PROVIDER NEWSLETTER. Florida 2016 Issue II IN THIS ISSUE UPDATING PROVIDER DIRECTORY INFORMATION

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1 Florida 2016 Issue II PROVIDER NEWSLETTER UPDATING PROVIDER DIRECTORY INFORMATION We rely on our provider network to advise us of demographic changes so we can keep our information current. To ensure our members and Provider Relations staff have up-to-date provider information, please give us advance notice of changes you make to your office phone number, office address or panel status (open/closed). Thirty-day advance notice is recommended. NEW PHONE NUMBER, OFFICE ADDRESS OR CHANGE IN PANEL STATUS: Send a letter on your letterhead with the information being updated. Please include contact information if we need to follow up on the update with you. Please send the letter by any of these methods: Call: , Option 2 FloridaProviderRelations@wellcare.com Fax: This contact information is only for the updates mentioned above in bold. Any other correspondence sent through these channels will not be reviewed or processed. IN THIS ISSUE Updating Provider Directory Information...Page 1 Take Positive Action in Managing Medications...Page 2 Problem List Reminder for Medical Records...Page 2 Disease Management Improving Members Health...Page 3 Updated Clinical Practice Guidelines...Page 3 We Are Building a Website that Works for You...Page 3 Coding Corner...Page 4 Healthy Behaviors Program...Page 6 Q Provider Formulary Update...Page 6 Better Quality Is Our Goal...Page 6 Tips for Improving Seven-Day Follow-Up After Hospitalization for Behavioral Health Patients...Page 7 Enhanced Customer Service Technology...Page 8 Medicare Quality Overview...Page 9 How to Improve Patient Satisfaction and CAHPS Scores, Part 1 of 3... Page 10 How Care Management Can Help Your Patients...Page 11 Provider Satisfaction Survey...Page 12 Provider Resources...Page 12

2 TAKE POSITIVE ACTION IN MANAGING MEDICATIONS SIMPLE INTERVENTIONS PROMOTE PROPER DRUG USE, PATIENT SAFETY WellCare encourages providers to make sure your patients are using the medications they need in the way they should be used. Some proactive steps you can take in this area can drive beneficial outcomes for patients. Providers can almost instantaneously improve their patients health care status by systematically reassessing the indications for and dosages of all of the medications (including herbal, over-the-counter and topical preparations) used by their patients. It s also the perfect time to uncover the use of illicit drugs and improper consumption of alcoholic beverages. For patients on a daily medication regimen, the use of a pill carrier, or even two if a patient is on an AM-PM dosing schedule, will help with compliance. Encouraging the use of this user-friendly tool can keep your patients on track with the medications they need to take and when they need to take them. Do you ask your patients if they keep an up-to-date list of all their medications in their wallet or purse? Does the list also include their known allergies? If not, you may want to encourage them to do so. When a patient goes to an emergency room or sees a specialist, a list of his/her current medications can keep his/her care on track, highlighting the need to treat the complete patient and potentially avoiding harmful drug-drug interactions. For Medicare patients discharged from an acute or non-acute facility, remember that the prescribing practitioner or clinical pharmacist should reconcile the discharged medications with the most recent medication list in the patient s medical record. This should be completed within 30 calendar days of discharge. An outpatient visit isn t required, just documentation in the patient s medical record that the reconciliation was conducted. Medical record documentation should include: Notation that medications prescribed upon discharge were reconciled with current medications by the appropriate practitioner, or Medications listed in the discharge summary are present on the outpatient medical record and evidenced by reconciliation with current medications by the appropriate practitioner, or Notation that no medications were prescribed upon discharge. PROBLEM LIST REMINDER FOR MEDICAL RECORDS Early this year, WellCare of Florida underwent an onsite audit by the National Committee for Quality Assurance (NCQA) which consisted of a comprehensive review of randomly selected medical records from participating providers. The results showed that 84 percent of the 50 medical records reviewed contained a designated problem list. These results have been sent to the Agency for Health Care Administration (AHCA) as part of our state reporting requirements. WellCare of Florida is dedicated to the facilitation and delivery of continuous and coordinated medical care and the inclusion of a standardized problem list is an integral part of this initiative. The problem list contains documentation of past and current medical treatment, health status and treatment plans. This is an easy-to-access tool that assists providers in treating the member s total health. Therefore, WellCare of Florida encourages all providers to use and maintain a current problem list for all members within their medical health records. To obtain an acceptable problem list, Medicaid providers may call and Medicare providers may call for assistance. 2

3 DISEASE MANAGEMENT IMPROVING MEMBERS HEALTH Disease Management is a no-cost, voluntary program to assist members with specific chronic conditions. A member is assigned a disease nurse manager who can help the member with: Education and understanding of his or her specific condition Identification of adherence barriers and ways to overcome them Individualized lifestyle modification suggestions to improve daily life Self-management of the member s condition to improve health outcomes Motivational coaching to encourage members when they face difficulties Improved communication with the member s primary care provider and health care team Disease Management can assist your members with the following conditions: Asthma Chronic obstructive pulmonary disease (COPD) Congestive heart failure (CHF) Coronary artery disease (CAD) Depression Diabetes Hypertension Obesity Smoking cessation For more information, or to refer a member to Disease Management, please call us at UPDATED CLINICAL PRACTICE GUIDELINES Clinical Practice Guidelines (CPGs) related to adult preventive health as well as diabetes have been updated and added to the provider website. Visit to access other CPGs related to preventive health and behavioral health as well as chronic conditions. WE ARE BUILDING A WEBSITE THAT WORKS FOR YOU WellCare recently launched a redesigned public website. Now we re redesigning our secure provider portal, where you can log in to complete tasks such as: Check member eligibility and co-payment information Submit authorization requests and check status Submit claims and check status View open care gaps and access reports Access a personal inbox with direct messages from WellCare What s next? We are visiting some of you, our providers, to find out how we can improve our website tools. We are planning to talk to people in billing, admissions, care coordination and more. Your feedback will help shape our new portal! Stay tuned for updates on the project. 3

4 CODING CORNER NOTIFICATION OF CLAIM EDITING UPDATE The information outlines updates to claim editing that are effective 02/01/2016. CLAIM EDITING UPDATE DESCRIPTION OF SERVICE UPDATES EFFECTIVE Multiple Initial Hospital Care within 3 Days According to WellCare s policy, an initial hospital care service (CPT ) billed within 3 days of a prior initial hospital care service for the same diagnosis should be billed with a subsequent hospital care service code (CPT ), not an initial hospital care service code, because the services rendered for the same diagnosis represent a continuation of the same episode of care. Effective 02/01/2016, WellCare Health Plans will deny claims for an initial hospital care service if an initial hospital care service has been billed in the previous 3 days with the same diagnosis by the same provider. Medical necessity dispute rights will be provided. Non-obstetric Transvaginal US and Non-obstetric Transabdominal US Pelvic ultrasound (76856 or 76857) and transvaginal ultrasound (76830) evaluate the patient for the same conditions at the same session. Therefore, they represent redundant services, and WellCare will not pay separately for the pelvic echography unless there are extenuating circumstances as to why both studies had to be performed. Effective 02/01/2016, WellCare Health Plans will deny claims for non-obstetric pelvic ultrasounds when billed with transvaginal ultrasounds. Medical necessity dispute rights will be provided. Arthrocentesis According to CMS policy, there are specific diagnoses that are appropriate indications for arthrocentesis, aspiration or injection of a major joint (20610 or 20611). Effective 02/01/2016, WellCare Health Plans will deny claims for arthrocentesis, aspiration or injection of a major joint when submitted without an appropriate diagnosis code. Medical necessity dispute rights will be provided. Continued on next page 4

5 Continued from previous page Screening Electrocardiogram (ECG) for Coronary Disease in Asymptomatic Adult Patients According to the U.S. Preventive Services Task Force (USPSTF), an electrocardiogram should not be performed routinely on asymptomatic adults who are at low risk for coronary heart disease. The USPSTF has determined that the incremental information provided by the resting electrocardiogram (beyond that obtained with conventional risk factor assessment) is not likely to alter risk stratification or improve clinical outcomes. USPSTF recommends against using electrocardiogram to screen for coronary disease in asymptomatic adults who are at low risk for coronary disease. Effective 02/01/2016, WellCare Health Plans will deny claims for (electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) when billed in the office setting, for patients 18 years of age and older, without an appropriate diagnosis. Medical necessity dispute rights will be provided. Duplex Scan for Carotid Artery Stenosis (CAS) in Asymptomatic Adult Patients According to the U.S. Preventive Services Task Force, it is not appropriate to screen for coronary disease in asymptomatic adult patients. Therefore, WellCare will not pay for a duplex scan of extracranial arteries (CPT or 93882) when it is billed in the office setting (POS 11) for a patient age 18 or older without a supporting carotid artery stenosis symptom diagnosis. Effective 02/01/2016, WellCare Health Plans will deny claims for duplex scans of extracranial arteries when billed in the office setting when the patient's age is more than 18 years and a diagnosis of carotid artery stenosis symptom is not present. Medical necessity dispute rights will be provided. NOTICE OF NEW INBOUND EDITS FOR FLORIDA MEDICAID CLAIMS AND ENCOUNTERS Effective March 15, 2016, WellCare began rejecting all institutional inpatient claim submissions that are billed in error with covered days that exceed the statement period and when either principal surgical or other surgical procedure codes billing dates are outside the period covered by the date span. These new Strategic National Implementation Process (SNIP) edits will align WellCare with the Florida Agency for Health Care Administration (AHCA) requirements. CLAIM REJECT ERROR DESCRIPTIONS: Missing or Invalid Value Code or Value Code amount. Expected Value Code 80 and Value Code amount to be a whole number of covered days. Invalid principal procedure date: per Agency for Health Care Administration (AHCA) billing guidelines, must be within statement billing dates. Invalid other procedure date: per AHCA billing guidelines, must be within statement billing dates. For more details, please refer to the pre-notification communication posted November 20, 2015 on the secure Florida provider portal for both the covered days and surgical codes. To access the secure provider portal, visit and select Provider Secure Login in the Provider drop-down menu on the top of the page. 5

6 MEDICAID HEALTHY BEHAVIORS PROGRAM The Healthy Behaviors Program rewards members for taking small steps that will help them live healthy lives. For simple tasks like completing primary care provider (PCP) visits, prenatal visits, and certain health checkups, members can earn rewards that are placed on reloadable Visa cards. Members can use these cards at a variety of locations to purchase items including milk, bread, diapers and over-the-counter (OTC) items from a pharmacy. The more services members complete, the more they can earn. In addition to receiving a reloadable Visa card, members can receive a discount card when they complete certain healthy activities such as: completing an HRA form within 90 days of enrollment, visiting their PCP within 90 days of enrollment, and attending a smoking cessation program. Providers can encourage their patients to participate in the Healthy Behaviors Program by signing and including their provider ID on applicable activity reports. For more information on WellCare s Healthy Behaviors Program, please contact your Provider Relations representative or call one of the Provider Services phone numbers at the end of this newsletter. Q PROVIDER FORMULARY UPDATE MEDICAID: The Staywell Preferred Drug List (PDL) has been updated. Visit ahca.myflorida.com/medicaid/ Prescribed_Drug/pharm_thera/fmpdl.shtml to view the current Staywell PDL and pharmacy updates. Visit Medicaid/Pharmacy for the Healthy Kids PDL and pharmacy updates. You can also refer to the Provider Manual available at Medicaid to view more information regarding WellCare s pharmacy Utilization Management (UM) policies and procedures. MEDICARE: There have been updates to the Medicare formulary. Find the most up-to-date complete formulary at Medicare/Pharmacy. You can also refer to the Provider Manual available at Medicare to view more information regarding WellCare s pharmacy UM policies and procedures. MEDICAID BETTER QUALITY IS OUR GOAL Our Quality Improvement (QI) Program is dedicated to finding ways to help deliver better care and services to our members in collaboration with our providers. SOME 2015 QI PROGRAM GOALS WE ACCOMPLISHED INCLUDE: Increased awareness around member satisfaction survey. Expanded the electronic medical record (EMR) flat file submission in the Florida network. Increased overall Star score for Medicare plan and Medicaid HEDIS measures meeting the 50 th percentile nationally. OUR GOALS FOR 2016 INCLUDE: Develop Consumer Advisory Board (CAB). Continue to execute on the integration of behavioral and medical strategies. Continue to solicit more providers to engage in the EMR flat file program for the exchange of HEDIS data. Explore alternative methods of care delivery (mobile, telephonic, etc.). We look forward to continuing to partner with our providers to ensure our members get the best care. To receive a copy of our QI Program description, please call our QI Department at

7 TIPS FOR IMPROVING SEVEN-DAY FOLLOW-UP AFTER HOSPITALIZATION FOR BEHAVIORAL HEALTH PATIENTS WellCare offers the following tips to improve seven-day follow-up after hospitalization for behavioral health (BH) patients: Please refer to the current Agency for Health Care Administration (AHCA) Medicaid (MMA) technical specifications for encounter/claims coding and practitioner information: LTC/Report_Guides/ /MMA_Performance_Measure_Specifications_ docx. BH inpatient facilities are expected to provide discharge instructions to WellCare s BH Utilization Management Department with 24 hours of discharge. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards require that transitions of care interventions from one setting to another are necessary to prevent/reduce BH inpatient readmissions. These discharge instructions must include specific discharge follow-up appointment information and updated contact information on the member so that WellCare s BH Utilization Management/Care Management staff is able to contact the member. For BH inpatient facilities that provide outpatient services, it is essential that you engage with your outpatient services to ensure that members are provided with an outpatient follow-up visit within three to five calendar days of discharge and that the appointment and contact information is given to the member at discharge. Optimally, this appointment should occur (and can be billed) on the day of discharge and the member can be walked over to outpatient services site for the appointment. The best practice is to have the inpatient practitioner and outpatient practitioner meet with the member and explain the importance of the seven-day follow-up appointment and transfer the member s care to the outpatient practitioner. For BH inpatient facilities that do not have outpatient services, it is essential to coordinate discharge follow-up appointments within seven days of discharge with outpatient BH facilities in the community. As noted above, the best practice is to coordinate this follow-up appointment with the outpatient practitioner and transfer the member s care to the outpatient practitioner. BH inpatient facilities can ask their BH Provider Relations representative about arranging bridge appointments (which occur on the day of discharge from the inpatient facility) with outpatient facilities in the community. BH inpatient facilities should ensure that members are able to have discharge medications in hand at the time of discharge; that members and caregivers are educated on the indications for these medications; and that members and caregivers understand how to administer these medications. Research indicates that between 40 and 50 percent of individuals with serious mental illness do not adhere to prescribed medications (Journal of Clinical Psychiatry. Oct. 2002; ). For members with histories of medication non-adherence, long-acting injectable medications should be considered. BH inpatient facilities should provide instructions to members on how to arrange transportation (a covered Medicaid service) to discharge follow-up appointments. BH outpatient practitioners should provide telephone reminders to members about discharge follow-up appointments with 72 hours of discharge and follow up with the member as soon as possible if he or she misses his or her appointment. If you have any questions about these tips, contact your BH Provider Relations representative. 7

8 ENHANCED CUSTOMER SERVICE TECHNOLOGY WellCare is dedicated to providing customer satisfaction and operational excellence in the communities we serve. We understand patient care is the priority, and your time is important. In order to make it easier for providers to do business with us, we have implemented some major technology improvements. Here are some of the improvements as well as tips for navigating the new system: ENHANCED PHONE CAPABILITIES WellCare has implemented a new Interactive Voice Response (IVR) system designed to enhance our communication channels and selfservice functionality for a better customer experience. IVR ENHANCED FEATURES AND FUNCTIONALITY: New technology to expedite provider verification and authentication within the IVR Provider/member account information is sent directly to the agent desktop from the IVR validation process so you don t have to reenter information saving you time Full speech capability, allowing you to speak your information or use your touch-tone keypad SELF-SERVICE FEATURES: Ability to receive member co-pay benefit information Ability to receive member eligibility information Ability to receive authorization information Unlimited claims information on full or partial payments and for multiple lines of claims denials Rejected claims information is now available through self-service TIPS FOR USING OUR IVR Please have the following information available with each call: Your WellCare provider ID number NPI or tax ID number for validation if you do not have your WellCare provider ID number For claims inquiries the member s ID number, date of birth, date of service and dollar amount For authorization and eligibility inquiries the member s ID number and date of birth WellCare also offers online resources via our secure provider Web portal such as: Member eligibility and co-pay information Authorization requests Claims status and inquiries Provider news Personal inbox with specific messages from WellCare To register, refer to the Provider Resource Guide. To contact Provider Services directly, call the state-specific, toll-free phone number provided on your Quick Reference Guide. For detailed instructions on using the IVR, see the Provider Phone Access Guide Job Aid. All documents are located on our website at Florida/Providers. Click on Overview under Medicaid or Medicare. If you wish to reach our EDI team for specific inquiries, you may reach them via at EDI-Master@wellcare.com. 8

9 MEDICARE MEDICARE QUALITY OVERVIEW QUALITY IMPROVEMENT PROGRAM GOALS WE ACCOMPLISHED IN 2015 INCLUDE: Completed assessments for members who are part of the WellCare D-SNP population. Completed individualized care plans for D-SNP members. Conducted interdisciplinary care teams with providers and health plan care managers to ensure that quality care is provided. Reviewed data on quality outcomes for diabetes, congestive heart failure, chronic obstructive pulmonary disease, and mental health diagnoses to ensure members receive high quality care. Deployed Clinical Healthcare Effectiveness and Data Information Set (HEDIS ) Practice Advisors to assist providers in improving health care outcome rates. Enhanced Care and Disease Management Programs by adding Health Coaches and expanding field-based resources. Continued to implement and expand the Community Advocacy Team throughout WellCare markets to ensure all members and providers share access to community resources. OUR CONTINUED GOALS FOR 2016 INCLUDE: Improving the WellCare D-SNP Model of Care Program to assist members with receiving the right care at the right time in the right setting. Reviewing and measuring the quality of care and services that our members receive. Working with providers as a team to help meet members health care needs. Working with providers to organize care so that together we can coordinate our members health care and improve their quality of service. Contracting with and maintaining high performance provider networks. Reviewing and updating our guidelines to ensure that a safe and healthy environment for care is maintained. Focusing on performance indicators as an organization to achieve quality excellence. WellCare appreciates our providers partnership in ensuring our members receive the best care. To receive a copy of our Medicare Quality Improvement Annual Evaluation and/or the D-SNP Model of Care Evaluation, please call Customer Service. 9

10 HOW TO IMPROVE PATIENT SATISFACTION AND CAHPS SCORES, PART 1 OF 3 WHAT IS THE CAHPS? The Consumer Assessment of Healthcare Providers and Systems (CAHPS ) surveys ask patients to evaluate their health care experiences. WellCare conducts an annual child CAHPS survey, which asks parents or guardians to rate experiences with their child s health care providers and plans. As a WellCare provider, you can provide a positive experience on key aspects of their child s care; we ve provided some examples of best practices to help with each of the sections. KNOW WHAT YOU ARE BEING RATED ON: 1. Getting Needed Care Ease of getting care, tests, or treatment child needed Obtained child s appointment with specialist as soon as needed. TIPS TO INCREASE PATIENT SATISFACTION: Help patients by coordinating care for tests or treatments and by scheduling specialist appointments or advising when additional care is needed to allow time to obtain appointments. 2. Getting Care Quickly Child obtained needed care right away. Child obtained appointment for care as soon as needed. Educate your patients on how and where to get care after office hours. Do you have on-call staff? Let your patients know who they are. 3. How Well Doctors Communicate Child s doctor explained things in an understandable way. Child s doctor listened carefully. Child s doctor showed respect. Child s doctor spent enough time with your child. The simple act of sitting down while talking to patients can have a profound effect. Ask your patients what is important to them; this helps to increase their satisfaction with your care. 4. Shared Decision Making Doctor/health provider talked about reasons you might want your child to take a medicine. Doctor/health provider talked about reasons you might not want your child to take a medicine. Doctor/health provider asked you what you thought was best for your child when starting or stopping a prescription medicine. Use office staff other than physicians to distribute decision aids that could help more patients learn about the medical decisions they are facing or simply to address medications. Decision making tools and quick reference guide are available at: professionals/education/curriculum-tools/ shareddecisionmaking/tools/index.html. Ask your patients, What should I know about you that may not be on your medical chart? 5. Coordination of Care In the last six months, did your child s personal doctor seem informed and up-to-date about the care your child got from other health providers? Your office staff should offer to help your patients schedule and coordinate care between providers. Continued on next page 10

11 Continued from previous page 6. Rating of Personal Doctor Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your child s personal doctor? Studies have shown that patients feel better about their doctors when they ask patients, What s important to you? 7. Rating of Specialist Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist? Help your members value their visit to a specialist and to be informed about their visit and the specialist s advice. Make sure both you and your medical team know the questions your practice is being rated on. Knowledge is power. For more information and research on ways to improve patient satisfaction, see Flipping Health Care: From What s the Matter? to What Matters to You? You can access this article and a video at the websites below. Sources and References: Christina Gunther-Murphy-What Matters Office Practice Setting IHI Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey HOW CARE MANAGEMENT CAN HELP YOUR PATIENTS Care Management helps members with special needs. It pairs a member with a care manager. The care manager is a registered nurse (RN) or licensed clinical social worker (LCSW) who can help the member with issues such as: Complex medical and behavioral health needs Solid organ and tissue transplants Chronic illnesses such as asthma, diabetes, hypertension and heart disease Children with special health care needs Lead poisoning For more information about Care Management, or to refer a member to the program, please call us at This no-cost program provides access to a registered nurse or licensed clinical social worker Monday Friday, from 8 a.m. to 5 p.m. We re here to help you! 11

12 PROVIDER SATISFACTION SURVEY WellCare is conducting the annual Provider Satisfaction Survey from May through July in all WellCare markets. Administered by SPH Analytics, the survey targets health care providers to measure satisfaction with WellCare, as well as support NCQA Standards for Health Plan Accreditation. PCPs, specialists and behavioral health providers are randomly selected and surveyed by mail, Internet and phone. Your participation is encouraged and appreciated. PROVIDER RESOURCES WEB RESOURCES Visit to access our Preventive and Clinical Practice Guidelines, Clinical Coverage Guidelines, Pharmacy Guidelines, key forms and other helpful resources. You may also request hard copies of any of the above documents by contacting your Provider Relations representative. For additional information, please refer to your Quick Reference Guide at or Florida/Providers/Medicare. PROVIDER NEWS Remember to check messages regularly to receive new and updated information. Visit the secure area of to find copies of the latest correspondence. Access the secure portal using the Provider Secure Login area in the Provider drop-down menu on the top of the page. You will see Messages from WellCare located in the column on the right. ADDITIONAL CRITERIA AVAILABLE Please remember that all Clinical Coverage Guidelines detailing medical necessity criteria for several medical procedures, devices and tests are available on our website at WE RE JUST A PHONE CALL OR CLICK AWAY! Medicare: Staywell FL033245_PRO_NEW_ENG Internal Approved Staywell Kids WellCare 2016 FL_03_16 12 FL6PRONEW74078E_0316