GLMS UHC IIRC Thursday, December 10, 2015 GLMS/First Floor Boardroom 7:30AM

Transcription

1 GLMS UHC IIRC Thursday, December 10, 2015 GLMS/First Floor Boardroom 7:30AM Committee Members in Attendance in Bold Brian Sosnin, DO UHC IIRC Chair Julie Daftari, MD UHC KY Medical Director Billy McCord UnitedHealthcare Network Physician Management Molly Mills-Kidd UnitedHealthcare Provider Advocate Cathy Owens UHC Physician Network Contractor Tess Wheeler LCKMGMA Representative, All Women OB/GYN GLMS Senior Advocacy Specialist Natalie Mesbah GLMS Administrative Assistant, PEPS Department SUMMARY Action Steps 8:46 WELCOME AND INTRODUCTION 22:12 9:31 22:30 26:22 Review September UHC IIRC Meeting Summary Dr. Sosnin requested the committee members review the September minutes from the last IIRC meeting. Dr. Sosnin made a motion to approve the September summary and the motion was granted. Old Business asked Molly Mills-Kidd for an update on three outstanding hassles. Recoupments are occurring after serum are prepared and sent with the patient and when a subsequent injection claim is not received for that patient. Molly informed Stephanie that she has been working with a team on the allergy injection recoupment hassles and will keep GLMS informed of those decisions. Molly is also awaiting a response to her request to update a prior authorization on the last hassle and will inform GLMS once that has been resolved. The committee continued to discuss the circumstances of the issues and Dr. Sosnin moved to end the discussion and have it brought back up to the UHC IIRC if more issues stem from these hassles. The committee discussed previous action steps that have been completed. Dr. Daftari answered a question from the last meeting of whether copays should be changed for OB/GYNs to reflect that of primary care instead of specialist, since UHC Premium Designation Program documentation classified them as primary care. The answer is if the visit is simply to see a doctor, it is a primary care visit and the copay should reflect that. Cathy Owens raised the point that UHC loads the OB/GYNs as specialists in their system but Dr. Daftari countered that the information she found stated OB/GYNs would take the same copays as family physicians, internists, and pediatricians. Dr. Daftari provided an example of how to read a member s benefit card. Stephanie stated she would forward that example to Tess Wheeler who raised the question at the last meeting Dr. Daftari addressed who is excluded from the PATH program. The PATH program will be comprised of UHC Medicare Advantage Primary Care Physicians (family physicians, general internists, and geriatricians). Any one not providing primary care services would be excluded from the PATH program. Summary approved, no changes or revisions to example of member benefit card to Tess Wheeler. 27:11 Dr. Sosnin asked Stephanie if she was able to add new programs to the 1

2 GLMS Exchange Insurances spreadsheet. Stephanie confirmed that she was able to and posted the spreadsheet and card examples online at GLMS.Org. Stephanie informed the committee that some physicians may notice that they are not listed as a provider under a particular Exchange product and call GLMS to inquire. She wanted to prepare the UHC representatives present at the meeting that she may be contacting them regarding questions from providers. The UHC reps informed Stephanie that their Exchange product provider listing has not changed so she may not get any calls from providers about not being listed. 30:54 The committee then discussed the responses from the GLMS Multi-Payer Roundtable held on October 29, There was a question asked at the Roundtable that not every payer was able to answer at the time of the meeting. The question was about the new rule dictating how much time must pass between a pain patient s first epidural and their following epidurals. The patient must show at least 50% improvement from the first shot before receiving additional injections. Dr. Daftari stated that UHC s policy follows the LCDs that are published so there is not much that they can do about the policy. 53:39 Stephanie asked Dr. Daftari if she knew what the LCD specifically stated and Dr. Daftari paraphrased that evidence-based guidelines state that a patient should only receive one shot in a three month time period to allow time to show if there is a positive response to an injection and if within three months there has been a 50% improvement, then they can repeat it. She purported that if a patient is receiving three injections every two weeks, then that might be causing another problem for the patient. Dr. Daftari informed the committee that when UHC develops a policy, they provide the references used when developing the policy. UHC s guidelines and best practices are developed using multiple literary resources. The committee continued to discuss the Roundtable and the benefits of having the private payers meet with the physicians and medical practice personnel. UnitedHealthcare (UHC) Updates Network Bulletin Cathy Owens distributed to the committee the most important updates from the October, November, and December Network Bulletins. Below are some of the items that were discussed from those bulletins. Premium Designation Program Update UHC will not be publishing new results in January They have changed some of the methodology and needed more time to work the kinks out. UHC published results in January 2015 and new results will be released in January Counseling Requirement Effective January 01, 2016 In order to approve prior authorization requests for breast cancer (BRCA) testing, UHC requires members to receive genetic counseling first. The genetic counseling must be performed by an independent counselor, not affiliated with a genetic testing lab. Cathy performed a search and found one independent genetic counselor in Louisville that is also within UHC s network. asked who pays for the genetic counseling. Dr. Daftari said if there is an indication then the test is covered. Dr. Sosnin stated he would be interested in hearing how this new requirement is working out by the next UHC IIRC meeting. Dr. Sosnin also would like for Stephanie to send out an alert to GLMS physicians about this new policy. Dr. Sosnin would also like a brief summary of what steps a physician should take, from beginning to end, on ordering the genetic counseling and ensuring it is covered. Cathy Owens agreed to look into UHC s resources for that request. Dr. Sosnin is interested in an update on the Counseling Requirement by the next UHC IIRC meeting. to notify GLMS physicians about Counseling requirement. Cathy Owens to provide a step-bystep guide for physicians requesting 2

3 Preferred Insulin Update Effective January 01, 2016, Humulin and Humalog insulin will be the exclusive mealtime insulin products available for the lowest brand copay for all UnitedHealthcare Medicare Part D plan members. Apidra, Novolin, and Novolog will no longer be covered on the formulary. Dr. Sosnin asked if the pharmacies are allowed to switch the insulin brands if the physician wrote a prescription for an uncovered insulin, unaware that it was no longer covered. Dr. Daftari responded that they can substitute the generic of a drug but not change the brand; the physician has to do that. Dr. Daftari suggested that the physician just issue instructions for what type of insulin they want the patient to take without a specific brand and that would allow the pharmacy to choose a brand that is covered by the patient s insurance. Dr. Sosnin requested the committee find out if it is still ok for a physician to write the pharmacy a letter, giving permission for them to switch brands of prescription drugs if what the physician wrote was no longer covered by the patient s insurance or because of formulary changes. Dr. Daftari suggested checking with the State Pharmacy Board for that answer. Dr. Daftari informed the committee that UHC also sends informational letters to the patient when there is a formulary change and encourages the patient to speak to their doctor about the new drug. The letter is specific to the drug that is changing and the recommended drug. Dr. Sosnin stated a spreadsheet detailing formulary changes would be helpful and Dr. Daftari cautioned that self-funded plans are at the employer s discretion and Medicare Advantage plans would be the better plan to base the spreadsheet on. Stephanie said it is possible to do a spreadsheet with links to the formularies. Dr. Sosnin asked that Stephanie also include links for the PA requirements. Medicare Made Clear UnitedHealthcare developed a new website called Medicare Made Clear. It is an informational website that is available to members for assistance during Medicare Advantage s Open Enrollment period. The site should also be available to members next year. Preparing for the Individual Exchange Open Enrollment Period UnitedHealthcare has prepared an informational article for physicians to give to their staff. The article details how the practice staff can answer questions about the physician s participation in health plans when a patient calls to ask. Patients who are unsure if their provider is a participant in their newly chosen health plan can also find out by consulting UnitedHealthcareOnline.com>Physician Directory> General Directory. Use Your Optum ID to Sign in to UnitedHealthcareOnline.com and Link Link will be replacing Optum Cloud Dashboard. It is a new program that will allow users to customize their home-page. The same applications will be used but will provide a more enhanced service. The user will be notified through when they will have their Optum ID transition date and then after that, they can use their Optum ID on both sites. UHC Commercial Reimbursement Policies: Revision to Maximum Frequency per Day for Codes Assigned MAI of 2 Effective first quarter 2016, the Maximum Frequency per Day (MFD) Policy will be revised to align with the Centers for Medicare and Medicaid Services (CMS) Medically Unlikely Edit (MUE) adjudication indicator (MAI) for procedure codes assigned a MAI of 2. This indicator is used by CMS to Counseling. UHC IIRC to contact the State Pharmacy Board to investigate if generic permission letters are acceptable. to create a spreadsheet of links to formularies. 3

4 1:36:47 identify Current Procedure Coding System (HCPCS) codes where units of service on the same date of service in excess of the MUE value would be considered contrary to code description or instruction, statute, regulation or sub-regulatory guidance. Units in excess of the MFD value will not be reimbursed for CPT/HCPCS codes assigned an MAI of 2. Consistent with CMS guidelines, no modifier override will be allowed nor will the MFD value be overridden by submitting documentation for adjustment requests. UnitedHealthcare Children s Foundation If there is a child who would benefit from a grant to help pay medical expenses, they can be referred to the UnitedHealthcare Children s Foundation. These awards are medical grants to help children gain access to health-related services not covered, or not fully covered, by their family s commercial health insurance plan. This grant is not limited to UHC patients. The only requirement is that they have coverage through a commercial health plan. New Coding for Intra-Uterine Devices Effective Jan. 1, 2016; HCPCS Code J7302 Deleted As of January 01, 2016, code J7302 will no longer be valid. Code J7297 will be used for Liletta and J7298 will be used for Mirena. There will not be a price decrease. Revision to Place of Service 22 and New Place of Service 19 CMS has developed a new place of service (POS) 19 as well as revising the description of POS 22. POS 19 is used for off-campus outpatient hospital services and POS 22 is used for on-campus outpatient hospital services. An off-campus outpatient hospital is a portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic, and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. An on-campus outpatient hospital is a portion of a hospital s main campus which provides a diagnostic, therapeutic, and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. The Multiple Procedure Payment Reduction Reimbursement Policies for Endoscopy and the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures has been delayed until March 01, New Medicare Advantage Referral Required Plans Effective January 01, 2016, UHC is introducing individual Medicare Advantage Plans that require a referral to specialists. There will be a Member ID card that specifies the referral plan given to members for ease in identifying this requirement. The card states Referral required. Important Change to Our Network of DME Providers Genadyne will no longer be a participating supplier/provider for negative pressure wound vac therapy, support surfaces and breast pumps in the UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions, and UnitedHealthcare Community Plan, effective December 31, In addition, Target will no longer be a participating supplier for breast pumps in the UnitedHealthcare DME network for UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions, and UnitedHealthcare Community Plan, effective December 31, New Business The committee agreed that there was no new business to discuss. 4

5 1:37:49 The next meeting will be Thursday, March 24, 2016, at 7:30am in the 1 st floor Board Room at GLMS. All committee members confirmed the date and were sent a calendar invitation. 1:41:08 Adjourn Addendum: On Monday, January 25, 2016, Cathy Owens provided clarification on genetic testing. You may recall we were all unsure about who orders the prior auth, who orders the test, etc. Attached is the form required to order the prior authorization. The best information that I can get is that the provider who believes genetic testing is warranted (the referring provider) would complete the top of the form and then forward it to the genetics counselor, who would complete their part and return it back to the referring provider, who would then call or fax to get the prior authorization. The BRCA test as well as screening and counseling will be covered without cost-share by most plans for women age 18 years of age and older with a family history of ovarian and/or breast cancer and who do not have a personal history or current diagnosis of ovarian and/or breast cancer. You can find this form and get more information on the policy at Clinician Resources>Oncology>BRCA testing. 5