Winter 2012 PROVIDER NEWS VNSNY CHOICE HEDIS INFORMATION VNSNY CHOICE Health Plans works with your office to promote preventive care and to improve chronic care for your patients. The outcome of these efforts is based on the Healthcare Effectiveness Data and Information Set (HEDIS), a group of quality improvement indicators developed by the National Committee on Quality Assurance (NCQA). INSIDE THIS ISSUE: Home Care Certification and Recertification 3 Annual Wellness Visit 3 VNSNY CHOICE Special Needs Plan (SNP) Medicare Model of Care 4 A Visionary Initiative at VNSNY CHOICE: Home Eye Exams 5 Home Care Certification and Recertification 6 Meet the VNSNY CHOICE Provider Relations Department 7 As a VNSNY CHOICE provider, you may be contacted to supply medical records for HEDIS reporting. The Centers for Medicaid and Medicare Services (CMS) requires VNSNY CHOICE and its network physicians to comply with HEDIS initiatives. The US Department of Health and Human Services has stated that supplying the requested records to us for HEDIS reporting does not violate the HIPAA Privacy Rule. See 45 CFR 164.506(c) (4). Thank you for your continued cooperation and partnership. Your assistance with timely completion of any medical record requests helps us communicate to the medical professionals and consumers that we are committed to meeting the highest standards of care. FREQUENTLY ASKED QUESTIONS: Who is conducting the medical record reviews? VNSNY CHOICE has contracted with MedReview, Inc., a professional medical record review organization, to conduct our medical record collection and review. Continued on page 2
2 HEDIS INFORMATION Continued from Cover Does HIPAA permit me to release records to the VNSNY CHOICE vendor, MedReview, for HEDIS data collection? Yes. You are permitted to disclose protected health information (PHI) to MedReview. A signed consent from the member is not required under the HIPAA privacy rule for you to release the requested information for purposes of treatment, payment and health care operations. Is my participation in HEDIS data collection mandatory? Yes. Network participants are contractually required to provide medical record information so that we may fulfill our regulatory reporting requirements. Will I be asked to change or resubmit claims? No. Do I have to participate even if I participate in one of the NCQA Recognition Programs? Yes. NCQA Recognition Programs do not satisfy HEDIS data collection requirements. How should I provide the records to MedReview? MedReview staff will either schedule an onsite review at your location or ask that you fax, scan and email through a secure VPN portal or mail the information to them. The methodology chosen will typically depend on the volume of records being requested from your office. What is my office's responsibility regarding HEDIS data collection? You and your office staff are responsible for responding to MedReview requests for medical record documentation in a timely manner. The MedReview staff will contact your office to establish a date for an onsite visit, or to arrange retrieval of requested information via fax, email or mail. A patient list will be provided to you so the requested medical records can be made available for the appointment to MedReview. If a patient included on the list is not part of your practice, you should notify the MedReview staff at the number provided to you immediately. Once a review is scheduled, your role will include providing a place for the reviewers to work and pulling the requested charts. The review staff will use their own office supplies and equipment to minimize the impact on your office and resources. What dates of service are included in the review? Office medical records are being reviewed for services received in the 2011 calendar year. However, some measures require additional periods of time, especially for exclusions. The specific periods of service for each member will be included with the chart request. Should I allow a record review for a member who is no longer with VNSNY CHOICE or for a member who is deceased? Yes. Medical record reviews may require data collection on services obtained over multiple years. Am I required to provide medical records for a member who was seen by a physician who has retired, died or moved? Yes. HEDIS data collection includes reviewing medical records as far back as 10 years. Archived medical records/data are required to complete data collection. When will the MedReview staff need the records? HEDIS data collection is a time-sensitive project. Medical records should be made available on the date of the onsite review, or by the date requested, in the case of fax/mail. Typically, data collection begins in mid- to late- February and ends in mid-may. It is imperative that you respond to a request for medical records within five days to ensure we are able to report complete and accurate rates to NCQA. Continued on page 5
3 Annual Wellness Visit: A Summary The March 2010 federal health care reform law established a new Medicare benefit focused on developing and then maintaining a personalized prevention plan. A beneficiary is eligible for an Annual Wellness Visit if he or she has: Medicare Part B coverage for at least 12 months, and Not received either an Initial Preventive Physical Examination, known as the Welcome to Medicare visit or had an annual wellness visit service within the past 12 months. The law requires that the patient complete a Health Risk Assessment (HRA) prior to the annual wellness visit. The purpose of the HRA is to help facilitate a conversation between the patient and their clinician about patient-specific health risks. This requirement was initially waived for 2011. VNSNY CHOICE reaches out to all new members to perform an HRA and then updates this HRA annually. You should be receiving a one-page summary of any completed HRA. A sample health risk assessment has been published by CDC and is available in the appendix in the link below, though the use of this example is not required. http://www.cdc.gov/policy/opth/hra/. How to Bill Medicare s Annual Wellness Visit The Center for Medicare Services (CMS) established a billing code that physicians must use to bill for a first AWV service, G0438, and a subsequent AWV service, G0439. The 2011 Medicare payment not adjusted for geography is approximately $172 for G0438 and $111 for G0439. Medicare, and Medicare Advantage plans such as VNSNY CHOICE Medicare, will pay the full amount, meaning that the beneficiary may not be billed for the typical 20 percent copayment nor toward a yet-to-be reached deductible. Diagnosis code V70.0 Initial Annual Wellness Visit G0438 Subsequent Annual Wellness Visit G0439 The documentation requirements for initial and subsequent annual wellness visits differ and are extensive. Much of what is required for the annual wellness visit is a clinician assessment of similar information to that assessed by the patient when completing the HRA. A complete physical exam is not a requirement of the annual wellness visit. CMS states that an annual physical exam remains a non-covered service by Medicare part B. An assessment of cognitive deficits by the clinician is required though it is left to the physician s discretion which tool to use for cognitive evaluation. More information about the annual wellness visit is available through the link below: http://www.cms.gov/mlnproducts/downloads/ AWV_Chart_ICN905706.pdf Arik Olson, MD, MBA, Medical Director, VNSNY CHOICE VNSNY CHOICE is growing!! Across its offerings, VNSNY CHOICE experienced robust growth in 2011. VNSNY CHOICE Managed Long Term Care (MLTC) reached a milestone by enrolling member number 10,000. VNSNY CHOICE is the first MLTC plan in New York State to achieve this result. VNSNY CHOICE was also granted approval to expand the MLTC plan in additional counties across the state. Efforts are underway and we will begin enrolling our first members in Nassau, Suffolk, and Westchester Counties in the first half of 2012. Also in 2011, VNSNY CHOICE Medicare grew by more than 25 percent, reaching 7500 members.
4 VNSNY CHOICE Special Needs Plan (SNP) Medicare Model of Care The VNSNY CHOICE Special Needs Plan (SNP) model of care is a structural framework guiding care management policies and operational systems for Medicare and Medicaid beneficiaries. Our model complies with requirements of the Center for Medicare and Medicaid Services (CMS) and Medicare Improvements for Patients and Providers Act (MIPPA). Model of Care Goals: Improve access to affordable care, preventive, medical, mental health and social services Improve coordination of care via integrated care planning Improve seamless transitions of care Assure appropriate utilization of services Improve beneficiary health outcomes All beneficiaries are auto-enrolled in care management upon enrollment in the SNP. The Health Risk Assessment (HRA) completed by our staff of clinicians is the evaluation tool to identify aspects of care and specialized needs of members related to medical, functional, psychosocial and cognitive/ mental status. An individualized care plan with problems, goals and interventions is developed and updated by the member s care manager. It is used to manage and monitor the member s care, needs and progress toward goals. The Interdisciplinary Care Team (ICT) is dedicated to quality and accountability in ensuring appropriate care and services are consistent with best practices, CMS guidelines and the VNSNY CHOICE mission. The ICT collaborates to determine the best course of action to facilitate meeting the medical, psychosocial, cognitive and functional needs of the beneficiary in a timely, costeffective manner. Participants of the VNSNY CHOICE ICT include nursing professionals, hospice and palliative care professionals, senior medical management staff, and Quality Management staff. In addition, a clinical pharmacologist, a rehabilitation consultant, behavioral and social services experts, medical directors and other clinicians are provided, as appropriate. You are invited to refer your VNSNY CHOICE members to discuss their clinical issues on rounds, and as a participating provider, you are welcome to attend rounds. Please contact the VNSNY CHOICE Provider Relations Department for further information
5 PHYSICIANS CORNER A VISIONARY INITIATIVE AT VNSNY CHOICE: HOME EYE EXAMS Are your patients who are 65 years and older getting annual glaucoma screening? Are your diabetic patients getting their retinal eye exams? If not, it may be because they are frail, elderly or homebound and unable to arrange an appointment for their vision care due to inclement weather, transportation or physical limitations. Though you may have reminded your patients many times during their visits to your office, many have still not had these important screenings. By our review of claims, we know exactly who needs these screening exams. What now? VNSNY CHOICE Medicare, a special needs plan, has made home vision care available to our members. Our in-network home visiting optometrists are multilingual and have been making visits to homebound patients and are available to visit your VNSNY CHOICE Medicare patients. Our VNSNY CHOICE Medicare plans have seen a remarkable increase in compliance with vision screening since we initiated this program, which is clear from the rise in our Healthcare Effectiveness Data and Information Set (HEDIS) quality measures related to glaucoma and retinal eye exams. Please don t hesitate to refer your VNSNY CHOICE Medicare members to their Nurse Case Managers to arrange for these at-home visits. Simply call us at 1-800-783-1444 and ask for the medical management department. We will be happy to assist you or your patients and their families with this or other care management questions, seven days a week from 8 AM to 5 PM. VNSNY CHOICE HEDIS INFORMATION Continued from page 2 May I request a specific data collection method? MedReview staff will work with your office to identify the most efficient way to obtain the necessary chart information. We recognize that each office is unique, and that this review can be time consuming. Please discuss your office constraints at the time of scheduling, so we can explore alternatives. What types of services and information in the medical record will be reviewed? The types of services reviewed are specific to each HEDIS measure, but in general include: History Lab results Problem list Specialist consultations Chart notes for a specified period Who should I contact if I have further questions/concerns regarding HEDIS data collection? You may reach: Janet Stieg, RN, at 212-897-6033 or email janet-stieg@medreview.us.
6 Home Care Certification and Recertification Did you know it is sometimes possible to receive reimbursement from Medicare and other payers including VNSNY CHOICE Medicare for one piece of home care related paperwork? In 2001, Medicare began paying physicians for initial certification and recertification of homecare orders for patients receiving Medicare skilled home care. Medicare skilled home care usually includes things like skilled nursing care for a major wound or physical therapy to help patients recover after a stroke or major orthopedic surgery. In 2011, as part of health care reform, a requirement was added that the physician signing the home care orders (and billing for home care certification) also must see the patient in a face-to-face encounter at least every 60 days. During the face-to-face encounter, the need for skilled home care must be documented by the physician in the progress note. For example, if the skilled need is for wound care, the relevant physical exam would include an examination of the wound. Billing Codes for Home Care Certification: G0180: Initial Home Care Certification Can be billed only once during an episode of skilled home care Requires documentation in a face-to-face encounter as to why skilled home care is medically necessary Requires a signed and dated copy of the 485 form be maintained in the patients medical record (the original is returned to the home care agency) Can only be billed by one physician involved in the patients care Cannot be billed for long term custodial home care services, like home attendant or home health aide services The date of the bill for G0180 would match the date the 485 was signed (not the date of the face-to-face encounter which would be billed separately as an office or home visit) G0179: Home Care Recertification Can be billed on the rare occasion that the patient continues to require Medicare skilled homecare for longer than 60 days Cannot be billed more than once every 60 days Requires documentation in a face to face encounter as to why skilled home care is medically necessary Requires a signed and dated copy of the 485 form in the chart, the date of this recertification must be at least 60 days after the prior certification or recertification Can only be billed by one physician involved in the patients care Cannot be billed for long term custodial home care services like home attendant or home health aide services The date of the bill for G0179 would match the date the 485 was signed (not the date of the face to face encounter which would be billed separately as an office or home visit)
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8 VNSNY CHOICE 1250 Broadway, 11th Floor New York, NY 10001 How to Reach Us Provider Services: Phone: 1-866-783-0222 Monday through Friday from 8:00 AM to 8:00 PM www.vnsnychoice.org Meet the VNSNY CHOICE Provider Relations Department! Stephen Lai CAIPA and Lower Manhattan Carl Ross-Jennings Brooklyn MLTC, S.I. MLTC & Medicare Hopeton Gordon Brooklyn Medicare Ben Greis Queens Medicare Elizabeth Alvarez Queens MLTC Nicole De La Vega Brooklyn MLTC, Queens Medicare Sergio Ferguson Bronx MLTC & Medicare Elizabeth Vargas Manhattan MLTC & Upper Manhattan Medicare Has your office moved? Have you added a practice location? Remember to notify VNSNY CHOICE of changes to your office address or telephone number so we can update our records, including provider directories.