We are delighted to announce that Ace Hodgin, M.D.

Transcription

1 Spring 2010 The Freedom Health Provider Newsletter Freedom Health Welcomes a New Chief Medical Officer We are delighted to announce that Ace Hodgin, M.D. has joined our team as Chief Medical Officer (CMO). He will oversee the health plan s Health Services Division, which includes Utilization Management, Case Management, Quality Assurance and Quality Improvement. Board certified in internal medicine, Dr. Hodgin received his medical degree from the University of Arizona and a Masters of Science in Health Administration from the University of Colorado. Dr. Hodgin has more than 26 years of experience in managed care services and executive leadership. He has held senior executive and chief medical officer roles with large size health plans as well as similar roles in IPA settings. His tenure includes management roles at PacifiCare and most recently, Bravo Health. His proven leadership and experience working with national Medicare and Medicaid health plans will be invaluable to us as we continue our pattern of phenomenal growth, Rupesh Shah, Freedom Health, CEO. I N S I D E Maximizing Care for the Special Needs Plans Population MIPPA Requirements for Special Needs Plans Patient Centered Medical Home Model Freedom Medicaid How to Bill for (CHCUP) Services Medicare and E-Prescribing What You Need to Know Free Webinar Registration How to Receive Incentive Payments How to Report E-Prescribing Measures Appeals & Grievances Basics Letter from our Chief Medical Officer Welcome to the Spring edition of The Pulse, a newsletter for Freedom Health physicians and providers. This year begins with the terrific opportunity to serve you. As the Plan grows and receives recognition among its peers, my focus is on continuing to make the health of your patients our first consideration. Inside is information that you and your practice can use when working with Freedom. This publication will be available to you on a quarterly basis both in print and through our website at You will find brief updates on medical management, claims processes and more. This edition highlights Special Needs Plans. Please take a moment to review the distinct levels of care and provider support available to your Freedom patients. Thank you for your participation in our programs and initiatives. I look forward to our collaboration in delivering exceptional patient care. Sincerely, Ace Hodgin, M. D. Chief Medical Officer Freedom Health, Inc am - 5pm, Mon - Fri TTY/TDD

2 Special Needs Plans Maximizing Care for Special Populations Special Needs Plans (SNP) are a type of Medicare Advantage coordinated care plan focused on individuals with special needs. Created by Congress in the Medicare Modernization Act (MMA) of 2003, the provision was re-established and expanded by the Medicare Improvements for Patients and Providers Act (MIPPA) of The plans target enrollment to one or more types of individuals with special needs identified by Congress as: 1) individuals with severe or disabling chronic conditions (15 categories). 2) dual eligible members (have Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit); and/or 3) institutionalized (SNP currently not available at Freedom for this population). Available Freedom Health Special Needs Plans Freedom Health s SNPs are tailored to members who have chronic conditions or are dual eligible. People who joined one of the plans listed below have a provider network, services and formulary benefits specially tailored to their condition and have all of their care coordinated through the Medicare SNP. PLAN NAME VIP Care VIP Care COPD VIP Savings VIP Savings COPD Medi Medi Partial DESCRIPTION Congestive Heart Failure (CHF), Cardiovascular Disease (CVD), and Diabetes Chronic Obstructive Pulmonary Disease (COPD), Chronic Lung Disorders, Asthma, Chronic Bronchitis, Emphysema, Pulmonary Fibrosis CHF, CVD, Diabetes COPD, Chronic Lung Disorders, Asthma, Chronic Bronchitis, Emphysema, Pulmonary Fibrosis Partial Medicare/Medicaid Duals Member Benefits An integrated network of physicians, facilities, and services to meet the special, diagnostic, and treatment needs of the SNP population; No or low co-pays to encourage use of preventative and ambulatory services ($0 PCP co-pay); Transportation services to increase access to care; Post hospitalization meal benefit to support frail member needs; Over-the-counter benefit; and $0 co-pay for home oxygen (COPD SNP). 2

3 MIPPA Requirements for Special Needs Plans The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 mandates specific quality and care measures for Special Needs Plans. To meet those requirements, collaboration among physicians, other providers and the Plan is essential. The role of a Primary Care Physician (PCP) is the cornerstone to success of this collaboration. Freedom Health has established the Patient Centered Medical Home Model to ensure Members receive all of the healthcare benefits available through a Special Needs Plan and the involvement of PCPs is crucial. Below is a brief overview. Patient Centered Medical Home Model PCP PLAN Delivers clinical care; Coordinates care across continuum (specialist and facility) using referrals and authorization requests; and Utilizes evidence-based care plans. Develops care plans, PCP and member education materials and guidelines; Drives multidisciplinary team; Provides comprehensive disease and case management; Coordinates social services support; Provides utilization management support; and Implements quality management program. To learn more about enrollment into one of our Special Needs Plans, please contact us at one of the offices listed below: Hillsborough/Pinellas: Phone: (813) ext 1200 Hernando/Pasco/Citrus: Phone: (352) Lee/Collier: Phone: (239) Marion/Lake/Sumter/Volusia: Phone: (352) Orange/Osceola/Seminole/Brevard: Phone: (407) Sarasota/Manatee/ Charlotte/Desoto: Phone: (941) Indian River/St.Lucie/Martin: Phone: (772) Sources: Centers for Medicare and Medicaid Services, Special Needs Plans at Your Guide to Medicare Special Needs Plans (SNPs) booklet, 3

4 MEDICAID Our Medicaid product, Freedom 1st is now available in the following counties: Miami Dade, Broward, Palm Beach, Manatee, Polk, Hillsborough and Marion. How to Bill for Child Health Check Up (CHCUP) Services Eligibility: Medicaid members are eligible for CHCUP services until their 21st birthday. Providers should bill for CHCUP s on a physician claim form using appropriate codes and modifiers. CHCUP claims can only be billed in the following formats: CMS1500, NSF, X12N 837P, or WINASAP 2003; Professional*. New Patient: An initial evaluation of a healthy individual requiring a history, exam, ordering of labs/diagnostics should be billed using one of the following codes: Infant (age under 1 year) Age 1 through 4 years Age 5 through 11 years Age 12 through 17 years Age 18 through 20 years - use EP modifier Established Patient: Re-evaluation of a healthy individual requiring a history, exam, labs/diagnostics should be billed using one of the following codes: Infant (age under 1 year) Age 1 through 4 years Age 5 through 11 years Age 12 through 17 years Age 18 through 20 years - use EP modifier Newborn Care: Services to newborns, including a physical exam, diagnoses, treatment & preparation of medical records should be billed using one of the following codes: (Old: 99431) Newborn Care - History and Examination (replaces code 99431) (Old: 99432) Normal Newborn Care - (replaces code 99432) (Old: 99435) Newborn Care - History and Examination (replaces code 99435) 4

5 Referral Codes: Federal regulation requires the inclusion of referral codes when billing for CHCUP services. For example, when referring a member for specialized treatment services because of a health problem identified during a CHCUP screening service, you should add the appropriate referral code from the list below. (In box 24H of a CMS 1500 form.) Code = AV Patient Refused Referral Code = S2 Abnormal, Treatment Initiated Code = N/NU No Follow-up Visit Needed Code = ST Abnormal, Child Referred for New Services Lead Testing: Blood lead screening as required. CPT code for venous lead testing: For children with abnormal blood lead levels, follow-up as appropriate. Dental Screening: A dental screening for children should include a direct referral to a dentist beginning at age 3 or earlier, if medically necessary. Vision & Hearing Screening: Perform objective testing, diagnosis and treatment, as required. Effective May 1st, Electronic Data Interface (EDI) claims submissions for Medicaid will be available through EMDEON. The Freedom 1st Payor ID number is Contact EMDEON with any transmission questions at Source: Florida Agency for Healthcare Administration (AHCA), Summer 2009 Provider Bulletin; AHCA website at ahca.myflorida.com. What You Need to Know About Medicare and E-Prescribing The Electronic Prescribing Incentive (erx) is a program for eligible healthcare professionals who are successful electronic prescribers (E-Prescribers). Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorized the program, which defines successful E-Prescribers as providers who: 1. Report the applicable e-prescribing quality measure in at least 50 percent of the reportable cases in a reporting year; or 2. Have at least 10% of Medicare Part B covered services made up of codes that appear in the denominator of the erx measure within a reporting period. In addition, providers must utilize e-prescribing systems that comply with the standards established in Part D Electronic Prescribing Program under section 1860D-4 of the Social Security Act. 5

6 erx Eligible Provider Types: Physician Physical or occupational therapist Qualified speech-language pathologist Nurse practitioner Physician assistant Clinical nurse specialist Certified registered nurse anesthetist Certified nurse midwife Clinical social worker Clinical psychologist Registered dietitian Nutrition professional Qualified audiologist (as of 2009) Incentives and Limitations The incentive has raised Medicare payments to providers who e-prescribe, with a 2 percent bonus in 2009 and 2010, a 1 percent bonus in 2011 and 2012, and a 0.5 percent bonus in However, beginning in 2012, the measure will penalize providers who do not e-prescribe, with a 1 percent Medicare payment penalty in 2012, a 1.5 percent penalty in 2013, and 2 percent in 2014 and thereafter. A provider may be exempt from the application of the payment adjustment if compliance with the requirement for being a successful E-Prescriber would result in a significant hardship. This is evaluated by the Centers for Medicare and Medicaid Services (CMS) annually and on a case by case basis. The American Recovery and Reinvestment Act of 2009 (Recovery Act), provides Medicare and Medicaid incentive payments to eligible providers, such as physicians and hospitals, in order to increase the adoption of electronic health records (EHRs). This includes added incentives for those who use electronic prescription programs (erx). Join our free webinar to: Learn about the Alteer Office Electronic Medical Record (EMR) and Dragon Easyspeak voice recognition systems, Watch a demo to see the usability of each system, and Learn how these systems can improve your practice and patient care. EMR and Voice Recognition Webinar, using Alteer Office and Dragon Naturally Speaking. Latte with Liza Latte with Liza Webinar Call or or LatteLiza@VHWus.com Please be sure to include the following in your voic or , so that we may send you the Webinar log-in instructions: Sponsored by Freedom Health and Visionary HealthWare Provider Network Affiliation (if any) Webinar Date You Wish to Attend Attendee Name Phone Number Address 6 Source: Department of Health and Human Services (hhs.gov) news release: Process Begins to Define Meaningful Use of Electronic Health Records.

7 How to Report the E-Prescribing Incentive Program Measures If eligible, you can report on the e-prescribing measure in two steps: STEP 1. Bill on one of the established denominator codes; and STEP 2. Report one of the three G-codes on more than 50% of applicable cases for the numerator. Each of the three codes (even the code for not generating prescriptions) counts toward the e-prescribing incentive. One of the G codes must be reported on the same claim as the denominator billing code. To Note Providers do not need to register to participate in this incentive program. Eligible professionals do not need to participate in Physician Quality Reporting Initiative (PQRI) to participate in the Electronic Prescribing (erx) Incentive Program. Updates to e-prescribing quality measures (specifications and/or reporting instructions) are available at on the CMS website. Reporting periods are for a calendar year, beginning with calendar year 2009 through Reporting options for this measure include: claims-based, registry-based, electronic health record (EHR)-based, and the Group Practice Reporting Option (GRPO). It s Back to Basics with Appeals & Grievances Freedom Health follows guidance from the Centers of Medicare and Medicaid Services (CMS) on the proper management of provider complaints, appeals and member grievances. Below is a brief overview on how to submit a request. Submit a provider complaint or a written claim appeal to: Provider Relations P. O. Box Tampa, FL Telephone: Fax: Submit a medical reconsideration request or member grievance to: Freedom Health, Inc. C/O Grievance and Appeals Coordinator P. O. Box Tampa, FL Telephone: Fax: Provider Complaints A provider who has a complaint may call the local Provider Relations representative or the Provider Services Department at the toll-free number listed above. Formal complaints will be addressed by the Grievance Department with the cooperation of any other departments involved with the complainant s concerns. Formal complaints will be resolved within 60 days of notification to Freedom. Claim Appeals Contact your Provider Relations representative for assistance with claim related questions. If an appeal is necessary, please submit your documentation within 90 days of explanation of payment (EOP) letter. Member Grievances A member, a member s representative or a provider on behalf of a member may submit a grievance by calling the Member Services department. All member grievances will be addressed by the Grievance department and given a resolution as promptly as possible but no later than 60 days from the date received. Medicare members should submit any issues within 90 days of the event that caused the grievance. Medicaid members can submit a grievance up to one year from the event. 7

8 Spring 2010 P.O. Box , Tampa, FL The Freedom Health Provider Newsletter It s Back to Basics with Appeals & Grievances (Continued from page 7) Member Appeals A member, a member s representative or a provider on behalf of a member may submit a member appeal by calling the Member Services department or sending a letter to the address listed above. Medicaid members may file an appeal within 30 days of the Plan s notice of action, or within one year if a notice was not issued. Medicare members should file their request within 60 days from the date of notice of the organization determination. The plan will resolve member appeals within the following time frames: 45 days for Medicaid members; Medicare members: a. 30 calendar days for medical care issues; b. 60 calendar days for payment issues. TEAR OUT Expedited Appeals Decisions are made as expeditiously as the enrollee s health requires and no later than 72 hours following receipt of the expedited request for appeal. Approval to expedite an appeal is granted when supported by the physician, indicating life or health of the enrollee is at risk if standard timeframes are applied. In the case of a necessary extension, the enrollee is notified of the determination as expeditiously as required by the enrollee s health condition but no later than 14 calendar days. - Report all Fraud and Abuse complaints through the customer service operations toll-free number. We Need to Know... The Centers for Medicare and Medicaid Services (CMS) requires that we keep certain information about our provider network. To allow us accurate reporting, please return this card with the appropriate information for your practice. We appreciate your help! Freedom Health Name 1. Are you currently an E-Prescriber? Yes, I prescribe electronically. Not at this time. 2. Does your practice meet the criteria for erx incentives? Yes No 3. Optional: I d like to receive information on your upcoming webinars. Please mail to: Freedom Health Provider Relations P. O. Box , Tampa FL or hand it to your local Provider Relations Representative. We are always here to serve you am - 5pm, Mon - Fri TTY/TDD