network news KPMAS Bioethics Committee FOR NETWORK PROVIDERS OF KAISER PERMANENTE

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1 network Produced by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., with the Mid-Atlantic Permanente Medical Group, P.C. Web site: news DECEMBER 2009 FOR NETWORK PROVIDERS OF KAISER PERMANENTE KPMAS Bioethics Committee Bioethics Committee members Anthony Morton, MD and Juli Navarrete, RN (Co-chairs) Robin Berman, LCSW Bill Burner, MD Stan Drake, MD Traci Holsteen, RN Leon Hwang, MD Purnima Joshi, MD Mary Kraynak, RN LoAnNguyen, MD Karen Puhl, RN Carol Samuels-Botts, MD Beverly Waddell-Jiggets, MD Doug Vanzoeren, MD Amy Tetteh-Griffin (Community Member) The KPMAS Bioethics Committee exists to promote ethical reflection and action in the provision of health care. The goals of the committee include the identification, analysis and resolution of ethical issues that arise in the delivery of high quality, affordable health care; consultation relating to ethical concerns in policy development; and the provision of high quality education programs on bioethics. Any Kaiser Permanente member, physician or employee may request an individual ethics consultation or present a case to the regional Bioethics Committee with the intent of clarifying the values that may be in conflict in making difficult medical decisions. The Ethics Program includes on-going efforts to make Kaiser Permanente members, physicians, and staff aware of their rights and responsibilities. In addition to educating the Regional Bioethics Committee, the Ethics Program is responsible for assisting physicians and staff with integrating ethical reflection in areas of decision making that routinely deal with issues that raise ethical concerns such as genetic diagnostics and therapeutics, new reproductive technologies, and end of life care. The Bioethics Committee, through monthly meetings and special task force activities, also provides broad guidelines to help Kaiser Permanente meet its ethical obligations as a Health Plan and Medical Group The Ethics Committee consists of no more than 20 and no less than 15 members reflecting specialty, gender, and ethnic diversity. There are standard departments and roles represented, including representatives from the following departments: Adult Medicine, Pediatrics, Surgical Specialties, Medical Specialties, OB-GYN, Nursing, Patient Safety-Risk Management, Membership Services, Operations Management, Pharmacy, Public Affairs/Marketplace, and a Community Liaison. Requests for a consultation with the Bioethics Committee may be made by contacting any member of the committee Kaiser Permanente medical coverage policies Find a referral management physician reviewer Formulary management Provider manual Documentation of coordination of care with primary care physicians 7 directory 2010 Provider request

2 Kaiser Permanente medical coverage policies Medical coverage policies (MCP) are developed and annually reviewed by the Kaiser Permanente Referrals and Medical Policy Management Team in collaboration with the primary and/or specialty care service chiefs or other board certified physicians, subject matter experts and practitioners within MAPMG and the Kaiser Permanente health plan. The development process includes a compilation of current scientific literature, expert medical opinion, national professional association guidelines and policy statements, criteria, guidelines or protocols developed nationally by Kaiser Permanente, state and/or federal mandates regarding coverage, information from Kaiser Permanente Interregional New Technologies Committee, and regional and/or intra-departmental consensus. MCPs can be directly accessed through the Kaiser Permanente Community Providers - MCP website at providers.kp.org/mas/utilizationguidelines.html. Kaiser Permanente medical coverage policies (current as of 10/30/2009) Abdominoplasty, Panniculectomy, and Ventral Hernia Repair Acupuncture - Adjunctive Therapy, Nausea and Vomiting, and Pain Conditions Ambulance Transportation Ground and Air Transport Autologous Stem Cell Cardiomyoplasty Benign Skin Lesion Treatment Biofeedback Blepharoplasty, Lid Ptosis and Brow Lift Surgery Botulinum Toxin Type A and Type B Breast Magnetic Resonance Imaging Breast Reduction Surgery and Gynecomastia Surgery Capsule Endoscopy Cardiac Rehabilitation Chiropractic Manipulation Circumcision (Excluding Newborn) Compression Garment for Upper and Lower Extremities Continuous Passive Motion (CPM) Machines Cranial Remodeling Bands and Helmets Foot & Ankle Orthotics Genetic Counseling, Testing for Breast and Ovarian Cancer Genetic Testing Home Hemodialysis (HHD) Hyperbaric Oxygen Therapy Infertility Intensity Modulated Radiation Therapy (IMRT) Interspinous Process Decompression System (X STOP) Intradiscal Electrothermal Therapy (IDET) For Discogenic Pain Morbid Obesity/Bariatric Surgery: DC, Federal, and VA Morbid Obesity/Bariatric Surgery: Maryland Jurisdiction Oncotype DX Assay Pectus Excavatum Pediatric Early Intervention Habilitation Services Pulmonary Rehabilitation Spinal Cord Stimulation Treatment of Vitiligo Umbilical Cord Blood Collection, Storage and Associated Testing Varicose Veins Virtual Colonoscopy 2

3 Need to get in touch with a referral management physician reviewer? Kaiser Permanente UM Physician Reviewers are available to speak with practitioners to discuss pre-service or concurrent medical necessity decisions. Practitioners are notified regarding adverse decisions through verbal or electronic notification followed by a written letter. If you wish to discuss any medical necessity pre-service or concurrent denial decision with the UM Physician Reviewer, call the Utilization Management Operations Center (UMOC) Monday to Friday from 8:30 AM to 5:00 PM at and select the appropriate prompt #. Alternatively, you may reach the UM Physician Reviewer through the Kaiser Permanente Page Operator at (703) or To reach the Utilization Formulary management Management Operations Center, call and select prompt # 4. Utilization Management Operations Center You can reach the Utilization Management Operations Center at and follow the prompts to speak with a staff member. The UMOC staff can assist you with the following: Provide information regarding utilization management processes Check the status of referral or an authorization Provide copies of criteria, guidelines or protocol utilized in decision making Answer questions regarding a benefit denial decision The Kaiser Permanente Mid-Atlantic States Commercial Formulary is a compilation of drugs approved for use by the Regional Pharmacy and Therapeutics (P&T) Committee. The P&T Committee with expert guidance from various medical specialties evaluates, appraises, and selects from available drugs those considered to be the most appropriate for patient care and general use within the region. The formulary is intended to promote rational, safe, and cost-effective drug therapy in the Mid-Atlantic States Region. The formulary process provides objective evaluation and selection of drugs. Composition of the Committee includes physicians from primary care and specialty departments, pharmacists, and representatives from nursing and quality departments. 3

4 The formulary is dynamic and updated with any additions and/or deletions approved by the Committee. Any FDA approved drug may be evaluated for Formulary addition or deletion, and any physician may request a drug s review. The request should be in writing and forwarded to the Regional P&T Committee along with supporting literature and references. Drug formulary addition/ deletion requests should include the name, strength and form of the drug being requested, the reason for the request with clinical references of its safety and effectiveness, what drug this would replace on formulary (if any), as well as contact name of the requesting physician along with their specialty. Drug addition/deletion forms are available at the regional pharmacy offices at or on the website. The entire formulary and its processes are reviewed at least annually. Drugs included on the formulary are readily available for prescribing, dispensing, and administration. Based upon their review, a drug or biological will be classified into one of four categories: Formulary drug (F) A drug, including specific strengths and dosage forms, reviewed and approved on the basis of sound clinical evidence that supports the safe, appropriate, and cost effective use of the drug. May be prescribed by all privileged prescribers, except where state laws and/ or regulations prohibit. Formulary drug with Restriction (FR) A formulary drug with prescribing restricted to specific prescribers, e.g. individuals, department, divisions, teams. Non-Formulary drug (NF) A drug not officially accepted for inclusion to the drug formulary. This includes: drugs that have been reviewed but denied admission to the drug formulary; new drugs not yet reviewed for addition to the formulary; a brand, strength, or dosage form of a drug not approved for addition to the formulary; formulary drugs for which prescribing or eligibility criteria or restriction are NOT met, i.e. weight management medication for a patient whose BMI = 22. Non-Formulary with Restrictions (NFR) A drug that has been reviewed, but admission to the formulary has been denied. Drug rider coverage for this drug meets specific restrictions for use when prescriptions are written for or are written in consultation with the specific prescribers, e.g. individuals, department, divisions, health care teams. Affiliated providers can keep current with drugs on the KPMAS Formulary by visiting kp.org/mas/formulary.html, and our MAPMG providers can search the formulary at co.kp.org/mas/masdrugformulary.html A printed copy of the formulary posted on the web can be made available upon request. The P & T Committee publishes a bi-monthly newsletter, titled Tips on Scripts. The newsletter provides drug information and lists recent formulary decisions. Paper and electronic copies of Tips on Scripts are distributed to our medical centers, but are also available to our affiliated practitioners electronically on the web at mas. If you are interested in receiving a copy, please contact the Regional Pharmacy Department at (301) The Tips on Scripts newsletter is posted in electronic format for our MAPMG at co.kp.org/mas/mastipsscripts.html 4

5 Non-Formulary Exception Process The Non-Formulary Exception Process provides physicians and patients with access to nonformulary drugs and facilitates prescription drug coverage of medically necessary, non-formulary drugs as determined by the prescribing practitioner. Patients can also have a non-formulary drug outside of the exception process anytime by paying full price for the drug if the provider deems it not medically necessary, and not harmful, but agrees to prescribing based on patient demand. Highlights of the Non-Formulary Exception Process: Non-formulary drugs should be used only if the patient fails to respond to formulary drug therapy, or has special circumstances requiring the use of a non-formulary drug. The practitioner makes the final decision regarding what drug is appropriate for the member. If the appropriate drug is not on the formulary and is deemed medically necessary by the practitioner, he/she documents the reason for the medical necessity in the patient s medical record and on the pharmacy prescription order. This documentation is transferred with the prescription to the Kaiser Permanente pharmacy or network pharmacy for appropriate dispensing. If a network practitioner writes for a non-formulary drug without the appropriate exception reason documented they should expect a telephone call from a pharmacist to suggest a formulary alternative or to obtain an exception reason, so the same documentation may take place. This allows Kaiser Permanente to track the use of non-formulary agents and decide whether they should be re-evaluated for formulary inclusion. Reasons why a physician may grant an exception include: Allergy/adverse reaction to formulary product Treatment failure on formulary drug Meets criteria/guidelines for appropriate use Once the physician chooses any of the above reasons, the prescription will be treated as a nonformulary exception, and will be covered at the appropriate co-payment. If the physician determines the non-formulary prescription is not medically necessary: The physician will discuss the formulary alternatives available with the member If the member insists on the non-formulary product but an appropriate formulary alternative is available, the physician may prescribe the non-formulary drug. * The physician will document the non-formulary prescription as a patient request/demand. * The drug will not be covered under the pharmacy benefit. * Patient will pay full price for the drug If a non-formulary (NF) prescription is not ordered through the KP HealthConnect electronic medical record and there is no NF exception reason documented, and the member presents to a Kaiser Permanente pharmacy to fill the prescription: The pharmacy will contact the prescribing practitioner to determine the formulary alternative or the NF exception reason. If an appropriate reason for exception is obtained from the prescribing practitioner, then the appropriate co-pay will be applied. If the reason for exception is not obtained, then the member may get the non- formulary medication filled if they pay the Kaiser Permanente member full price. The member may request a review of their case through Member Services. If the physician prescribes a non-formulary prescription drug for a patient with network pharmacy benefit, without indicating a nonformulary exception and the member goes to a network pharmacy to fill the prescription, the member may: Get the non-formulary medication filled and pay the standard retail price, or Ask the pharmacist to request a formulary alternative or a non-formulary exception, or Contact Kaiser Permanente Member Services at and request a non-formulary exception review. 5

6 Provider Manual Provider relations department is the key contact to request any materials or documents including a copy of the Provider Manual. The contact number is The Provider Manual is electronically available to all practitioners. Providers can obtain a copy of the updated Provider Manual at the provider website www. providers.kp.org/mas. Once on the provider website we ask providers to select the Provider Information tab, once the drop down menu appears please select Provider Manuals. From the website you can get a copy of our provider manual in two ways: To request that we send you a copy by mail. Choose the Forms tab click Request a provider manual. Download form and fax your request to Download a copy of our provider manual by chapter. Documentation of coordination of care with primary care physicians (PCPs) Kaiser Permanente continues to be a leader in promoting the integration of behavioral and medical health care and views care coordination between Behavioral Health and Primary Care to be a critical aspect of treatment. Behavioral Health providers are asked to obtain the member s consent and to communicate the following to the patient s PCP within seven (7) days of the beginning of treatment. Date of initial service Patient s diagnosis and brief assessment of their findings Treatment plan and recommendations Medications prescribed. If you are not sure how to contact the member s PCP, you may mail or fax treatment information to the following address and we will make sure the PCP gets your report. Kaiser Permanente Regional HIMS 6526 Belcrest Road, Suite 207 Hyattsville, Maryland FAX: (301)

7 2010 Provider Directory request for information In preparation for our 2010 Provider Directory we ask that all providers update their information if they have not done so or there have been changes recently to your office. For any questions you may have, please contact the provider communications team at Changes may be made by fax to: or by mail: Kaiser Permanente Attn: Provider Relations 2101 E. Jefferson Street, 2 East Rockville, MD Please use the format provided below on your letterhead. SAMPLE LETTER <<DATE>> Tax identification #: address: Effective date of change(s): Requestor: Reason for the request: Address change (practice location or billing) *identify whether adding or deleting demographic change Adding a provider or practitioner to an existing group contract *identify whether adding or deleting provider If adding or deleting a provider please include: First and last name Sex Title or degree NPI number CAQH number UPIN or social security number Primary specialty with secondary specialty if applicable Practice locations w/ phone and fax numbers Foreign languages If urgent care/ will the provider have a panel of kaiser permanente patients. 7

8 The Mid-Atlantic Permanente Medical Group, P.C E. Jefferson Street Rockville, MD Presorted Standard US Postage PAID Rockville, MD Permit # 4297 December 2009 The Mid-Atlantic Permanente Medical Group, P.C E. Jefferson Street, Rockville, MD