More than a score: working together to achieve better health outcomes while meeting HEDIS measures

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1 NEVADA ProviderNews Vol More than a score: working together to achieve better health outcomes while meeting HEDIS measures We know you ve heard of Healthcare Effectiveness Data and Information Set (HEDIS ), which was established by the National Committee for Quality Assurance (NCQA). We send you report cards, letters and reminders about members overdue for services related to HEDIS measures. You might even be eligible for incentive payments when helping members get these important services. We thank you for giving our members the highest quality care possible. Working together to meet these benchmarks, we have the best chance of improving our members health outcomes and, ultimately, their quality of life. Our Quality Improvement program When it comes to quality, we re guided by: n Sound advice from internal and external experts n Standards set by the Nevada Division of Health Care Financing and Policy (DHCFP) and NCQA n Current research that forms the criteria we use n First-hand experience from case managers who know our members needs Our comprehensive program: n Adheres to HEDIS standards and measures our progress to meet annual goals n Objectively monitors and evaluates the care and services our members receive n Reflects the demographic and epidemiological needs of each population served n Encourages both members and providers to recommend improvements n Identifies ways we can promote and improve patient safety Summary of 2013 Amerigroup quality improvement program achievements: n Awarded one of the two Medicaid Managed Care contracts in Nevada to provide Medicaid recipients access to health services providers.amerigroup.com/nv n Increased community outreach and education provided over 10,000 phone calls, arranged 2,000 appointments, and supported nearly 150 health and wellness events in the community n Amerigroup medical director met with individual provider group leaders to discuss challenges and opportunities to increase preventive health rates and member care n Distributed HEDIS report cards to providers showing performance as compared to NCQA and Amerigroup aggregate scores n Began collaboration with DHCFP to develop strategies to accommodate the 2014 Medicaid expansion n Implemented a new credentialing system to streamline and improve communications between our health plan and providers n Integrated technology to improve our services, such as a provider self-service website to check precertification requirements and submit requests, supporting documents and claims appeals, and mobile apps for members to access referral directories and ID cards HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Our Quality Management program direction in 2014: n Prepare for successful NCQA accreditation n Institute new member welcome meetings, providing education to both English and Spanish-speaking members on health benefits, rights and responsibilities, preventive care guidelines, communication with providers, and how to use their health services n Implement a monthly provider orientation webinar n Monitor health care needs of new expansion population including behavioral health and more complex chronic disease management n Increase interventions to continue improving overall performance measures n Expand medical records review in primary care providers and OB-GYN offices to monitor compliance with EPSDT, preventive care, and chronic disease management. To review the Quality Management (QM) program summary, contact Quality Management at We welcome your suggestions! Contact your Provider Relations representative or the QM director to let us know how we might improve our program or if you would like to participate in the medical advisory committee.

2 Our benchmarks for clinical performance and service satisfaction In the summer of 2013, the provider satisfaction survey was distributed to 529 providers representing contracted provider groups. More than 34 percent (34.5 percent) of providers responded to the survey. Amerigroup Nevada received an 82 percent overall satisfaction score. Nearly nine in 10 providers (87 percent) would recommend Amerigroup to other physicians: n Providers noted highest satisfaction ratings in areas of technology, claims processing and reimbursement, network and utilization management n Areas increasing more than 10 percentage points from the previous year were pharmacy and drug benefits, Disease Management Centralized Care Unit (DMCCU), continuity and coordination of care n The Easy to work with Amerigroup rating increased from 62 percent in 2012 to 74 percent in 2013 surveys The areas with greatest opportunity for improvement: n Customer service knowledge and information about claims to resolve issues n Quality management clinical practice guidelines and Early and Periodic Screening, Diagnosis and Treatment (EPSDT) member outreach initiatives Through your feedback, we have moved toward first-call resolution to increase provider satisfaction and have initiated monthly provider orientation webinars to share information, receive feedback, and to provide staff training and resources. When we asked how we could help providers serve Amerigroup members, your number one suggestion was through education and communication. Providers suggested we improve how we explain our benefits to members and that we increase communication with patients as well. To that end, marketing and quality management staff now offer monthly new member meetings at various locations throughout Clark and Washoe counties. Topics include benefits, preventive care, memberprovider communications, and a questions and answers session. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality. Provider satisfaction survey: This annual survey is conducted to gain insight from our providers about our performance as a health plan. The survey covers areas such as communication, technology, claims processing and customer service. Healthcare Effectiveness Data and Information Set (HEDIS): A program developed by the NCQA to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 80 measures across five domains of care. Consumer Assessment of Healthcare Providers and Systems (CAHPS ): A survey evaluating member satisfaction with care and services received through the past six months by questioning a random sample of plan members about their doctors and the health plan. HEDIS, CAHPS and the provider satisfaction survey results help us identify areas of strength and areas where we need to focus our improvement efforts. We use the results to: n Measure our performance against our goals n Determine the effectiveness of actions we implemented to improve our results n Continually improve our operations and strengthen our relationship with providers Thank you for participating in our network, for providing quality health care to our members and for cooperating in our annual review process.

3 HEDIS: Quality is more than just the HEDIS scores. It s about the woman in high-risk case management who delivers a healthy full-term baby or the child with well-controlled asthma who can run and play with his friends. We reach out to members through mailings, phone calls, health fairs and other activities. As a physician, you can help improve quality care delivery by using every opportunity to assess members health. For example, use a child s sick visit for URI to also complete the EPSDT/well-child exam or be aware of the potential link between increased BMI, childhood obesity, asthma symptoms and increased incidence of childhood diabetes. This year, 46 percent of our HEDIS scores increased by 0.3 to percent, but the results still indicate that we re not taking advantage of opportunities to impact the quality of our members health for today and in the future. This year, we were pleased to see the members satisfaction ratings of the health plan, personal doctor and specialist met the 50th percentile. Other areas, such as getting needed care, getting care quickly and how well doctors communicate remained in the 10th percentile. CAHPS: In the annual CAHPS survey, members provide feedback on the strength and weaknesses of the health care system. Surveys are sent to adult The health plan initiated new member members and also to the orientation meetings this year to tell members parents of pediatric members. about their health plan benefits and how to navigate the system. Discussion with members revealed members were confused about what to expect, beginning with the first phone call to the doctor s office through the after-appointment checkout. Basic questions include: What happens next? How long does it take? What do I need to do? Many of the issues are related to office processes and interactions and are influenced by communications and fear of the unknown. By improving staff awareness of the importance of communication and educational skills, we can positively impact member understanding.

4 Quality improvement resources for you We re here to support you in delivering timely, quality care to our members. Here are some tools you can take advantage of as a valued provider in our network. This information is also available on the provider website at providers.amerigroup.com/nv. Access to case management In addition to our disease management program, we also offer complex case management for our high-risk members as a component of our population health programs. Using claims and utilization data, we identify members at risk for or susceptible to certain diseases. Then, we: Use evidence-based guidelines to coordinate care with the members and their families, physicians and other health care providers Work with everyone involved with our members care to help implement case management plans based on member needs Provide education and support to our members and their families to help our members improve their health and quality of life Use a collaborative process of assessment, planning, facilitation, and advocacy for options and services for our members The goal is to meet an individual s health needs through communication and available resources to promote quality, cost-effective outcomes. Where indicated, we coordinate and integrate case management services for those members with co-occurring behavioral health and physical health disorders. If you have a high-risk member you would like to refer to this program, please call Clinical practice and preventive health guidelines On our provider website, we offer clinical care and preventive health guidelines. Our guidelines are based on current research and national standards and are known to be effective in improving health outcomes. Effectiveness of guidelines is determined by scientific evidence, professional standards or expert opinion. Our guidelines are available on our provider website at providers.amerigroup.com/nv. ADHD Adult hypertension Adult obesity Adult preventive health Asthma BH screening assessment and treatment Bipolar disorder (Adolescents) Bipolar disorder (Adults) Child and adolescent hypertension Childhood obesity Child preventive health Chronic kidney disease Congestive heart failure Chronic obstructive pulmonary disease Coronary artery disease Diabetes mellitus Family planning High risk OB HIV Immunizations Major depression Postpartum care Routine antepartum care Schizophrenia Smoking cessation during pregnancy Substance use disorders (Adults) Need a paper copy of a guideline? Call Provider Services at We ll be glad to send you a copy.

5 Your Provider Relations representative is your go-to source for questions about your contract, community events, patient outreach support opportunities, quality or incentive programs, and training opportunities. Call your Provider Relations rep today! Utilization Management criteria If one of our medical directors denies your service request, we ll send you and the member a notice of action letter, including the reason for denial, the criteria/guidelines used for the decision, and an explanation of your appeal process and rights. To speak with a medical director about the service request denial, call To request a copy of the specific criteria/guidelines used for the decision, call or write to: Medical Management Amerigroup Community Care 9133 W. Russell Road Las Vegas, NV Our Utilization Management team Our Utilization Management (UM) team members, including the clinical professionals who coordinate our members care, are governed by the following statements: n UM decision-making is based only on appropriateness of care and service and on existence of coverage. n We do not specifically reward practitioners or other individuals for issuing denial of coverage or care. n Financial incentives for UM decision makers do not encourage decisions that result in underutilization. Pharmacy tools Need up-to-date pharmacy information? Log in to our provider website to access our list of medical injectables, prior authorization forms and clinical criteria. Have questions about the formulary or need a paper copy? Call our Pharmacy department at Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 10 a.m. to 2 p.m. Pacific time. Members rights and responsibilities Our members defined rights and responsibilities are in your provider manual and also on our provider self-service site. If you d like us to mail you a copy, call Provider Services at Our Member Services representatives are advocates for our members. To reach Member Services, please call (TTY ). We re available 24 hours a day, 7 days a week to accept precertification requests. You can submit requests one of the following ways: Calling Faxing Online at providers.amerigroup.com/nv Have questions about utilization decisions or the UM process in general? Call our clinical team at , Monday through Friday from 8 a.m. to 5 p.m. Pacific time.

6 PRSRT STD U.S. Postage PAID Amerigroup P.O. Box Virginia Beach, VA ProviderNews Questions? Medicaid providers call Medicare providers call Appointment availability and after-hours access Each year, we ensure members are able to schedule appointments in a timely fashion and experience continuous 24-hour coverage. In the second quarter of 2014, primary care, specialty and behavioral health providers received brief phone surveys to verify service availability. Although the overall appointment availability was slightly lower than in 2013: n Ninety percent of urgent/emergent appointments were available within time standard. n Sick and routine care visits were less available. Providers were also surveyed for after-hours access. The answering service was reached after hours, but some providers did not call back within 30 minutes of being contacted by their answering service. The provider website puts information you need for day-to-day care of our members right at your fingertips. NVPEC Appointment availability and after-hours access requirements are available on the Amerigroup provider website and in your provider manual. Amerigroup appreciates the care you provide for our members, evaluation of clinical practice guidelines, feedback about our services, participation on our medical advisory committees, patience with medical record reviews and collaboration on member education and events. We re committed to ensuring our members have the access they need to quality care and health education. By working together, we can continue to help improve our members health care outcomes, their quality of life and the health care system overall. The material in this newsletter is intended for educational purposes only and does not constitute a recommendation or endorsement with respect to any company or product. Information contained herein related to treatment or provider practices is not a substitute for the judgment of the individual provider. The unique needs and medical condition of each patient must be taken into account prior to action on the information contained herein.