Did you know? There are 19 HEDIS/pharmacy measures currently used to gather data for provider reports.

Transcription

1 STARS 101!

2 Topics Did you know? Improve your Practice s Star Rating Focus Measures Targeting Care Opportunities Key Reminders Reporting Member Engagement Forms Resources Contact Information 2

3 Did you know? Four categories are used by CMS to measure quality of Medicare Advantage and Prescription Drug Plans. Ratings are composed of various measures falling within four categories: (1) Operational Excellence Measures (2) Part D Measures (3) HEDIS and Clinical Quality Measures (4) Operational Measures. There are 19 HEDIS/pharmacy measures currently used to gather data for provider reports. Plans are rated from 1-5 every year. Ratings are released yearly prior to the open enrollment period. Preferred Care Partners was rated an overall 4 Star Plan for Medica HealthCare was rated an overall 3.5 Star Plan for Plan ratings reflect member care and satisfaction, using national clinical and service-quality measures, health outcomes and member feedback. 3

4 How can you Improve your Practice s Star Rating? Submit encounter for each and every service provided Document all services on medical record that are reported to the Health Plan Encounter data is the cleanest and most efficient way to report HEDIS data If rendered services are not billed on a timely basis to the Health Plan, your HEDIS noncompliant list and scorecards will not be accurate and will reduce your overall calculation/rate Minimize the volume of chart reviews conducted at your practice, which are required to obtain accurate HEDIS calculations, by submitting encounters that are both accurate and timely 4

5 Focus Measures Measure Weight Description Adult BMI (Body Mass Index) Assessment (ABA) Ages with Body Mass Index (BMI) Documented Yearly or Year Prior Breast Cancer Screening (BCS) Ages with Mammogram completed (10/1/ /31/2015) Care for Older Adults (COA) Functional Status Assessment, Medication Review, and Pain Screening (SNP) Colorectal Cancer Screening (COL) Comprehensive Diabetes Care (CDC) - Blood Sugar Controlled / HbA1c Controlled Comprehensive Diabetes Care (CDC) - Diabetes Care - Eye Exam Comprehensive Diabetes Care (CDC) - Kidney Disease Monitoring Controlling High Blood Pressure (CBP) Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) Osteoporosis Management in Women who had a Fracture (OMW) High Risk Medications Medication Adherence (Diabetes, Hypertension, and Cholesterol) Completed Yearly for all Special Needs Plan (SNP) members Preferred: Preferred Special Care Miami-Dade (HMO SNP) and Preferred Medicare Assist (HMO-POS SNP). Medica: Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP) Ages with screening FOBT (1YR), Colonoscopy (10YR) or Sigmoidoscopy (5YR) Plan members with diabetes who had an A1c lab test during the year that showed their average blood sugar is under control (<9.0%) - last result Plan members with diabetes who had an eye exam to check for damage from diabetes, current year or negative exam year prior Plan members with diabetes (type 1 or type 2) who had a urine microalbumin test in current year Plan members who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) in current year - last result Plan members who were diagnosed with RA and were dispensed one prescription for anti-rheumatic drug (DMARD) in current year Female members who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis within 180 days post fracture Plan members with two prescriptions for certain drugs with a high risk of serious side effects in current year Plan members with an oral diabetes and/or hypertension and/or cholesterol prescription who fill their prescription to cover 80% or more of the time in current year 5

6 Targeting Care Opportunities A. Adult BMI (Body Mass Index) (ABA) Description: Any member between years of age Time-Frame: Every two years; i.e. 1/1/ /31/2015 YES Submit Encounter to Health Plan with E/M & ICD-9 (V85.0-V85.5). Document BMI percentage (%) value AND weight on signed Medical Record. BMI is to be assessed and discussed with member in every visit and documented at least once a year. Addressing Common Mistakes You will not receive credit if BMI is in the medical record and not submitted via Encounter to the Plan. Documenting height & weight only and not the value AND weight on the medical record is incorrect & will not generate a positive hit. Must document value AND weight. 6

7 Targeting Care Opportunities B. Breast Cancer Screening BCS Description: Women between years of age are screened for breast cancer by having a routine mammogram exam completed. Time-Frame: Every 27 months; i.e. 10/1/ /31/2015 YES Refer member via script to complete mammogram yearly. Provide Health Plan with any mammography exam available in Medical Record. Bill exclusion codes to Plan for members with bilateral or two unilateral mastectomies. Addressing Common Mistakes Ultrasounds, biopsies, and MRIs will not count for measure. If member refuses, care opportunity will not be closed and member will not fall off of your non-compliant list. 7

8 Targeting Care Opportunities C. Care for Older Adults (COA) Functional Status Description: Any Special Needs Plan (SNP) member with documentation in the medical record of functional status assessment completed in current year. Time-Frame: Every year; i.e. 1/1/ /31/2015 YES Submit Encounter to Health Plan with CPT II: 1170F for any functional status assessment fully documented. You may use the COA Form provided by Health Plan to ensure completeness of measure. Complete yearly for every member to ensure compliance. Addressing Common Mistakes If the COA Form is completed and in medical record, but not submitted to the Health Plan via Encounter, you will not receive credit and member will not fall off of noncompliant list. 8

9 Targeting Care Opportunities D. Care for Older Adults (COA) Medication Review Description: Any Special Needs Plan (SNP) member with at least one medication review conducted by prescribing practitioner or clinical pharmacist during the measurement year and the presence of a medication list in the medical record. Time-Frame: Every year; i.e. 1/1/ /31/2015 YES Submit Encounter to Health Plan with either CPT for Medication Review 90863, 99605, or CPT II: 1160F for a completed medication review. Submit Encounter to Health Plan with either CPT II for Medication List 1159F or HCPCS: G8427. Reporting for Medication Review and Medication List must be received by Health Plan with same DOS to be compliant. Addressing Common Mistakes If the COA Form is completed and in medical record, but not submitted to the Health Plan via Encounter, you will not receive credit and member will not fall off of noncompliant list. If you submit Encounter with medication review only, member will not be compliant for measure. A medication list is not necessary to be included as part of medical record - this is incorrect. It must be included. *You may use the COA Form provided by Health Plan to ensure completeness of measure. Complete yearly for every member to ensure compliance. 9

10 Targeting Care Opportunities E. Care for Older Adults (COA) Pain Screening Description: Any Special Needs Plan (SNP) member that was assessed for pain (positive or negative findings). The results of the assessment are completed using a standardized pain assessment tool and documented. Time-Frame: Every year; i.e. 1/1/ /31/2015 YES Submit Encounter to Health Plan with either CPTII: 1125F when pain is present or bill CPTII: 1126F when pain is not present. Only one is required. You may use the COA Form provided by Health Plan to ensure completeness of measure. Complete yearly for every member to ensure compliance. Addressing Common Mistakes If the COA Form is completed and in medical record, but not submitted to the Health Plan via Encounter, you will not receive credit and member will not fall off of noncompliant list. Use a standardized pain assessment tool. 10

11 Targeting Care Opportunities F. Colorectal Cancer Screening (COL) Description: Plan members between years of age who had screening exam for colorectal cancer. Appropriate screening exams include Fecal Occult Blood Test (FOBT), Sigmoidoscopy, or Colonoscopy. Time-Frame: Depends on the screening: FOBT: One every year; i.e. 1/1/ /31/2015 Sigmoidoscopy: Every five years; i.e. 1/1/ /31/2015 Colonoscopy: Every ten years; i.e. 1/1/ /31/2015 YES Refer member to *Quest lab for FOBT and Gastroenterologist for Sigmoidoscopy or Colonoscopy (request authorization if within 5 years). Addressing Common Mistakes If member refuses, care opportunity will not be closed and member will not fall off of your non-compliant list. Bill exclusion codes to Health Plan for members with colorectal cancer or total colectomy. Provide medical record to Health Plan for any colonoscopy available in Medical Record or documentation that member was screened. 11

12 Targeting Care Opportunities G. Comprehensive Diabetes Care (CDC) Blood Sugar Controlled/HbA1c Description: Plan members with diabetes who had a HbA1c lab test during the year that showed their average blood sugar is under control (<9.0%). Time-Frame: Most current results, under (<9.0%), within year (1/1/ /31/2015) Note: The last result will be used to determine compliance. TRUE Refer member to *Quest lab for HbA1c to ensure lab results are received by the Health Plan. If there is an Encounter and no subsequent results within 7 days, member will be non-compliant. The most current result will be used to determine compliance. If last testing of the year is not controlled, member will be noncomplaint. Providers can submit Encounter to the Health Plan on the service & results. Submit CPT: for HbA1c Test or Also, bill results for HbA1c test by using CPT II: Less than 7.0: 3044F; or Between use 3045F; or Level Greater than 9.0 use: 3046F. *Quest Laboratories is the exclusive contracted vendor for laboratory services* Addressing Common Mistakes As long as there is one result controlled within the year, the member is compliant - this is incorrect. It ll be based on the last value of the year. As long as test is completed, member is compliant - this is incorrect. The Health Plan must receive value and it needs to be controlled. 12

13 Targeting Care Opportunities H. Comprehensive Diabetes Care (CDC) Eye Exam Description: Plan members with diabetes who had eye exam to check for damage due to diabetes during the measurement year or had a negative exam in prior year. Time-Frame: Negative or Positive within year (1/1/ /31/2015) or negative result within (1/1/ /31/2014) YES Refer member to an in-network vision provider (Ophthalmologist or Optometrist) for their yearly eye exam. No script is required. Addressing Common Mistakes If member refuses, care opportunity will not be closed and member will not fall off of your non-compliant list. Provide medical record to Health Plan for any eye exam that is available in Medical Record for current year conducted by an Eye Care Professional. Also, provide any negative exam available within the medical record for prior year also conducted by an Eye Care Professional. Ensure you are discussing annual eye exams with your patients that have been diagnosed with Diabetes. 13

14 Targeting Care Opportunities I. Comprehensive Diabetes Care (CDC) Kidney Disease Monitoring Description: Plan members with diabetes (type 1 or type 2) who had a urine microalbumin test during the measurement year or who had received medical attention for nephropathy during the measurement year. Time-Frame: Every year; i.e. 1/1/ /31/2015 YES Complete screening in office or refer member to *Quest lab for screening in the current year. Addressing Common Mistakes If member refuses, care opportunity will not be closed and member will not fall off of your non-compliant list. Submit Encounter to Health Plan to demonstrate Nephropathy screening or Urine Microalbumin or Evidence of Treatment for Nephropathy (ESRD). * Quest Laboratories is the exclusive contracted vendor for laboratory services* 14

15 Targeting Care Opportunities J. Controlling High Blood Pressure (CBP) Description: Plan members who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year. Time-Frame: Every year; i.e. 1/1/ /31/2015 Note: The last BP will be used to determine compliance. YES If a member was diagnosed with Hypertension (ICD-9: 401, 401.1, or 401.9), please document blood pressure on signed medical record and submit Encounter to the Health Plan. Use: 3074F for Systolic less than 130; 3075F for Systolic between ; 3077F Systolic greater than 140; 3078F Diastolic less than F Diastolic between F Diastolic greater than 90 The last blood pressure documented in the year will be used to determine compliance. If controlled, compliant. If not controlled, member will be non-compliant. Addressing Common Mistakes As long as there is one result controlled within the year, the member is compliant - this is incorrect. It ll be based on latest value. BP does not need to be recorded on a medical record that is signed - this is incorrect. It must be documented on a signed medical record. 15

16 Targeting Care Opportunities K. Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) Description: Plan members who were diagnosed with rheumatoid arthritis and were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD). Time-Frame: In the year member was diagnosed Note: Member will become eligible for measure once they ve been diagnosed with Rheumatoid Arthritis (714.0; 714.1; 714.2; ) twice within 1/1/ /30/2015! Most members are incorrectly diagnosed. YES If member was correctly diagnosed, member is suggested to be put on a DMARD to close care opportunity. DMARDS include: Cyclophosphamide, Methotrexate, Sulfasalazine, Hydroxychloroquine, Gold Sodium Thiomalate, Azathioprine, Minocycline, Cyclosporine, and Leflunomide. Exclusions apply if member was diagnosed with HIV during the member s history through 12/31/2015 and/or pregnant during measurement year. Addressing Common Mistakes If ART was incorrectly diagnosed more than once, member will not be removed from the non-compliant list for that calendar year. If the member is adherent by taking samples and not filling a script, they will not reflect as adherent. 16

17 Targeting Care Opportunities L. Osteoporosis Management in Women who had a Fracture (OMW) Description: Female Plan members who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis within 180 days post fracture. Time-Frame: 180 days post fracture (i.e. fracture occurred 1/1/2015; BMD or prescription must be completed by 6/29/2015) YES If member had a fracture (ICD-9: , , , , , , , , , , 81.65, 81.66) Then (A) Refer member to diagnostic facility or mobile diagnostic provider for a BMD test within 180 days OR (B) Prescribe member Alendronate OR Risedronate OR Raloxifene within 180 days. Medication must be filled to count. To avoid member falling into the eligible population, ensure that all members are being tested for Osteoporosis yearly through BMD test. Addressing Common Mistakes If member has a fracture on 1/1/2015, they have until 12/31/2015 to have their BMD test completed or be prescribed medication - this is incorrect. They only have 180 days post fracture. If a member was given a prescription for medication, 17 but did not fill the RX, member will not be compliant.

18 Targeting Care Opportunities M. High Risk Medication (HRM) Description: Plan members who filled prescriptions for certain drugs with a high risk of serious side effects, when there may be safer drug choices. Time-Frame: Every year; i.e. 1/1/ /31/2015 Note: Member will be non-compliant once they ve filled the same RX twice within the same year with a high-risk! Member cannot become compliant once they ve reached the two fills. YES Members will fall part of the non-compliant list if they have filled two prescriptions in the same year for the same high-risk medication. High Risk medications include: (1) Estrogen, Estrogen Patches (Alternative: Estrogen Creams) (2) Carisoprodol; Cyclobenzaprine; Metaxolone; Methocarbamol, Orphenadrine (Alternative: Baclofen, Tizanidine) (3) Chlorpropamide Glyburide (Alternative: Glimepiride, Glipizide) (4) Cyproheptadine; Diphenhydramine (Alternative: Loratadine (OTC Bft) (5) Meprobamate (Alternative: Anxiety: Alprazolam, Buspirone) (6) Nifedipine (Short Acting Only) (Alternative: Nifedipine ER, Amlodipine) (7) Zolpidem; Zaleplon (Alternative: TRAZODONE) To avoid member falling into the eligible population, avoid that second refill if a safer alternative exists! Addressing Common Mistakes Member cannot become compliant if they fill the same high-risk drug twice within a year, but is changed to a safer alternative and is filled in that same year. 18

19 Targeting Care Opportunities N. Medication Adherence Description: Percent of plan members with an oral diabetes and/or hypertension and/or cholesterol prescription who fill their prescription to cover 80% or more of the time they are supposed to be taking the medication. Time-Frame: Every year; i.e. 1/1/ /31/2015 YES Members need to be adherent for at least 80% of days to be compliant. For example, if member has to be on medication 365 days, they need to at least fill to cover 295 (80%) pills to remain adherent. Prescribe member medication with 90-day supply, with 3 refills to ensure adherence throughout the year. Addressing Common Mistakes If the member is adherent by taking samples and not filling a script, they will not reflect as adherent. For Diabetes: Biguanides, sulfonylureas, thiazolidinedione, and DiPeptidyl Peptidase (DPP)-IV Inhibitors For Hypertension: ACE (Angiotensin Converting Enzyme) or ARB (Angiotensin Receptor Blocker) For Cholesterol (Statins): Statin 19

20 Key Reminders Medical Records must be: Complete and clearly substantiate the measure Signed and Credentials included Legible Member Name & Date of Birth must be included Submit your Encounters to the Health Plan: Preferred: Electronically using Payer ID: (preferred method) Free via using Payer ID: (preferred method) Paper mailed to Claims Department Medica: Electronically using Payer ID: (preferred method) Free via (preferred method) Paper mailed to Claims Department See your Quick Reference Guide for a full list of codes applicable for HEDIS and Stars. Contact the Health Plan immediately for any issues, concerns, or questions! [email protected] 29

21 Reporting The Plan is committed to providing you with a non-complaint list and provider scorecard on a recurring basis throughout the year to help you address care opportunities. Non-Compliant List: Did you know? You can request a copy of your noncompliant list by member/by page to easily place within your paper medical records! You can also obtain an excel version. Ask Your Plan representative today. Delivery: Via Provider Relations Representative and/or Stars Network Specialist Available via Provider Portal (Register today if you haven t already to take advantage of all features available) Preferred: Medica: us for a copy: [email protected] 21

22 Reporting Provider Scorecard: Delivery: Via Provider Relations Representative and/or Stars Network Specialist *Please check your agreement or with your provider relations representative to confirm eligibility for P4P incentives/bonus. 22

23 Member Engagement HouseCalls Annual Assessments conducted at the member s home to target care opportunities (including labs) Quarterly member newsletter with important preventative care information Annual notice of participating pharmacies where members can receive Influenza vaccination at no additional cost (Patient/Provider website, Provider Posters, Newsletters) Annual announcement notifying members of the existence of the patient Survey (CAHPS/HOS February - August) and the importance of completion IVR (Interactive Voice Response) call-out campaign to remind members of their upcoming refills Member outreach for MTMs (Medication Therapy Management) internal and via HouseCalls Future Live Date (more information to come ) Quarterly member non-compliant letter mailing advising members of their pending preventative screenings Dedicated Stars outbound Call Center to contact members with care opportunities and coordinate screenings 23

24 Forms Forms: A. Care for Older Adults (COA) Form Description: This form can be completed in its entirety, signed, and reported to the Health Plan by Claim submission to ensure compliance of COA measures. This form also captures BMI. Form includes a full list and description of applicable codes. Example: Reminders: 1- Fill out form in its entirety 2- Sign the form 3- Attach a medication list 4- Report to the Health Plan 5- Keep form and medication list visible in Medical Record 24

25 Forms Forms: TAPS Therapeutic Alternative Prescribing System Description: A generated Rx script for certain alternative prescriptions depending on condition. If physician agrees with Rx, physician selects medication most fitting for patient, signs, and faxes/submits to the desired pharmacy to generate fill for patient. Patient is contacted by physician to advise of prescription. TAPS may be generated to change high-risk medications to a safer alternative, DMARD for patients with Rheumatoid Arthritis, prescription for a drug to treat or prevent osteoporosis and switching brand to generic. How to Obtain: Ask your Provider Relations Representative or Stars Specialist for a copy. Example: Reminders: 1- Form must be signed and faxed to the Pharmacy by the provider to complete request for prescription. The Plan will not submit on the provider s behalf. 25

26 Forms Forms: Health Maintenance Form Description: A form that may be used by the physician to ensure discussion of all Stars related measures, as well as allow for tracking care opportunities. This form can be kept in the patient s medical record for constant reference. The back of the form also includes additional information on each measure. How to Obtain: Ask your Provider Relations Representative or Stars Specialist for a copy. Example: Reminders: 1- Report to the Health Plan any assessed care opportunities. 2- This is only a tool; you should document all discussions and care opportunities addressed on a legible, complete, and signed medical record. 26

27 Resources Resources: Quick Reference Guide Description: Lists all of the 19 HEDIS/pharmacy measures currently used to gather data for provider reports. It includes all applicable codes, eligibility requirements, exclusions, thresholds, weights, etc. Example: Reminders: 1- Please refer to this document for a detailed list of measures, applicable screenings, and reporting requirements. 27

28 Resources Resources: High-Risk Medications - Description: Flyer includes list of high-risk medications (red) with their safer alternatives (green) that exist for same condition. - Example: 28

29 Resources Resources: Measure Exclusions Description: List of exclusions per measure, to remove ineligible members from the universe. Reporting exclusion codes would remove the member from your target list. Example: 29

30 Resources Resources: Ultima RX Description: A trusted pharmacy option locally managed and operated by UnitedHealthcare South Florida. Their staff is dedicated to improving STARS measures, which help with high adherence measures, high risk medications, and meeting the needs of diabetic patients with hypertension. 30

31 Resources Resources: Stars Subject Matter Expert (SME) Description: Your office has been assigned a Stars SME who is scheduled to visit your office during the year to provide education, share resources, collect medical records, offer as resource, identify discrepancies, etc. This individual is available to you should you have any questions, concerns, etc. If you currently do not know who your assigned Stars SME is, please us at [email protected]. Flu Vaccine Codes to Bill Description: Flu measure is calculated 100% through the yearly CAHPS survey to randomly selected members. Help us ensure that your patients are getting their flu vaccine. To help us have accurate records, if you are administering the flu for your patients, please report to the Health Plan by using the codes listed below: Influenza: CPT 90654, 90656, 90660, 90662, 90673, 90686, Q2034, Q2035, Q2036, Q2037, Q2038, Q2039 Administration for Influenza: CPT 90471, 90472, 90473, G

32 Contact Information Department Phone Stars Department Network Management Services Pharmacy Department n/a uhcsouthflorida.com (877) Medica p. (866) Preferred p. (800) n/a Ultima RX (305) n/a PCPMHP00032_