January / February 2012 M a n a g e d b y P r i m a r y P r o v i d e r M a n a g e m e n t C o. IN THIS ISSUE: A Letter from the Editor 1 Welcome from Customer Service Vision Care Notice for Care1st Health Plan Easy Choice Health Plan 2 About our Online Claims Submissions HEDIS Measures for Medicare and SNP in 2012 1 2 2 3 A LETTER FROM VANTAGE MEDICAL GROUP This newsletter marks the first issue from Vantage Medical Group which will be published and distributed every other month. The newsletter will bring you the latest news and information about the changes that are happening within the managed care world as it directly affects the IPA, and the provider. Our goal is to help provide a line of communication between the IPA and its physicians. Each issue, will contain valuable information on helping the provider build their business, and give updates on various Medi-care and Medi-cal guidelines. We will also give status updates on key internal changes within the provider network, such as fax implementation, usage data, and feedback on member & provider surveys. We hope you find this newsletter informative and entertaining as we strive to develop a beneficial open line of communication with our providers. This newsletter is provided free of charge, and we welcome your comments or suggestions. Thank you. About Our Case Management Program 5 Fax System Status Update 5 Did You Know about... NEW REGULATIONS for Physician Assistants Effective August 11, 2011, Section 1399.547, Title 16 of the California Code of Regulations, mandated by Business and Professions Code section 138, requires that Physician Assistant inform patients that they are licensed and regulated by the Physician Assistant Committee. The notification must include the following statement and information: NOTIFICATION TO CONSUMERS PHYSICIAN ASSISTANT ARE LICENSED AND REGULATED BY THE PHYSICIAN ASSISTANT COMMITTEE (916) 561-8780 W ELCOME FROM CUSTOMER SERVICE We at Primary Provider Management Company, Inc. realize the importance of providing excellent customer service. While we recognize that you ve had some challenges contacting our Customer Service Department recently and experienced some unusually long wait times, we want to assure you that we are making changes to improve service to our providers in 2012! We have reinvented ourselves and developed a new structure. We are the Action Care Team (ACT). We re comprised of utilization management, claims management, and customer service staff working in concert to provide immediate assistance and solutions to our customers. Our goal is to apply a one and done approach to each opportunity that arises as a result of an inbound customer request. We are in the process of adding to our Customer Service staff and will have a full staff by the end of January. One of the recent changes we made was to relocate our Customer Service Department to an area where they have access to the Utilization Management nurses. This partnership allows for more immediate responses to callers questions. Providing excellent customer service is ACT s primary focus and you ll experience those results in 2012!
Page 2 Did You Know about... NEW REQUIREMENTS on claims and encounters. Effective January 1, 2012, Federally-mandated changes to the way claims and encounters are submitted by providers are required. These changes may impact the way your practice or biller needs to transmit electronic claims data to payors, clearinghouses, and other covered entities. Three of the changes include: 1. A requirement that Box #32 on the CMS 1500 must be a physical address, not a P.O. box; 2. Zip codes must now include all 9 digits; 3. Individual NPI s must be included in Box #24J for all rendering/servicing providers. Complying with these changes, even on traditional paper forms, will help your claims get processed faster and with less rejection due to noncompliance. For more information, please visit: https://www.cms.gov/ electronicbillingeditrans/ 18_5010d0.asp V ISION CARE FOR CARE1 ST HEALTHPLAN Update: E ASY CHOICE HEALTH PLAN Vantage Medical Group (VMG) is once again pleased to announce the addition of another Health Plan payer to offer Medicare line of business to your practice. VMG and Easy Choice Health Plan (ECHP) have entered into an agreement and is now active effective JANUARY 1, 2012. ECHP has entered into the Inland Empire on January 1, 2012. However, Easy Choice has been established in Los Angeles and Orange Counties since 2008. ECHP members receive all the basic healthcare benefits traditionally covered under Medicare plus more. Medicare beneficiaries interested in learning more about ECHP may call 1-866-999-3945. Benefit and enrollment information is also available on line at www.easychoicehealthplan.com. Please be advise that effective January 1, 2012, Care 1 st Health Plan will be shifting the responsibility of optometry services for Medicare and Medi-Medi members. VSP will be the contracted provider for this service. We will no longer be responsible for this service. As a VMG physician, you will have access to this product by way of your existing VMG Agreement. Your compensation for ECHP members will be reimbursed at your current contracted Medicare rates. Claims submission and utilization management (referrals) for ECHP members shall remain the same as all other VMG business. We are committed to providing you with the best possible service and competitive rates. If you should have any questions or comments, please feel free to contact your Provider Services Representative directly or our Provider Relations department at (951) 280-7700. A BOUT OUR ONLINE CLAIMS SUBMISSIONS We ve partnered with Office Ally to bring all of your claim and encounter services online! At no charge, Office Ally will enable you to submit all of your claims and encounters electronically. Office Ally provides on-site training, and will have your staff efficiently utilizing this dynamic tool at no cost to you. By submitting electronically, your productivity will be increased, the need to call for claims status will be eliminated, and you will be afforded increased oversight of claims and encounter submissions. Providers may view a member's eligibility, and their assigned Primary Care Physician (PCP). Eligibility is also available in E-Lists format, enabling users to easily sort and analyze reports. Office Ally also allows our providers to access our internal network, to submit and look up authorization requests all through a streamlined web interface. To find out more about Office Ally, and for specific payor ID information, please contact Provider Relations for more information.
Page 3 HEDIS MEASURES FOR MEDICARE AND SNP IN 2012 This year the IPA would like to take a proactive approach in preparing our providers with the necessary information to meet all documentation requirements for HEDIS and encounter submissions. At this time we would like to inform you on the new elements required for Medicare and the Special Needs Population or SNP. In 2011 five new elements were added as part of the screening criteria for Care for Older Adults. Advanced Care Planning: This element is found during chart review and discusses the patient s preferences for resuscitation, life sustaining treatment and end of life care. Evidence in the medical record must include any of the following: The presence of an advance care plan in the medical record Documentation of an advanced care planning discussion with the provider and the date it was discussed (must be noted for 2012) Notation that the member previously executed an advance care plan. Functional Status Assessment: Documentation in the medical record must include evidence of a complete functional status assessment and the date in the measurement year in which it was performed. Notations for a complete functional status assessment may include any of the following: Notations that Activities of Daily Living (ADL) were assessed (e.g. bathing, dressing, eating, using toilet, walking, transferring in/out of chairs Notations that Instrumental Activities of Daily Living (IADL) were assessed (e.g. shopping for groceries, driving or using public transportation, using the telephone, meal preparation, housework, home repair, taking medications, handling finances) Notations that at least 3 of the following four components were assessed: Cognitive status Ambulation status Sensory ability (hearing, vision, speech) Other functional independence (e.g. exercise, ability to perform job, etc) Results of assessment using a standardized functional status assessment tool, not limited to: SF-36 ADL List Assessment of Living Skills and Resources (ALSAR) Barthel ADL Index Physical Self-Maintenance (ADLS) Scale Bayer Activities of Daily Living (B-ADL) Scale Extended Activities of Daily Living (EADL) Scale Independent Living Scale (ILS) Katz Index of Independence in Activities of Daily Living Kenny Self-Care Evaluation Klein-Bell Activities of Daily Living Scale Kohlman Evaluation of Living Scales (KELS) Lawton & Brody s IADL scales Medication Review: A medication review conducted by a prescribing practitioner or clinical pharmacist each year and the presence of a medication list in the medical record. Documentation includes the following: A medication list in the medical record and evidence of a medication review by a prescribing practitioner or clinical pharmacist and the date when it was performed Notation that the member is not taking any medications and the date when it was noted Pain Screening: Documentation in the medical record must include a comprehensive pain screening or pain management plan and the date it was performed. Evidence of a comprehensive pain screening may include the following: Notation of a comprehensive pain assessment Pain assessment limited to an acute or single condition, event or body system (e.g. toothache, earache, localized pain from trauma) does not meet criteria for a comprehensive pain assessment Results of a pain screening tool are acceptable if documentation indicates that a comprehensive pain screening was performed Evidence of a pain management plan many include the following: Notation of no pain intervention and rationale Notation of plan for treatment of pain, which may include use of pain medications, psychological support and patient/family education Notation of plan for reassessment of pain, including reassessment time interval Medication Reconciliation Post discharge: A type of review in which the discharge medications are reconciled with the most recent medication list in the outpatient medical record. Documentation in the medical record must include evidence of a medication reconciliation and the date when it was performed. It must be done within 30 days of discharge. Any of the following evidence in the chart meets the criteria: Notation that the medications prescribed or ordered upon discharge were reconciled with the current medications as found in the outpatient medical record by the appropriate practitioner type A medication list in the discharge summary that is present in the outpatient chart and evidence of a reconciliation with the current medications conducted by an appropriate practitioner type Notation that no medications were prescribed or ordered upon discharge Throughout the year the IPA and / or health plans may request access to your medical records to review for evidence of these and other HEDIS criteria. By providing the correct CPT codes on encounters, you can avoid unnecessary medical record reviews as compliance will be measured using administrative data. To assist you further a comprehensive table of the Medicare/SNP HEDIS measures has been provided. This includes all the HEDIS elements the IPA will focus on for 2012. Should you have any questions on HEDIS elements please contact the Quality Management Department at (951) 280-7826. Did You Know... Depending on the health plan s incentive program, providers can get extra incentive bonuses for submitting encounter data on specific HEDIS elements. Contact your Provider Representative for more information. Some health plans have web portals set up for providers to view their membership s preventive health needs (HEDIS) and also submit their encounters directly on line. Contact your Provider Representative for more information.
Page 4 HEDIS MEDICARE TABLE HEDIS Measure Age Description CPT Codes Access to Preventive Services/Health Risk / Assessment 20 and Member requires a full comprehensive physical that documents a status and plan for all chronic conditions G0438, G0439 Adult BMI Assessment 18-75 Requires documentation of a BMI calculation value, in the medical record Care for Older Adults 66 and Advanced Care Planning 1157F, 1158F, S0257 Medication Review / list 90862, 99605, 99606, 1160F Functional Evaluation 1170F Pain Screening 0521F, 1125F, 1126F Breast Cancer Screening 40-69 Breast Cancer Screening for women 77055-77057 Colorectal Cancer Screening 51-75 One of the following: Fecal Occult Blood Test 82270, 82274 Flexible sigmoidoscopy (during 2012 or in 45330-45335, 45337-78342, 45345 past 4 years) Comprehensive Diabetes Care Glaucoma Testing Osteoporosis Management in women who had a fracture Colonoscopy (during 2012 or in past 9 years) 44388-44394, 44397, 45355, 45378-45387, 45391, 45392 18-75 HbA1c Control <8% 83036, 83037 18-75 HbA1c Poor Control 83036, 83037 18-75 LDL-C Screening 80061, 83700, 83701, 83704, 83721 18-75 LDL-C (Control) 80061, 83700, 83701, 83704, 83721 18-75 Nephropathy screening test 82042, 82043, 82044, 84156 67 years 65 and 92002, 92004, 92012, 92014, 92081-92083, 92100, 92120, 92130, 92135, 92140, 99202-99205, 99213-99215, 99242-99245 Bone Mineral Density (BMD) test is 76070, 76071, 76075-76078, 76977, 77078- performed on date of fracture or 180 days 77083, 78350, 78351 after. Annual retinal or dilated eye exam 18-75 Diabetes Care Eye Exam 687028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, Controlling Blood Pressure 18-85 BP < 140/90 Rheumatoid Arthritis Management 18 years received at least one medication for a, Pharmacy Review disease modifying antirheumatic drug Testing to confirm COPD Reducing the Risk of Falling Medication Reconciliation Post Discharge Follow-up after hospitalization for Mental Illness 40 years 65 and 66 years 6 years Antidepressant Medication Management 18 years Annual Monitoring on Patients on Persistent Medications Use of High Risk Medications in the Elderly Pharmacotherapy Management of COPD Exacerbation Persistence of Beta Blocker Treatment After a Heart Attack 18 years 65 and 40 years 18 years Use of spirometry testing in the assessment and diagnosis of COPD Falls or had problems with balance or walking in the last 12 months, and received a fall risk intervention Must be performed within 30 days of discharge Hospitalized for mental health disorders & had an outpatient visit, intensive outpatient encounter or partial hospitalization Newly diagnosed & treated with medication & remained on meds Received at least 180 days of treatment of med therapy Received at least one or two different high risk medications COPD exacerbations who had an acute admit or ER encounter Received persistent beta-blocker treatment for six months after AMI 94010, 94014-94016, 94060, 94070, 94375, 94620 90862, 99605, 99606, 1111F E.D.- 99281-99285
Page 5 We re on the Web! To view past issues, please visit: www.vantagemedicalgroup.com P r i m a r y P r o v i d e r M a n a g e m e n t C o m p a n y, I n c. 2115 Compton Ave. Corona, CA 92881 Phone: 951-280-7700 E-mail: qm@ppmcinc.com The Committee : Deborah Lopez, RN, MHA, Compliance Officer Retanya Bennett, Quality Management/Compliance Liaison Ana Liza Santiago, LVN, MBA, Quality Management Specialist Scott Tsai, LVN, Quality Management Observed Holidays PPMC Closed February 20 th In honor of President s Day, PPMC will be closed for business on Monday February 20, 2012. Vantage Medical Group has been dedicated to providing the highest level of commitment and support for its physicians since 1984. Our goal is to provide the highest quality service and care to our members and providers. Moreover, Vantage Medical Group lives up to its performance. Past audits have demonstrated routine referral turnaround in 48 hours, claims payment within 30 days, timely and accurate distribution of capitation payments. Vantage Medical Group offers competitive rates as well as access to many Health Plan contracts. A BOUT OUR CASE MANAGEMENT PROGRAM We want our providers to be aware that our Case Management Department is taking a proactive approach in managing the care for our Medicare members. While providing service to our members, you may identify patients who may require close monitoring. As a physician, you may refer a patient for Case Management at any time. As we receive a new referral, a Case Manager will evaluate the patient and if needed will open a new case file to follow the patient s progress. Routinely the Case Managers will be contacting your office to obtain patient updates and any needed information to coordinate needed care or service. Our goal is to become thoroughly familiar with the patient and anticipate any future needs, while supporting your treatment plan. Additional aspects of our Case Management Program for Medicare members may include the following: Assisting new members with obtaining a primary care appointment within 90 days of enrollment, as per CMS requirements. Patients assigned to case managers will have developed care plans for their individual needs. Monitor Medicare population s preventive health screens and alert providers when patients are in need of exams Monitor chronic diagnoses and assist providers with periodic documentation, reviews and education to identify and support more appropriate HCC Codes Coordinate hospital admissions and discharge planning needs Work collaboratively with Health Plans to provide any health education needs A provider may refer a patient to Case Management at any time by either faxing in the attached Case Management Referral form included in this newsletter or by calling (951) 280-7811 and speak to a case manager. F AX SYSTEM STATUS UPDATE PPMC caters to 1000 s of providers every day. Occasionally our fax channels reach a capacity to where you may receive a busy signal resulting in a fax Busy status. We understand that not all offices have digital fax machines, which could automatically resend Busy fax failure attempts, and it results in lost time as staff manually have to resend faxes that failed. We are in the process of expanding further our fax channel capacity. In the mean time, please note that PPMC s peak times for faxing are mid morning from 10am to 12:30pm and mid afternoon 2pm to 4pm Monday through Friday. Our hours for receiving faxes are between the hours of 1am to 5pm, Monday through Friday. Any fax sent outside of peak times will most likely succeed the first time than if otherwise sent during peak times. A reminder: If your office has changed location or you have changed or added new office and/ or fax numbers in the last 6 months, please forward the update information to connectsupport@ppmcinc.com
Page 6 Vantage Medical Group, INC. 2115 Compton Ave. Corona, CA 92881 Case Management Referral Form Date: Name: DOB: Sub. #:: Address: City/State/Zip: Phone #: PrimaryLanguage: Secondary Language: Hlth Plan: PCP Name: PCP Phone: PCP Fax#: Referral Source/Resource PCP Specialist Member Self Referred Facility Member s Family Other Medical Director QM Nurse Inpatient CM OOA/SNFCM UM Nurse Hlth Ed Nurse Please Specify Reason for Case Management: Please fax the completed Case Management Referral Form to: 951-280-8203