PROVIDER Tufts Health Plan Senior Care Options Tufts Medicare Preferred HMO NEWSLETTER DECEMBER 2016 Update Your Practice Information Providers are reminded to notify Tufts Health Plan of any changes to their contact or panel information, such as a change in their ability to accept new patients, a change of street address or phone number, or any other change that affects their availability to patients. For Tufts Health Plan to remain compliant with the CMS regulatory requirements, changes must be communicated in writing as soon as possible so that members have access to the most current information in the Provider Directory. How to Update Your Information You can check your current practice information by going to the Find a Doctor search at tuftshealthplan.com/provider. If that information is not correct, please update it as soon as possible by completing the Standardized Provider Information Change Form or Tufts Health Plan s Provider Information Change Form, available in the Provider Forms section of the Resource Center on Tufts Health Plan s public Provider website, and returning it by fax or mail as noted on the form. Medicare Annual Election Period Begins October 15* Now is the time to make sure your patients are in the right plan. Many people are unaware that Medicare alone covers only 80 percent of their health care costs with high deductibles and additional coinsurance. Financial concerns may prevent your patients from seeking care or may cause them to cancel appointments. Encourage your patients to consider joining one of our Medicare plans for more comprehensive coverage and predictable costs. Tufts Health Plan offers several high-quality health plans including: } Medicare Advantage (HMO) plans with monthly premiums as low as $0 including Part D prescription drug coverage } Senior Care Options plans** with $0 monthly premium and $0 cost share for medical services and prescription drugs } Medicare Supplement plans For additional questions or plan materials, contact } kathy_barniak@tufts-health.com, or } peter_lacombe@tufts-health.com. *Good news! Because Tufts Medicare Preferred HMO and Tufts Health Plan SCO plans received five out of five stars for 2016, your patients may not have to wait until January 1, 2017, to get better health coverage they may be eligible sooner. Tell your patients to call Tufts Health Plan at 800.867.2000 or visit thpmp.org. **For adults age 65 and over who are also eligible for MassHealth Standard Reminder: Tufts Health Plan Senior Care Options Annual Care Model Training Requirement The Centers for Medicare & Medicaid Services requires that Tufts Health Plan Senior Care Options (SCO) care model training be offered to providers upon provider enrollment and annually thereafter. Tufts Health Plan has developed an online educational training, which can be completed in approximately 30 minutes. Refer to the Training section of Tufts Health Plan s public Provider website to access the training: } Go to tuftshealthplan.com/provider. } Select Training Tufts Health Plan SCO Tufts Health Plan SCO Care Model (registration required). To document your participation, complete the evaluation survey at the end of the training and attest that you have reviewed the information. If you have any questions about the training or how to access the training, or to request an on-site training delivered by a Tufts Health Plan SCO clinical team member, please call Provider Relations at 800.279.9022. Your patients look to you for advice, so please let them know they have until December 7, 2016, to choose better coverage for their health care needs. tuftshealthplan.com/provider
Five-Star Rating Received From Medicare As previously communicated in the November 1 issue of Provider Update, for a second year in a row, Tufts Health Plan has earned five stars out of a possible five for its Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options (SCO) plans from the Centers for Medicare & Medicaid Services (CMS) as part of its annual star ratings for 2017*. This is Medicare s highest rating and makes Tufts Medicare Preferred HMO and Tufts Health Plan SCO among the best plans in the country. We are very proud of this rating and consider it the result of a healthy and productive collaboration with our provider network. Many thanks for all that you have done to help all of us achieve this honor. Below you will find the answers to some frequently asked questions as well as additional information regarding some of the star measures. As a reminder, our star rating for 2018 is based on clinical activities ending this year on December 31, 2016. We will send you information regarding Star 2019 in January 2017. How is the five-star rating growing your patient-base? 1. Open enrollment all year As a five-star-rated plan, Medicare beneficiaries can enroll in or switch to Tufts Medicare Preferred HMO at any time during the 2017 calendar year (and not only during the 2017 annual enrollment period in the fall). 2. If your patients are interested in joining If your patients are interested in joining or would like to know more about our plan options, they can call 800.867.2000 (TTY 888.899.8977) Monday Friday 8 a.m. 8 p.m. (from October 1 February 14, representatives are available seven days a week, 8 a.m. 8 p.m.) A representative will return your call on the next business day for voicemail received after hours and on holidays. 3. Reasons your patients may be interested in joining Tufts Medicare Preferred HMO or Tufts Health Plan SCO include: } Their current plan is costing more than anticipated or does not cover needed benefits. } They require more medical services and would like to reduce copays. } Their prescription needs have changed. How You Can Help While we are proud of this accomplishment, we cannot rest on our laurels. Other health plans are working hard to improve on these measures, and thresholds to achieve stars are climbing every year. Tufts Health Plan did not achieve our own targeted performance for a few measures that rely on your management of Tufts Medicare Preferred HMO and Tufts Health Plan SCO members. Improving on these measures will improve the quality of life of your patients and prevent downstream hospitalization and morbidity. In addition to continuing our high performance on most HEDIS-related star measures, here is where we ask you to focus: 1. Osteoporosis Management in Women Who Had a Fracture (HEDIS) For patients age 67-85 who have had a fracture, a bone mineral density test or prescription to treat osteoporosis is strongly recommended to prevent future fracture. When appropriate, this should occur within six months of the fracture. We send lists of our members who had a fracture to each medical group in case the member neglects to inform you of a fracture for which he or she received care at an ED or orthopedist s office. 2. Rheumatoid Arthritis Management (HEDIS) Patients with two or more visits with a diagnosis of rheumatoid arthritis (RA) in a calendar year should be prescribed a DMARD, where clinically appropriate. Coding of M06.9 for patients with RA-like diseases (e.g., osteoarthritis, polymyalgia rheumatica, DJD) should be reviewed and retracted, as these conditions have their own ICD-10 codes and should not be entered on a claim as RA. Several national organizations recommend DMARD therapy for all patients with RA, regardless of the activity of the disease, unless there is a contraindication. Remember methotrexate is an effective first line agent, and there are other generic DMARDs for those who can t take methotrexate. TNF inhibitors are expensive for the health plan and the patient. 3. Diabetes Care Kidney Disease Monitoring (HEDIS) All patients diagnosed with diabetes should be monitored for nephropathy. Patients who show evidence of nephropathy (e.g., seen by nephrologist, had a renal transplant, have nephropathy, ESRD or CKD) do not need further testing. Those without evidence of nephropathy should: a) Have a urine albumin or protein test, or b) Be dispensed an ACE inhibitor or ARB 4. Reducing the Risk of Falling (Health Outcomes Survey of a random sample of patients) CMS asserts that ALL people age 65+ should have an intervention to prevent falling. In our population, 1/3 fall each year. Five percent require medical treatment for the fall. Overall, known falls cause medical expenses of $25 per member per month, and studies show 1/3 of falls can be prevented if patients at high risk are identified and assessed, and risk factors mitigated. Please assess your patients for their fall risk and have a conversation with them regarding their balance and walking, especially if they have had a fall in the past. Examples of ways to encourage safety include: } Suggest using a cane or walker. } Suggest an exercise or physical therapy program, especially a bimodality exercise program. (two or more of strength, balance and aerobic exercise). Tufts Medicare Preferred HMO members have discount programs and can be reimbursed for up to $150 per year for classes and gym memberships (up to $150 per year for Tufts Medicare Preferred HMO members and up to $200 per year for Tufts Health Plan SCO members). 2 continued on page 3
(continued from page 2) } Suggest a vision or hearing testing. } Recommend a home safety evaluation. } Recommend OTC vitamin D supplement. 5. Monitoring Physical Activity (Health Outcomes Survey of a random sample of patients) Discuss exercise and physical activity with all patients. Based on their current physical state, talk to patients about whether they should start, increase or maintain their current level of physical activity. For example, you may advise patients to start taking the stairs or increase their walking from 10 to 20 minutes every day. 6. Patient Access to Needed Care (CAHPS survey of random sample of patients) Members have reported an increased difficulty obtaining timely appointments with both their PCPs and specialists. Be sure your office staff is speaking to patients about what they need and how long they think they can wait for an appointment. Consider setting up appointments with specialists for your Medicare Advantage patients so pertinent information is relayed more quickly. If you have further questions about our star results or any of the measures above, please contact Andrew Beltz, Senior Business Analyst, Star Program at andrew_beltz@tufts-health.com. *Medicare evaluates plans based on a five-star rating system. Star ratings are calculated each year and may change from one year to the next. For more information on plan ratings, go to medicare.gov. 2016 2017 Seasonal Flu Vaccine for Senior Products The Centers for Disease Control and Prevention (CDC) states that those with the highest risk and who have the greatest need for a flu vaccination include adults 65 years of age and older, and individuals of any age with underlying medical conditions, e.g., asthma, diabetes. Timing of Flu Vaccination We see high rates of vaccination with our Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options (SCO) members. We would like you to help assist your patients with getting the flu shot by encouraging vaccination as soon as the vaccine is available. The CDC advises that people get vaccinated by the end of October. We recommend that providers reach out to their patients early in the flu season to schedule them for a flu vaccine. While we encourage members to first try to get the vaccine from their PCP, as we try to support the PCP relationship, we have other options for those who are unable to do so. Availability of Flu Vaccine Flu vaccine will be available to your patients at the following locations this year: } At the member s provider s office. } Through town- and school-based public clinics. } At CVS MinuteClinics located in Massachusetts, New Hampshire, Rhode Island, Connecticut and New York. } At CVS/pharmacy stores in Massachusetts, Rhode Island, and New Hampshire (MA and RI have an age restriction of 18+ and NH of 9+. These restrictions are state regulations. specific to pharmacy administration.) } Participating pharmacies within the Caremark network. This expanded network is for members who receive their pharmacy benefit through Tufts Health Plan. } In the member s home for members who have been approved for and are currently receiving home health care services at the time of their vaccination. } At any other self-pay clinic/vaccination site. (Member reimbursement would apply.) Providers are reminded to encourage members to contact participating flu clinics before scheduling a vaccination to check on vaccine availability and to confirm that the clinic/ vaccination site accepts Tufts Health Plan. Coverage for Seasonal Flu Vaccine Tufts Medicare Preferred HMO and Tufts Health Plan SCO members are covered for a flu shot each year with no out-of-pocket cost. If a member pays out of pocket for the flu vaccine, he or she can submit for reimbursement from Tufts Health Plan. Members who are unsure where they can get a flu vaccination may call Customer Relations at the number on their member ID card. Telemarketing for Diabetic and Topical Medications Tufts Health Plan has recently been made aware of fraudulent telemarketing outreach to members offering free diabetic supplies and topical medications, and would like to remind providers to look out for the following: What to Look For } Members are receiving excessive levels of supplies (e.g., twice as much as needed). } Members are receiving supplies without an obvious medical need. } Medications/supplies not prescribed by you. } Unsolicited faxes to switch a member s supplier or sign a prescription Alert your office staff and ask the member. } Member states he or she is receiving supplies that were not requested, or more supplies than were requested or can be used. continued on page 4 3
(continued from page 3) What to Do If You Identify One of These Activities } Contact your Tufts Health Plan point of contact using the existing channels. } Contact Joshua Orr, Director of Fraud Prevention and Recovery Unit at 617.923.5839 or joshua_orr@tufts-health.com. } Call our anonymous Fraud Hot Line at 877.824.7123. } Use our anonymous web-based reporting option at tuftshealthplan.alertline.com. } Call Health Integrity, the National Medicare Drug Integrity Contractor Hotline (MEDIC) at 877-7SafeRX. Rheumatoid Arthritis Management Rheumatoid Arthritis (RA) is a complex disease that may require routine follow-up and disease modifying antirheumatic drugs (DMARD) essential to reduce inflammation, relieve symptoms, prevent joint and organ damage, improve physical function, and reduce long-term complications or medication adverse effects. There are many drugs considered DMARDs with different side effect profiles. Most patients can tolerate one of them. What You Can Do 1. Ensure each member diagnosed with RA schedules a minimum of two appointments each year with a PCP or rheumatologist to monitor response to therapy or progression without DMARD. 2. Ensure accurate RA diagnosis and coding. Refer to a rheumatologist any patient-suspected case of persistent synovitis of undetermined cause or any patient with documented and coded RA that you are deciding not to treat with a DMARD. 3. Prescribe DMARD therapy in all appropriate patients. CMS standards stress that greater than 85 percent of patients are appropriate for DMARD therapy. What percentage of your RA patients are not on a DMARD? Medication Reconciliation A completed medication reconciliation and documentation is required for all Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options members within 30 days of discharge from an acute inpatient/skilled nursing facility to a community setting. This is to support the standardization of best practice across the network and the increased focus on potentially avoidable admissions and readmissions, while addressing new expectations set forth by the Centers for Medicare & Medicaid Services. What You Can Do Documentation in the medical record must include evidence of medication reconciliation (defined in the following list) and the date when it was performed. Any of the following meets criteria: } Documentation that the provider reconciled the current and discharge medications } Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications) } Documentation of the member s current medications with a notation that the discharge medications were reviewed } Documentation of a current medication list, a discharge medication list, and notation that both lists were reviewed on the same date of service } Evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review } Documentation in the discharge summary that the discharge medications were reconciled with the current medications. There must be evidence that the discharge summary was filed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days). } Notation that no medications were prescribed or ordered upon discharge Medication reconciliations may only be performed by a registered nurse, nurse practitioner, clinical pharmacist, physician assistant or physician. An outpatient visit is not needed. Once you have documented that the reconciliation has been done, acceptable provider billing codes include 99495, 99496 and 1111F. The first two codes are for the transitional care bundle. These codes provide additional revenue to your practice as Tufts Health Plan does not include these codes in the Tufts Medicare Preferred HMO PCP capitation payment, but they require special billing and other services be provided during the 30 days after discharge. If because of those extra requirements your office chooses not to bill one of those codes, please bill 1111F. It does not provide additional revenue, but if we have received the code, we won t need to request chart evidence of the reconciliation should your patient be included in our chart review sample. And you will be able to demonstrate your practice s quality for patients in transition. 4
Custom Care Program for Eligible Tufts Medicare Preferred HMO Members Beginning January 1, 2017, Tufts Health Plan will launch its Custom Care Program, a Medicare Advantage Value-Based Insurance Design (MA-VBID) model test for eligible Tufts Medicare Preferred HMO members. This is part of a new initiative to increase the quality and reduce the cost of care for members, encourage active participation in care management and improve clinical outcomes. The Custom Care Program will be offered exclusively to members of nonemployer-group Tufts Medicare Preferred HMO plans who have received a diagnosis of chronic heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD), and who are either currently participating or willing to participate in Tufts Health Plan care management. Custom Care members will have cost share waived for PCP office visits, and the cardiology or pulmonology office visit cost share will be at the standard PCP level of payment for the selected HMO plan. Custom Care ID cards will reflect the waived PCP copay, and will carve out pulmonologist and cardiologist copays from the specialist level. Provider and member online portals, EDI and IVR will also reflect these cost share values. Members who are diagnosed with COPD and/or CHF and participating in care management will be automatically enrolled in the Custom Care Program, and will receive a letter and new ID card. Members who are diagnosed with COPD and/or CHF (but are not currently participating in care management) will be notified by Tufts Health Plan via mail in January 2017 that they are eligible if they enroll in care management. Members then must contact Tufts Health Plan Customer Relations to begin participation in care management and subsequently in the Custom Care Program. CMS guidelines prevent Tufts Health Plan from promoting its participation in the model test to prospective enrollees, and from outreaching to members whom we have not identified as eligible for the program. Providers are encouraged to refer eligible members who are not yet enrolled in care management or who are not automatically enrolled by Tufts Health Plan in the Custom Care Program. If you have a patient who may qualify for the Custom Care Program, contact your care manager. If you do not know your care manager, you can get the name and contact information by calling Provider Relations at 800.279.9022. New members will be identified throughout the year by regular examination of claims history. Providers are reminded to check copayments and eligibility at each visit, as members may be disenrolled at any time and copayment amounts may change. Osteoporosis Management Secondary fractures in older adults increase mortality risk, length of hospital stay, and admission to long-term care facilities as well as lower quality of life and increase health care costs. Having a prior fracture, regardless of confirmed fragility fracture, is a major predictor of a future fracture particularly within the first five years after the initial fracture. Tufts Health Plan s goal is to improve quality health care for its members by reducing secondary fractures. In case you are not made aware your patient had a fracture from a hospital or orthopedic surgeon, Tufts Health Plan identifies and sends notification to medical directors and PCPs for female members 67 85 years of age who suffered a new fracture and who have not had a bone mineral density scan within the past two years or medication to treat osteoporosis within the past year. What You Can Do Within six months of fracture date: } Schedule a bone mineral density scan There will be no charge to the member. Tufts Health Plan also offers an in-home scan (in certain geographic areas) if needed. } Prescribe medication Bisphosphonates, calcitonin, denosumab, raloxifene, etc., or a medication to treat or prevent osteoporosis unless there is a medical contraindication. 5
PCP Resources on the Public Provider Website Tufts Health Plan s public Provider website contains resources for PCPs contracted with Tufts Health Plan. Providers who render services to members of Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options can access these resources in the following sections of our website: } Provider Resource Center: From the Division dropdown menu, select Medicare or Tufts Health Plan Senior Care Options } Provider Training: From the left-navigation menu, select: Medicare and then Tufts Medicare Preferred HMO and Tufts Health Plan SCO PCP Resources or Tufts Health Plan Senior Care Options and then Tufts Medicare Preferred HMO and Tufts Health Plan SCO PCP Resources PROVIDER NEWSLETTER NEWS FOR THE NETWORK Tufts Health Plan 705 Mount Auburn Street Watertown, MA 02472 tuftshealthplan.com/provider Presorted Standard U.S. Postage PAID Brockton, MA Permit No. 301? For More Information ADDRESS SERVICE REQUESTED } tuftshealthplan.com/provider } Provider Relations: 800.279.9022 WHAT S INSIDE Update Your Practice Information... 1 Medicare Annual Election Period Begins October 15... 1 Reminder: Tufts Health Plan SCO Annual Care Model Training Requirement... 1 Five-Star Rating Received From Medicare...2 2016 2017 Seasonal Flu Vaccine for Senior Products...3 Telemarketing for Diabetic and Topical Medications...3 Rheumatoid Arthritis Management...4 Medication Reconciliation...4 Custom Care Program for Eligible Tufts Medicare Preferred HMO Members...5 Osteoporosis Management...5 PCP Resources on the Public Provider Website...6