheet.pdf We ve Moved! We recently moved our For Providers web content to a new address: If you bookmarked any pages on the old site, those links will automatically redirect you to the new pages, but you may want to update your bookmarks when it s convenient. Please visit when you have a moment! 11

12 Chlamydia and Gonorrhea: Have the Conversation Two years ago the US Preventive Services Task Force (USPSTF) issued a final recommendation statement on screening for chlamydia and gonorrhea. The USPSTF states: 1. Sexually active women age 24 years and younger should be screened for chlamydia and gonorrhea. Women older than 24 years who are at increased risk for these infections also should be screened. 2. There is not enough evidence to determine the potential benefits and harms of screening men for chlamydia and gonorrhea. Are you discussing these sexually transmitted infections with your US Family Health Plan patients who meet these criteria? For more information, please visit Provider Remittances Please Save All for Your Files! Please save all of your remits received from Martin s Point, including remits that do not have a check attached. Requests for Remittance Advice Martin s Point generally sends remits weekly for claims processed since the last remit. If you have had an extenuating circumstance causing you to no longer have access to your remit, please call Provider Inquiry at for a new remit. Requests will not be accepted if the remit was generated fewer than 30 days ago or is older than one year. Provider Portal Did you know you can view claims status on our Provider Portal? This includes line item payment and denial details, the remittance date, and the check number, if one was included. This information is also available on the portal if no check accompanied the remit. Please visit the Provider Portal at: martinspoint.org/ If you have not registered for the portal, please contact Provider Inquiry at Important Reminder: If you use a third party for billing and following up on claim status, please forward your Martin s Point remits to them. Access to these remits creates efficiencies in making adjustments to accounts as needed, as well as keeping in line with the Martin s Point remittance request guidelines. 12