PARTICIPATING PROVIDER
ORIENTATION
First Choice VIP Care
This training program is designed to familiarize Providers with First
Choice VIP Care and the Plan
’
s Model of Care, the role of the Provider
in the Model of Care and the Plan
’
s resources available to the Provider
and Member.
3 3
•
First Choice VIP Care is a member
of the AmeriHealth Mercy Family
of Companies - industry leader in
managing medically complex
members.
•
Growing our vision and mission to
provide healthcare services to the
underserved.
•
First Choice VIP Care enables us
to offer our existing and eligible
chronically ill Medicaid members, a
seamless transition to a Medicare
Advantage Special Needs Plan.
Who We Are
We help people get care,
stay well and build healthy
communities.
We have a special concern
for those who are poor.
Mis
sion
Statement
Plan
Overview
Plan Overview
First Choice VIP Care is contracted to provide Medicare Hospital (A), Medical (B)
services, and Prescription Drug Coverage (Part D) services in the following counties;
Pickens, Greenville, Spartanburg, Anderson, Laurens, Abbeville, Saluda, Lexington,
Richland, Orangeburg, Berkeley, Charleston.
Members must live in one of these counties to join the plan.
First Choice VIP Care
Will accept only those beneficiaries with dual Medicaid/Medicare eligibility.
Summary of First Choice VIP Care’s Benefit Package
• Ambulance Services
• Cardiac and Pulmonary Rehabilitation Services
• Catastrophic Coverage • Chiropractic
• Dental Services
• Diabetes Program and Supplies
• Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
• Doctor Office Visits
• Durable Medical Equipment • Emergency Care
• Hearing Services • Home Health
• Hospice – Initial Consultation • Inpatient Hospital Care
• Inpatient Mental Health Care • Kidney Disease and Condition
• Out-of Network Catastrophic Coverage • Out-of-Network Initial Coverage
• Outpatient Mental Health Care • Outpatient Rehabilitation
• Outpatient Services/Surgery
• Outpatient Substance Abuse Care • Pharmacy
• LTC Pharmacy
• Mail Order Prescriptions
• Out-of-Network catastrophic Prescriptions • Outpatient Prescription Drugs
• Retail Pharmacy • Podiatry
• Preventive Services and Wellness/Education • Prosthetic Devices • Skilled Nursing Facility
Supplemental Benefits – Dental, Vision and Hearing
DENTAL SERVICES
Preventative Dental
•
Oral Exams – 1 every 6 months
•
Cleaning – 1 every 6 months
•
Fluoride Treatment – 1 every 6 months
•
Dental x-rays – 1 every year
•
Non – routine services, including minor
restorations (such as fillings, simple
extractions and denture repair)
Comprehensive Dental
•
Non-routine services
•
$500 every two years
•
Includes coverage for minor
restorations
•
Fillings, simple extractions and denture
repair
VISION SERVICES
•
Up to one supplemental routine Eye
Exam every year
•
Up to one pair of eyeglasses or
contact lenses every two years
HEARING SERVICES
•
Up to one supplemental routine
Hearing Exam every year
•
Up to one fitting evaluation for a
hearing aid every three years
•
Up to $1,000 coverage for hearing
aids every three years
Supplemental Benefits (continued) – OTC and Transportation
Over the Counter
• Typically includes medicines or
products that alleviate or treat
injuries or illness
• No statement from a medical
provider required or documentation
of a diagnosis to use the benefit
• Up to $60 every three months
• No roll-over quarter to quarter
Transportation Services
•
Must be Plan approved location
•
(24) one-way trips per year to a
plan approved location
•
Car, shuttle, van services,
including non-emergent
transportation to doctor visits,
preventive services, pharmacies
and fitness center
•
Authorization and scheduling rules
apply
Supplemental
Benefits
(continued)
– 24/7/365
Nurse
Line
If members are unable to reach their PCP’s office, registered nurses are
available 24/7days to assist members through the Nurse toll-free Call Line
First Choice VIP Care Nurse Call Line: 1-877-693-8275
Supplemental
Benefits
(continued)
– Rapid
Response
and
Outreach
Team
The Rapid Response and Outreach Team (RROT) consists of Care Managers (Nurses
and Social Workers) who are trained to help members investigate and overcome barriers
to achieve their healthcare goals. Outreach Services include:
•
Contacting members
•
Educating members
•
Calling Providers
•
Calling Pharmacies
•
Completing surveys and assessments to support special projects
Providers may request RROT support directly by calling toll free at
(800) 575-0418, 8 am – 5 pm, Monday through Friday.
Member Welcome Packet
First Choice VIP Care Member welcome packet:
Cover (Welcome) Letter
Provider & Pharmacy Directory
The Plan’s Formulary
Evidence Of Coverage (EOC) document
Health Risk Assessment (HRA) and return envelope
Multi-Language Insert
Notice of Privacy Practices
• Member materials including a summary of benefits compared to Original Medicare and complete evidence of coverage information are accessible via our web site at
www.firstchoicevipcare.com.
Member Identification and Eligibility Verification
Member eligibility varies. Providers can verify eligibility by using the following
Provider tools:
•
Calling Provider Services at: (800) 575-0418
•
Visiting our website at
www.firstchoicevipcare.com
and accessing
NaviNet
Member
Identification
Prior
Authorization
Requirements
• Elective / non-emergent air ambulance Transportation
• All out of network services (excluding emergency services)
• In-patient services
– All inpatient hospital admissions, including medical, surgical, skilled nursing and rehabilitation
– Obstetrical admissions/newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean.
– In-patient medical detoxification – Elective transfers for inpatient and/or
outpatient services between acute care facilities
• Behavioral health care (mental health and substance abuse services)
– Inpatient hospitalization – Outpatient services
• Home-based services
– Skilled nursing visits: authorization is required after 6 visits (per calendar year) – Home Health Aide Services: authorization
is required after 6 visits (per calendar year)
– Home infusions & injections: Authorization required for charges of $250 and over – Enteral Feedings, including related DME • Therapy and related services
– Speech therapy, occupational therapy and physical therapy provided in home or outpatient setting
– Chiropractic services – Cardiac rehabilitation
Prior
Authorization
Requirements
(continued)
• All DME rentals and rent to purchase items • Durable medical equipment/Medical
supply/prosthetic device purchases
– Purchase of all items in excess of $500 – Prosthetics and orthotics in excess of
$500 in total charges.
– The purchase of ALL wheelchairs (motorized and manual) and all
wheelchair accessories (components) regardless of cost per item.
– Nutritional Supplements • Hyperbaric oxygen
• Medications: 17-P and all infusion/injectable medications listed on the Medicare
Professional Services Fee Schedule with billed amounts of $250 or greater;
infusion/injectable medications not listed on the Medicare Professional Services Fee Schedule are not covered by First Choice VIP Care
• Surgery (for sleep
apnea/uvulopalatopharyngoplasty (UPPP) • Religious non-medical health care institutions
(RNHCI)
• Surgical services that may be considered cosmetic
• Cochlear implantation
• Gastric bypass/vertical band gastroplasty • Hysterectomy
• Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks
• Outpatient radiology services; CT scan, PET scan, MRI, MRA, MRS, SPECT scan,
nuclear cardiac imaging
• All miscellaneous/unlisted or not otherwise specified codes
• All services that may be considered experimental and/or investigational
All request for services are subject to Medicare coverage and limitations
Referral Requirements
Services
that
Require
Referrals
•
Specialist
visits
(except
Direct
Access
Services
– see
below)
•
Podiatry
services
•
Outpatient
diagnostic
procedures
(unless
otherwise
specified)
•
Ambulatory
surgery
center
services
•
Diabetes
self
‐
management
training
Direct
Access
Services
that
Do
Not
Require
Referral
•
Direct
access
to
women’s
specialists
for
routine
and
preventive
services.
•
Direct
access
to
mammography
and
influenza
vaccinations
Referral Submission
17
The PCP should follow the steps outlined below prior to advising the Member to
access services outside of the office:
•
Verify Member eligibility
•
Determine if the needed service requires a referral or Prior Authorization
•
Select a participating Specialist/ hospital or other outpatient facility appropriate
for the Member's medical needs from the Specialist Directory, as appropriate
•
If an appropriate Network Provider is not listed in the Network Provider Directory
please call Provider Services for assistance at (800) 575-0418.
Once a Network Provider is selected, the referral process can be completed
electronically or using the traditional paper process .
Electronic
Referral
Submissions
Electronic referrals through NaviNet:
PCP offices can use Referral Submission
to submit referrals quickly and easily, and can look
up referrals they submitted via Referral Inquiry.
Specialists, hospitals and ancillaries can use Referral Inquiry
to view and retrieve referrals.
•
Simply log on to NaviNet (
https://Navinet.Net
) and select First Choice VIP Care from Plan
Central
•
Select Referral Submission or Referral Inquiry and follow the steps to refer a patient or
view referrals
•
To find specific instructions about these transactions, refer to the User Guides listed under
Customer Service
If your office is not currently using NaviNet, you can enroll on-line at:
Paper
Referral
Submissions
19
Paper Referrals
Paper referral forms may be downloaded and printed from our website at www.firstchoicevipcare.comor hardcopies can obtained by calling Provider Services at (800) 575-0418.
• Issue a referral form for procedures requiring referrals.
• When issuing a referral form, make sure the form is legible and that all the required fields are completed. There is
a sample referral form on www.amerihealthvipcare.com under Provider Forms.
• The date of service must not be prior to the date the referral was requested.
• A copy of the paper referral must be submitted to the First Choice VIP Care. Please refer to the referral form or
www.firstchoicevipcare.com to select an option for submission.
Give a copy of the referral form to the member to present to the consulting specialist/hospital or other outpatient
Important Information - NaviNet
What is NaviNet?
–
A web-based solution for providers and health plans to share critical administrative,
financial and clinical data
–
America’s largest real-time healthcare communications network, securely linking
providers nationwide through a single website
Provider portal address:
–
https://connect.NaviNet.net
Informational web site
–
www.NaviNet.net
–
NaviNet
Web
Portal:
www.navinet.net
Phone:
(888)
482
‐
8057
Must be accessed via Internet Explorer v. 7.0 or above
–
Older versions of IE may not work appropriately
–
Not accessible via Firefox, Safari or Google Chrome
NaviNet (continued)
NaviNet Functions:
View Member Eligibility
Member Rosters
View Third Party Liability Information (TPL)
Claims Status & Updates
Prior Authorization
HEDIS Performance
On-Line Remittance Advice
Care Plans
Clinical Summary
Care Gaps
Provider
Claims
and
Customer
Service
Provider Services – (800) 575-0418
Provider claims issue resolution
Verify member eligibility
Verify PCP assignments
Obtain Member ID #
Claims Submission and Processing
First Choice VIP Care has a state of the art claims processing system and contact
centers
• Our average time for processing clean claims is less than 30 days
• Bill office visits and services on a CMS-1500 form or electronically
• Initial claims must be submitted within 365 days from date of service (or 60 days from receipt of primary EOB)
• Rejected claims (claims with missing data elements) must be corrected and resubmitted as a new claim within 90 days from the date the claim was rejected.
• Denied claims (claims that do not meet the requirement for payment under First Choice VIP Care guidelines must be resubmitted as corrected claims within 90 days from the date the initial claim was rejected
Paper claims should be sent to: First Choice VIP Care
Claims P.O. Box 307
Linthicum, MD 21090-0307
Electronic
Data
Information
(EDI)
To transmit claims electronically, contact your EDI software vendor and provide the First Choice VIP Care payer ID: A37510
– Arrange electronic claims submission through your EDI vendor or through Emdeon Provider Support at (877) 363-3661
Electronic Funds Transfer (EFT)
– Simplifies the payment process by providing fast, easy and secure payments – Reducing paper
– Eliminating checks lost in the mail
– Not requiring a change to your preferred banking partner
–
Enroll through our EFT partner, Emdeon Business Services or sign up via our
fast and easy links on www.firstchoicevipcare.comAccess to Care
Access to Care
First Choice VIP Care PCPs and specialists must meet standard guidelines as outlined in the provider manual to help ensure that Plan members have timely access to care
Access standards must:
• Assure member accessibility to health care services
• Establish mechanisms for measuring compliance with existing standards
• Identify opportunities for the implementation of interventions for improving accessibility to health care services for members
The following areas will be monitored by the Plan to ensure physicians’ access standards are continually met:
Office Accessibility
• PCP office hours must be clearly posted and reviewed with members during the initial office visit • The PCP is required to arrange for coverage of primary care services during absences due to
vacation, illness or other situations that render the PCP unable to provide services • A Medicare-eligible PCP must provide the coverage to Health Plan members
Provider
Appointment
Scheduling
Appointment Scheduling
• First Choice VIP Care monitors access standards on an annual basis. Specialists who are serving in the PCP role (i.e. Internal Medicine, Pediatrics, or OB/GYN) are subject to the PCP Access Standards
• Timely Access Standards for appointment availability for Primary Care Physicians (PCPs) and Specialists as outlined on slide 27
Missed Appointment Tracking
• If a member misses an appointment with a provider, the provider should document the missed appointment in the member’s medical record.
• Providers should make at least three attempts to contact the member and determine the
reason. The medical record should reflect any reasons for delays in performing the examination • Medical record should include any refusals by the member
Physician
Office
Standards
Primary Care Providers Access
standards:
Emergent Care 24X7request
• Immediately or referred to ER
Urgent Care
•
Within 2 calendar days
Routine Care
•
Within 14 calendar days of
member’s call
Specialty Care Providers
Access standards:
Routine Care
• Within 30 business days of request
Access
to
Care
Access to After-Hours Care
Members should have access to quality, comprehensive health care services 24 hours a day, 7 days a week.
• PCPs must have either an answering machine or an answering service for members during after-hours for non-emergent issues.
• The answering service will forward calls to the PCP or on-call provider, or instruct the member that the provider will contact the member within 30 minutes.
• When an answering machine is used after hours, the answering machine must provide the member with a process for reaching a provider after hours. The after-hours coverage must be accessible using the medical office’s daytime telephone number
• For emergent issues, both the answering service and answering machine must direct the member to call 911 or go to the nearest emergency room.
First Choice VIP Care will monitor access to after-hours care on an annual basis by conducting a survey of PCP offices after normal business hours
Provider Account Executives
First Choice VIP Care prides itself on having a provider representative available to
providers – an Account Executive
•
Your Account Executive will provide on-site education, issue resolution, and
assistance with credentialing
•
First Choice VIP Care will communicate through on-site orientations, routine site visits,
provider workshops, letters, the provider manual, the provider resource center on the
web site and provider newsletters
•
A listing of First Choice VIP Care Account Executives may be accessed via our web
site at
www.firstchoicevipcare.com
The
Provider
Manual
•
The First Choice VIP Care provider manual is on our web site at
www.firstchoicevipcare.com
•
The provider manual is an extension of your provider contract with First Choice VIP
Care
•
Identifies key provider roles & responsibilities
•
Member rights & responsibilities
•
The Plan’s Quality programs, credentialing & utilization management
•
The Plan’s Model of Care
Provider Marketing Compliance
The Center for Medicare and Medicaid Services (CMS) is concerned with provider
marketing activities for the following reasons:
•
Providers may not be fully aware of benefits & costs and may inadvertently misinform
the member
•
Providers may confuse the member regarding their role as their health care provider
versus acting as a plan representative
•
Providers may face a conflict of interest
Acceptable
Provider
Marketing
Practices
Acceptable Provider Marketing Practices:
• Provide the names of Plan sponsors with which they contract and/or participate
• Provide information and assistance in applying for the Low Income Subsidy (LIS)
• Make available and/or distribute First Choice VIP Care marketing materials
• Refer their patients to other sources of information, such as SHIPs, plan marketing representatives, the State Medicaid Office, local Social Security Office, CMS’ website at http://www.medicare.gov/ or 1-800-MEDICARE
• Share information with patients from CMS’ website, including the “Medicare and You” Handbook or “Medicare Options Compare” (from http://www.medicare.gov), or other documents that were written by or previously approved by CMS
Cultural and Linguistic Requirements
Our Cultural Competency program, has been built upon 14 of the national standards for
Culturally and Linguistically Appropriate Services (CLAS) as set forth by the Federal
Department of Health and Human Services
As a provider of health care services who receives Federal financial payment through the
Medicare and Medicaid programs, you are responsible to make arrangements for:
Standard 4- Language assistance at no cost to patients/consumers
Standard 5- Signage and written notices of interpreter services available at no cost
Standard 6- Use of qualified/certified interpreters and translators
Standard 7- Translation of vital documents
Language assistance information should be at all points of contact and during all hours of
operation
Slide 33
PJ1 Inserted a new slide, condensing the information about CLAS
Cultural
and
Linguistic
Requirements
Providers are required to:
•
Provide written and oral language assistance at no cost to Plan members with
limited English proficiency or other special communication needs, at all points of
contact and during all hours of operation. Language access includes the
provision of competent language interpreters, upon request
•
Provide members verbal or written notice (in their preferred language or format)
about their right to receive free language assistance services
•
Post and offer easy-to-read member signage and materials in the languages of
the common cultural groups in your service area. Vital documents such as
patient information forms and treatment consent forms, must be made available
in other languages and formats
Cultural and Linguistic Services Available
We have an arrangement to make our corporate rate available to participating plan
providers. For more information on using this telephonic interpreter services please
contact Provider Services at (800) 575-0418.
Providers who are unable to arrange for translation services for an LEP, LLP or sensory
impaired member should contact First Choice VIP Care Member Services at
1-866-654-3705 and a representative will help locate a professional interpreter who communicates
in the member’s primary language.
Providers may request a full copy of First Choice VIP Care’s Cultural Competency Plan
free of charge, or, access this information in the Provider Manual. For additional
information and to view the CLAS standards to go
www.omhrc.gov
. For language
Member Rights and Responsibilities
Member Rights and Responsibilities
Federal law requires that health care providers and facilities recognize member
rights. Members have the right to request and receive from their health care
provider, a completed copy of the Patient’s Bill of Rights and Responsibilities.
Providers may refer to the Provider Manual for a detailed listing of the
Member’s Rights and Responsibilities.
Fraud Waste and Abuse
Designed in accordance with federal rules and regulations, First Choice
VIP Care’s compliance program is aimed at ensuring compliance with all
Medicare Advantage program requirements and preventing and detecting
activities that constitute fraud, waste and abuse.
•
First Choice VIP Care has developed a Compliance and Fraud, Waste
and Abuse online training program. The program includes:
•
Compliance requirements
•
FWA policies and procedures
•
Investigation of unusual incidents and
•
implementation of corrective action
•
First Choice VIP Care has provider training materials available via its
website:
www.firstchoicevipcare.com
.
•
Materials, which are available by contacting the Provider Network
Management team, include information regarding the following…
Fraud Waste and Abuse
Fraud
“Fraud” is an intentional deception or misrepresentation made by a person with
the knowledge that the deception results in unauthorized benefit to that person
or another person. The term includes any act that constitutes fraud under
applicable federal or state law. As applied to the federal health care programs
(including the Medicaid and Medicare programs), health care fraud generally
involves a person or entity’s intentional use of false statements or fraudulent
schemes (such as kickbacks) to obtain payment for, or to cause another to
obtain payment for, items or services payable under a federal health care
program. Some examples of fraud include:
• Billing for services not furnished;
• Soliciting, offering or receiving a kickback, bribe or rebate; or
• Violations of the physician self-referral prohibition.
Fraud Waste and Abuse
Waste
“Waste” means to use or expend carelessly, extravagantly, or to no purpose.
Abuse
“Abuse” is defined as provider practices that are inconsistent with generally accepted business
or medical practice and that result in an unnecessary cost to the Medicaid or Medicare
programs or in reimbursement for goods or services that are not medically necessary or that
fail to meet professionally recognized standards for health care; or recipient practices that
result in unnecessary cost to the Medicaid or Medicare programs. In general, program abuse,
which may be intentional or unintentional, directly or indirectly results in unnecessary or
increased costs to the Medicaid program. Some examples of abuse include:
•
Charging in excess for services or supplies;
•
Providing medically unnecessary services; or
Fraud Waste and Abuse
False Claims Act
The Federal false claims act (FCA) is a federal law that applies to fraud involving
any contract or program that is federally funded, including Medicare and Medicaid.
Health care entities that violate the Federal FCA can be subject to civil monetary
penalties ranging from $5,000 to $10,000 for each false claim submitted to the
United States government or its contactors, including state Medicaid agencies.
The Federal FCA contains a “qui tam” or whistleblower provision to encourage
individuals to report misconduct involving false claims. The qui tam provision allows
any person with actual knowledge of allegedly false claims submitted to the
government to file a lawsuit on behalf of the U.S. Government. The FCA protects
individuals who report under the qui tam provisions from retaliation that results from
filing an action under the Act, investigating a false claim, or providing testimony for
or assistance in a federal FCA action.
Fraud Waste and Abuse
Reporting and Preventing FWA
Compliance with state and federal laws and regulations is a priority of First Choice VIP Care. If you or any entity with which you contract to provide health care services on behalf of First Choice VIP Care beneficiaries become concerned about or identifies potential fraud, waste or abuse, please contact: • First Choice VIP Care toll-free at (866) 833-9718; or
• You may also send an e-mail to the Medicare Compliance Officer at [email protected] to report potential FWA; or
• Report suspected Medicaid Provider Fraud or possible abuse, neglect or financial exploitation of patients in Medicaid facilities by contacting:
South Carolina Attorney General’s Medicaid Fraud Unit (803) 734-3660
OR
First
Choice
VIP
Care
–
The Model of Care
The First Choice VIP Care Model of Care is an Integrated Care
Management Approach to health care delivery and coordination for Dual
Eligible (Medicare/Medicaid) individuals.
The Model of Care focuses on:
• Improving Health Outcomes
• Access to Essential Services/Affordable Care
• Coordination of Care through the Medical Home/Primary Care Physician
• Access to Preventive Services
• Seamless Transitions
The Model of Care - Structure and Roles
Each member enrolls with a Medical Home/Primary Care Physician.
The model includes care and support from health care providers, community agencies
and service organizations.
A 26-question Health Risk Assessment (HRA) is used to collect;
– Physical and behavioral health history
– Preventive care
– Level of activity
– Medication use
The assessment is mailed with the Member
’
s welcome packet.
Staff follow up with the Member by phone and mail to collect the data.
Members receive an annual postcard reminding them to call the Plan and update the
HRA information.
Assessment
and
Plan
of
Care
Development
Data from multiple sources is used to develop the Plan of Care
:
•
Review of available claim and pharmacy history
•
Data from the Health Risk Assessment
•
Input from the member, Primary Care Physician and other providers
Interdisciplinary
Care
Team
Each member has an interdisciplinary care team that address
the member
’
s unique needs:
•
Primary Care Physician/Medical Home
•
Specialists – Physical & Behavioral
•
Health Plan nurses, Medical Directors, & pharmacists,
•
Home Health Care
•
Social Workers
•
Community Mental Health Workers
The PCP/Medical Home
The PCP/Medical Home has an important role in the Interdisciplinary
Team. Key Responsibilities include:
Assisting members to determine which services are necessary
Connecting members to appropriate service
Serving as a central communication point for the member’s care
Review the Plan of Care sent by the Health Plan
Providing feedback to the Health Plan
Updates to the Plan of Care
Updates are made routinely to the Plan of Care and come from multiple
sources:
Member or Provider call
Updated HRA (annual)
Care Transition (hospital, nursing home)
Claim, Pharmacy or Utilization trigger
Identifying
Vulnerable
Sub
‐
Populations
The Plan uses several mechanisms to identify vulnerable sub-populations:
•
Claim data is analyzed to identify members with:
•
Conditions targeted for chronic care improvement, such as diabetes, heart
disease, COPD and renal disease
•
Health needs, such as missing preventive care or recommended condition
monitoring
•
Utilization of emergency room and inpatient services is reviewed to identify members
with opportunities for improved outpatient management
•
Predictive Risk Scores are calculated using the DxCG methodology to identify
members who are at risk for future avoidable health care episodes
•
Health Risk Assessment data is reviewed for triggers identifying unmet health needs
or the presence of chronic conditions
Chronic Condition Improvement Programs
The Plan offers several Chronic Care Improvement Programs:
•
Diabetes
•
Asthma
•
Chronic Obstructive Pulmonary Disease
•
Depression
•
Members may self refer, be referred by a provider, or are identified
through claim data analysis
Clinical Practice Guidelines
The Plan’s Clinical Practice Guidelines are:
• Adopted from nationally-recognized organizations
• Serve as a guide to practitioners, but do not replace clinical judgment
• Available on the Plan’s website; hard-copy available from Provider Services
upon request
Guideline Topics
:
50
– Diabetes
– Anxiety Disorder in Adults – COPD
– Preventive Health Services
– Depression
– Coronary Vascular Disease – Hypertension
Provider
Focus
on
Preventive
Services
Remember, Medicare members have an annual preventive physical
examination. During each office visit please remember to:
• Coach the member on appropriate physical activity
• Ask about falls and fall prevention
• Ask and coach on smoking cessation
• List all relevant diagnoses on the claim
• Check to see if the member needs:
– Cancer Screening
– Mammography or Colonoscopy
– Glaucoma Testing
High
Risk
Medication
in
the
Elderly
Providers, please carefully evaluate alternatives prior to starting
an elderly member on the following medications:
Antihistamines (promethazine, cyproheptadine, diphenhydramine, hydroxyzine)
Skeletal Muscle Relaxants (cyclobenzaprine, methocarbamol, carisoprodol, chlorzoxazone) Oral estrogens
CNS Stimulants (amphetamines, anorexiants, methylphenidate)
Urinary Anti-infectives (nitrofurantoin, nitrofurantoin macrocrystals, nitrofurantoin macrocrystals-monohydrate
Narcotics(pentazocine, meperidine)
Others(dicylcomine, meprobamate, nifedipine IR, scopolamine, thioridazine, benzodiazepines, barbiturates)
Focus
on
Health
Outcomes
The Plan’s goals include improving health outcomes for:
Diabetes Care
– HgbA1 and LDL testing/management
– Diabetic retinal exam
– Nephropathy screening
– Blood pressure control
Cardiac Care
– LDL testing/management
– Beta-blocker treatment after heart attack
Blood Pressure Control
COPD Management
Focus
on
Seamless
Transition
Everyone plays a role ensuring seamless transition:
54
Health Plan Staff
Notify PCP/Medical Home of planned or unplanned
transition for admission and at discharge
Contact members to verify plans, establish point of contact
Provide Plan of Care
information to sending and receiving facility/provider, including changes at discharge
PCP
Contact admitting physician to coordinate care
After discharge, review and reconcile medications
See the member at office visit post discharge
Hospital
Send discharge summary/orders with medication list to Plan Admitting Physician be available to speak with the Medical Home/PCP regarding member’s care needs
Model of Care Evolution
The Plan’s Model of Care is evaluated using several data sources
:
Claims (medical, behavioral health, pharmacy)
Authorizations
HEDIS reports
Member surveys (CAHPS, HOS)
Practitioner and Facility surveys
Provider workshops
Communicating
the
Plan
of
Care
on
Transition
The Transition Team collects and communicates information related
to a member’s transition from one health care setting to another:
56
Transition Team
With Member & Provider Input
Sends Updated Plan of Care
Medical Home/PCP Hospital/Facility/Agency Receiving the Member
