Provider Training Quality Enhancement 2016

Transcription

1 Provider Training Quality Enhancement

2 What s Ahead? Why Are We Here? 3 NCQA Accreditation & HEDIS 4-6 Medicare Start Rating & HEDIS 7 Provider s Role and Expectation 8-11 Staying Healthy During Pregnancy Breastfeeding 17 CHCUP Immunizations 23 Putting It All Together 24 Questions 25 Key Contacts 26 Thank You 27 2

3 Why Are We Here? Increase customer satisfaction. Our customer, being you, the provider, and our members. Assist our providers in gaining a better understanding on what we expect in providing the best quality of care to our members. Increase awareness on our various outreach initiatives. Maintain compliance with both state and federal regulations and accreditation standards. Monitor performance and help identify best practices for CHCUP, preventive care, early intervention services, staying healthy during pregnancy and immunizations. 3

4 Coming Up.HEDIS, Accreditation &Medicare Stars In the next couple of slides you should be able to identify the following: 1. What is HEDIS? 2. Who is NCQA? 3. Why are they important? 4. Why are Medicare Stars important? 5. What components comprise Medicare Star ratings? 4

5 What is HEDIS? The Healthcare Effectiveness Data and Information Set (HEDIS ) is a set of performance measures developed by the National Committee for Quality Assurance (NCQA). Used by more than 90 percent of health plans to assess important aspects of care and service provided to members. Allows consumers to compare the performance of health plans on an applesto-apples basis. HEDIS results used to identify where to focus quality improvement efforts. Measures include acute care, preventive care, chronic care measures and member experience (satisfaction). HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). 5

6 NCQA Accreditation and HEDIS NCQA is a health care accreditation organization that supports quality improvement and value for health plans and providers. NCQA uses HEDIS results to accredit and rate health plans annually. NCQA Accreditation is a requirement for most States. HEDIS rates account for about one half of the NCQA accreditation score. 6

7 Medicare Star Ratings and HEDIS Medicare beneficiaries have the option to choose their own Medicare health plan. CMS Medicare Star Ratings help beneficiaries compare quality among health plans. (1= worst to 5=best). Five domains Staying Healthy: Screenings, Tests and Vaccines Managing Chronic Conditions Member Experience with Health Plan Member Complaints, Problems Getting Services, & Improvement Health Plan Customer Service HEDIS contributes to 30% of the Star Ratings score. 7

8 Next Up! Doctors Roles and Expectations The next two slides will talk about what Molina expectations are for our contracted physicians and their vital role in achieving the best quality of care to our members. Key Points are: 1. HEDIS and Timely record retrieval. 2. Preventive Care and CHCUPS 3. How our providers will receive feedback. 8

9 Provider s Role and Expectations Well visit vs. Sick visit. Missed opportunities School based physical exam. Use the appropriate forms (such as AHCA forms, EMR) Perform the appropriate screenings according to the CHCUP periodicity schedule that ensures that children have a health screening on a routine basis. Member outreach (via phone and mailing reminders) Increase CHCUP scores to meet the AHCA 80% goal. Timely Encounter / Claims submission. Correct coding and documentation. 9

10 Provider s Role and Expectations cont. As a Provider you play a central role in promoting the health of our members You and your office staff can help facilitate the HEDIS process by: Providing the appropriate care within the designated timeframes Accurately documenting all care in the patient s medical record Accurately coding all claims Timely submissions of encounters: Providers must submit all professional, institutional, dental, RX encounters on a TIMELY BASIS. We monitor encounter data submissions for timeliness, accuracy and volume Plans are held to stringent guidelines for submitting encounter data to AHCA (within 7 days of adjudicating a claim) Finally, by responding to our requests for medical records within 5 business days HEDIS is reported collectively for each plan, not by provider or member. 10

11 Provider Feedback Providers receive benchmark data and feedback in respect to their performance through: Provider Engagements Benchmarks Current and Past Rates Identify Barriers to Service Medical Record Review Outcomes Provider Services Feedback Report Cards for: CHCUP HEDIS Missing Service Reports 11

12 Now Featuring Healthy Pregnancy Here is a short introduction on tips for a healthy pregnancy 12

13 Staying Healthy During Pregnancy 13

14 Nutritional Requirements 14

15 Exercising During Pregnancy Exercising during pregnancy can provide benefits for you and your unborn child. Below are a few tips to keep while exercising: Wear comfortable clothing and support your breasts Stretch before and after Pace yourself and start slowly and stop if you feel tired or too warm Avoiding jumping exercises and exercises on your back Stay away from hot tubs and saunas (especially during the first trimester) 15

16 After having a beautiful baby, there are a few factors to consider such as: Breastfeeding, Regular and frequent Well Visits for your child Maintaining immunizations. The next few slides will provide more information that providers and members will find useful. 16

17 Breastfeeding Important in mother baby bonding through skin to skin contact Cost effective Reduces health problems for mothers Type 2 Diabetes Breast Cancer Ovarian Cancer Postpartum Depression Breast milk contains all of the necessary nutrients Recommended for the first 12 months Helps baby fight off infections 17

18 Child Health Check up (CHCUP) Health screening evaluation that shall consist of: Comprehensive health and developmental history (including assessment of past medical history, developmental history and behavioral health status) Comprehensive physical examination Developmental assessment & nutritional assessment Appropriate immunizations according to the appropriate Recommended Childhood Immunization Schedule for the United States (Florida shot registry) Laboratory testing (including blood lead testing) Health education (including anticipatory guidance) Dental screening (including a direct referral to a dentist for enrollees beginning at age three or earlier as indicated, sealants and complete oral evaluation) goal 28% Vision screening, including objective testing as required Hearing screening, including objective testing as required; diagnosis and treatment Referral and follow-up as appropriate 18

19 Child Health Check Up (CHCUP) Definitions: Screening Ratio - This ratio indicates the extent to which CHCUP eligible receive the number of initial and periodic screening services required by the state's periodicity schedule. Participation Ratio This ratio indicates the extent to which eligible are receiving any initial and periodic screening services during the year. Health plans must reach 80% for screening and participation rate. 19

20 Screening and diagnostic services to determine physical or mental defects in recipients under age 21 Health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered. CHCUP screenings must includes periodic comprehensive child health assessments: examinations and evaluations of the general physical mental health growth development, and nutritional status of infants, children, and youth. CHCUP Records As a minimum, these screenings must include, but are not limited to: comprehensive health and developmental history, comprehensive unclothed physical examination, appropriate vision testing, appropriate hearing testing appropriate laboratory tests, dental screening services furnished by direct referral to a dentist for children beginning at 3 years of age. Screening services must be provided in accordance with reasonable standards of medical and dental practice 20

21 CHCUP: What we are currently doing Ongoing record reviews at the Providers offices. Mailing reminders/postcards and follow-up calls to members whose CHCUP screening and preventive screenings are due. Member outreach calls by Quality Improvement staff to identify barriers and remind members of due services. Health and wellness newsletter are sent that focuses on preventative care during the Spring and Fall seasons to both members and providers. PIPs (Performance Improvement Project) on CHCUP. A Service Due Reminder Report are sent to providers 3 months prior to screening due dates for their members. Provider training to promote proper nutrition, breast-feeding, immunizations, CHUCUP and preventative care and early intervention services. 21

22 CHCUP! Fact Check CHCUP is a lot of information, so let s do a quick check on what we covered. 1. Preventive screening is key! Molina must meet 80% rate for screening and prevention. 2. Screenings must be comprehensive (developmental, nutrition, growth, mental). 3. Members must be under 21 years old. 22

23 Immunizations Immunizations are a key factor in maintaining a healthy child. Below are the required vaccinations for our childhood population. Administering these vaccines on a timely basis is essential in Molina quality standard of care. Childhood immunization (2 years)- HEDIS Combination 2 and 3 DTaP IPV MMR HEP B VZV PCV ADOLESCENTS(13 YEARS) Meningococcal Tdap/TD Reminder- Register with Vaccine for Children ( VFC) program and submit data to Florida Shots. 23

24 Putting It All Together What we learned: 1. What is HEDIS? 2. Why is NCQA vital to Quality Improvement? 3. Why the provider role is one of the most important roles in providing effective quality care? 4. Why is staying healthy during pregnancy important? 5. Benefits of breastfeeding 6. Why should we vaccinate our members? 7. What is CHCUP? And Molina s role in CHCUP? 24

25 Questions 25

26 Key Contacts Chief Medical Officer Director of UM Director of QI Director of Provider Relations Director of HealthCare Services Vice President of Healthcare Services Dr. Mark Bloom Jorge Garcia Sandra Brower Lissette Martinez Bonnie Blitz Jeffrey King You may reach us at:

27 Thank You! 27