How to support your provider with patient care

Transcription

1 Staff Newsletter #15 Telephone Access Standards Page 4 HIPAA Case File Page 5 Cultural Corner: Caring for Adolescent Patients Page 7 Summer 2012 How to support your provider with patient care In today s busy practices it s important to find ways to help support your provider with patient care. How? Use IEHP s online provider alerts. When you check these alerts daily and share them with your provider, you help improve patient care, allowing providers to better respond to IEHP patient needs. By logging on to the IEHP secure Provider Website, you can view all five of these Provider Alerts: Nurse Advice Line Alert Members who have called the IEHP 24-hour Nurse Advice Line in the past five days. The alert includes the date of the call, reason for the call and what medical advice and instructions were given. Behavioral Health Specialist Alert Members who have seen a behavioral health specialist in the past 30 days and which members have agreed to share this information with their PCP to help coordinate care. 3 Hospital/ER Services Alert Members who may have accessed a hospital or emergency room in the past five days, including the date of service and name of the hospital. Continued on Page 2

2 NEW How to use the online P4P form for IEHP Medicare DualChoice Members In February 2012, IEHP rolled out the new online P4P form for IEHP Medicare DualChoice members. For annual physical exam visits, IEHP will continue to pay $300 per visit. This form was developed to meet many HEDIS required elements. With your use of the form, we aim to decrease medical record reviews from your office during HEDIS chart collecting. If you handle the billing for your provider, here are some tips to help you submit a complete P4P form: Print out the P4P form before the patient comes into the exam room; the form contains information specific to each patient Remind your provider to fully complete the P4P form Verify that all ICD-9 codes are documented on the patient s medical record and the P4P form Better care from page 1 4 Care Plan Alert Members (seniors and people with disabilities, adult day healthcare recipients and Medicare DualChoice members) who have care plans, which are based on Health Risk Assessment (HRA) surveys developed by IEHP. The surveys are a self-assessment of the member s medical and behavioral needs. To view an example of a care plan go to the Secure Provider Website. 5 Print out these care plans and add them to the patient s medical record. Medicare DualChoice Annual Visit Alerts Members who are due for a DualChoice Annual Visit. You must use the new form in order to be reimbursed. 1. Log on to the Secure Provider Site 1. Navigate to the P4P screen 2. Click on the P4P entry link 3. Click on the DualChoice annual visit link Since the new form was introduced, there has been an increase in member diagnoses submitted. IEHP appreciates your commitment to supporting your providers. You make a difference. 2 (909)

3 This Summer Be Prepared with First Aid Kits While on a road trip, a woman felt intense pain in her neck, causing her to pull over to the side of the road. She quickly realized she had been stung by a bee, which was still buzzing about near the rear window where her child was sitting. She quickly let the window down so the bee could fly out and pulled the stinger out of her neck. Her neck was swollen and itchy. Accidents like this can happen anywhere, anytime. This summer, protect you (and your family) with a first aid kit you can carry with you as you travel to the beach, park or campsite. A first aid kit can help prevent infections, excessive blood loss or swelling. You can buy a first-aid kit or make your own by putting some basic items in a small plastic bag, tool kit or tote bag (be sure to keep it out of the reach of children). Top 10 Essentials for a First Aid Kit 1. Band-Aids in various sizes 2. Gauze pads/rolls and adhesive tape 3. Elastic bandage (ACE bandage) 4. Antibiotic ointment & hydrocortisone cream 5. Alcohol or alcohol wipes 6. Instant hot and cold packs 7. First-aid booklet 8. Over-the-counter pain reliever 9. Antihistamine like Benadryl for allergic reactions Headache Reliever FIRST AID 10. Over-the-counter medications that relieve nausea or diarrhea Head Relie Headache Reliever Allergy Reliever Headache Reliever Once you put your kit together, recheck it every year for items that may need to be replaced. Antiseptic Ointment (909) Headac Relieve 3

4 Are you following the Claim Submission Requirements? NEW In May, IEHP began using its new submission requirements for processing claims. In February, your office should have received a set of laminated sample claim forms, highlighting the new requirements. If you submitted claims after May 1 that were denied, you may have forgotten to include the correct requirements. If you need help with using the guides or need more samples of required fields, call the Provider Relations Team at (909) The new claim submission requirements help: Expedite the handling of your claims Ensure data completeness Improve submission of encounter data to regulators Telephone Access Standards Although we live in an era where people communicate through multiple channels, such as text messaging and social media, members still rely on the telephone to reach their doctor. That s why you should ensure your phone system follows these standards (which come from Provider Policy 9A): Answer time All calls must be answered within six rings. An automated system may answer if it provides an option for members to speak to a live person. Hold time If you have to put callers on hold, tell them the reason for the delay and offer to let them wait or have the call returned. Avoid leaving a member on hold for more than five minutes. Non-urgent calls must be returned within three business days. Urgent but non-emergency calls must be returned the same day. You must attempt to return the member s call at least three times. After hours PCP access All IEHP PCPs and IPAs must provide 24/7 telephone access for members. The IEHP 24-Hour Nurse Advice Line cannot be used as an substitute for access to PCP after hours. Automated answer system All providers must have an after-hours answering system. Here s a suggestion for your automated message: Thank you for calling Dr. Xxx s office. Our office is currently closed. If this is a life-threatening emergency please hang up and dial or go to the nearest emergency room. If this is not a life-threatening emergency, you may leave a message after the tone and your call will be returned shortly. You may also call back during regular office hours [ provide your office hours ]. The IEHP 24-hour Nurse Advice Line is also available, at This number is on your IEHP Member ID Card. 4 (909)

5 HIPAA Case File HIPAA rules are now tougher and penalties steeper. To see how you can protect your practice from HIPAA violations, read on to see how one medical practice fell short in exercising good HIPAA practices. A small cardiac medical practice in Phoenix had a complaint filed against them, alleging that the practice was posting patient names and surgery appointments online. The practice responded to the complaint by saying that someone forgot to turn on their computer s software privacy settings. But this was more than a single mistake. When the Office of Civil Rights (OCR) investigated, it found a long history of non-compliance: On a daily basis, the practice sent ephi over the internet to their staff 's personal accounts. There was no documentation that showed office staff had received training on HIPAA policies, procedures and PHI. The practice lacked safeguards (administrative and technical) to protect the privacy of patients. As a result, the practice was fined $100,000, and issued a one year Corrective Action Plan. How can you help your practice avoid HIPAA violations? Create written office policies and procedures to address patient information and its release. Ensure each staff member receives HIPAA training when hired and attends a refresher course every year. Review your office layout to identify potential HIPAA hazards, such as a receptionist who can be overheard by patients in the waiting room; computer screens that can be seen by patients or charts left out in clear view. IEHP offers free on-site HIPAA training programs. Sign up today. Call the IEHP Compliance Department at Ask for Lori. (909)

6 IEHP Scrub of the Month Her eagerness to share her knowledge with co-workers and patients for the last three years has earned Elva Ramos the honor of Scrub of the Month. Working as the office manager for Dr. David Elva Ramos Lozano s primary care practice in Moreno Valley, Elva is like a jack- of- all trades, handling P4P, staff training and patient referrals. She also supports Dr. Lozano with documentation. Her passion to see co-workers grow in their jobs is appreciated in the office. Office staff members say Elva recognizes individuals who are doing a great job and kindly points out areas where improvement can be made. Sweet and responsible, Elva s dedication to the job has made a difference. Nominate a co-worker Do you work with a winner? A hard worker who brightens your office with kindness, inspiring your team to do its best? Tell us why: Write your reason why you think this person should be Scrub of the Month. Keep it under 500 words. If you give us the best reason, we ll give you and your co-worker a $50 Target gift card. Send your name, office location and work phone number. Fax, mail or your entry: Fax: (909) On cover sheet, write ScrubTalk - Scrub of the Month Nomination. Mail: IEHP ScrubTalk - Scrub of the Month Nomination, P.O. Box 19026, San Bernardino, CA providerservices@iehp.org Q. A. ASK Susie I am the office manager for an OB/GYN physician. Could you advise if we are obligated to provide CPSP (Comprehensive Perinatal Services Program) for IEHP members? CPSP ensures that Medi-Cal pregnant women receive extra care in the areas of nutrition, psychosocial and health education. These services reduce low birth weight rates of babies and health care costs for women and infants. All Medi-Cal IEHP members must be offered a CPSP risk assessment once during each trimester and at their postpartum visit. Once a risk assessment is completed, an Individual Care Plan (ICP) must be created based on the findings. Since a Perinatal Notification Outcome (PNO) is not a full risk assessment, it shouldn t be used as a substitution for the CPSP risk assessment. If your office refers members to a CPSP program for services, please remember, you must fully document in the member s medical record the referral and obtain the risk assessments and ICP to ensure appropriate care coordination. Ask Susie about IEHP procedures or programs: Call (909) Fax to Ask Susie at (909) providerservices@iehp.org 6 (909)

7 Cultural Corner Caring for Your Adolescent Patients Adolescents are a diverse and challenging group a culture unto themselves. They are at a vulnerable time in their lives no longer children, not yet adults. They are questioning beliefs that they have accepted at face value up until now as their values and sense of identity begin shifting away from family and toward their peers. It is not always easy to establish rapport with teens when they visit your office. It may be a challenge in some cases,but responding with sensitivity to young patients concerns can open doors to providing the important medical care and guidance they need. Here are some general guidelines to keep in mind: When greeting teens and their parents or guardians, acknowledge the teen first, whether through eye contact, a handshake, or a simple hello. This will show respect for the teen and enhance rapport. Take the teen s questions or comments seriously. Keep a positive attitude toward the teen, avoiding judgmental responses or responses that make light of their concerns ( when you grow up, you re too young to worry about that ). Avoid medical jargon. When asked, explain any procedure or test in simple terms that a teen can understand. Be attentive and empathic. If the teen seems anxious, show genuine concern to ease any fears he or she may have. Ask the teen if he or she prefers to have a parent present or not during the exam. Younger adolescents may feel more comfortable with a parent in the room, while older teens may want privacy to discuss more sensitive issues. However, never assume what the patient may want based on age. Always ask. To further make adolescents feel at home, provide age-appropriate materials in the waiting area as well as in the clinical office. Provide interest-based teen magazines (fashion, music, sports, etc.). Make educational materials available. Place brochures on topics such as puberty, STDs, sexuality, and contraception in the examination room (or waiting room, if appropriate). Or have materials on hand to distribute if the teen has questions. (909)

8 P.O. Box San Bernardino, CA Staff Newsletter 2012 Inland Empire Health Plan. All Rights Reserved. PS Information you should know IEHP P4P Web Site - To print copies of current P4P overviews, correspondence, forms, schedules and information below, go to Providers/P4Pprogram.htm Recommended Immunization Schedule Shows ages for routine administration of current licensed childhood vaccines for children up to 18 years old Recommended Preventive Pediatric Healthcare Details Well Child Screening Procedure and recommended age bands in which service should be performed Recommended Catch-Up Immunization Schedule Provides minimum intervals between doses for children whose vaccinations have been delayed Reimbursable PM160 Immunization Codes IEHP quick reference guide for reimbursable PM160 Immunizations and Rates Vaccine Reimbursement Schedule - Pays for IEHP members not enrolled in the Medi-Cal Program. Reimbursement Process: Submit a CMS1500 claim form with CPT code, quantity dispensed and billed amount to...iehp Claims Department P.O. Box 10129, San Bernardino, CA Provider Manuals available by lines of business: 2012 Healthy Families/Healthy Kids 2012 Medi-Cal 2012 Medicare DualChoice (HMO SNP) Please adhere to provisions in this manual. To visit this page, go to: http: //ww2.iehp.org/ IEHP/Providers/Information+Resources/ HandbooksandManuals/ProviderPNPManuals.htm IEHP Benefit Manuals - offered as guidelines to determine benefit eligibility not as a standard of medical care or as a contractual agreement for payment. Standards of medical care are determined on the basis of all facts and circumstances for each case. Benefit Manual Information - Subheadings Examples of Covered Benefits and Examples of Non-Covered Benefits give specific examples but are not meant to be all-inclusive list of examples, unless specified in text of benefit. *If a benefit question is not addressed in the Benefit Manual, contact the IEHP Provider Relations Team at (909) IEHP Provider Policy and Procedure Manual Rules and regulations that IEHP and its contracted Providers must comply with, as governed by these state agencies: The California Department of Health Care Services (DHCS) California Department of Managed Health Care (DMHC) California Managed Risk Medical Insurance Board (MRMIB) The Centers for Medicare and Medicaid Services (CMS) Moving Your Office? Please give the IEHP Provider Relations Team (and your IPA) a 60-day notice. Member notification is required by DHCS and DMHC. Your IEHP patients will be notified, so they can keep receiving their medical care. Questions? Ideas? Reach Your Provider Relations Team at (909) Fax: (909)