Incentive Programs
PIP webcast now available
A Partners in Performance (PIP) webcast is now available! The webcast is available within the Provider Manual at the URL below. It contains a section on using provider tools and resources, including details about how to enter data into Patient Profiles, as well as information about report options, timeframes and use of Filemart. We’re planning to use this new tool every year for the PIP program. We’d appreciate your feedback! View the webcast. Remember, you must be logged in to view our performance program information. Note - We’ve discovered an error in the narration for some measures. The narration indicates payment is per member per month when it is actually per member per measure. The only 2009 PIP measures that are paid per member per month are Tobacco Status and Advice and Recorded BMI Level. PIP annual lab monitoring A member in two or more drug classes within the measure will be represented as a separate denominator for each drug class. For example, Jane Doe is on both an ACE and a diuretic and has had the appropriate lab (the same lab list applies to both drug classes). Jane Doe will be represented in the denominator twice — as if she were two separate members — and will also be in the numerator twice for meeting the lab requirements for both drug classes. This means that, for purposes of calculating the payout, one member increases the denominator count to two in this case, creating a higher payout potential. New Filemart lab result worksheet If you’re not receiving the monthly PIP lab result worksheet for your diabetic members, please contact your PAE. This new report is similar to the blood pressure report and shows the last date of service and most current lab value received. Review all members on the report (including those showing “YES”) by focusing on the “Lab Result Info Message” column. Percent Generic PIP measure Please note that only members in HMO/POS are included in this measure. Non-adherent member exclusion procedure The Non-Adherent Member Exclusion Procedure was introduced as part of the PIP program in 2009. At the time of introduction, we omitted the Asthma Medication Management measure from the procedure specifications posted in the PIP technical manual and in the program brochure. This was omitted in error. Exclusions are allowed for members that are not following physician recommendations for asthma care. Providers may submit non-adherent exclusion requests for these cases. We apologize for any inconvenience to your practice. News & Updates
Register online for a Priority Health Academy Don’t miss this convenient, affordable opportunity to enhance your skills and understanding of a variety of subjects. We will again offer three academies across the state:
Code with Confidence course Join Judy Breuker, CPC, CCS-P, CHBME, ACS, PCS, CPC-E/M, CHC, CHAP, for this class at the Priority Health Conference Center. Classes will be Mondays from 5:30 - 8:00 p.m., February 1 - April 19, 2010. This class is limited to the first 35 paid enrollees. Classes fill quickly, so register early! ICD-10-CM class Judy Breuker, CPC, CCS-P, CHBME, ACS, PCS, CPC-E/M, CHC, CHAP, will conduct an ICD-10 class on March 10, 2010, from 8:00 a.m. to noon at the Priority Health Conference Center. Watch our website and future newsletters for more information. Add your website to our Find a Doctor tool You may add your website to our Find a Doctor online search by emailing the link to your field service representative (FSR) or PAE. We’ll include this link in the Provider Information section of your practice’s page. View sample. Terminating employee Web access Please contact the Provider Helpline or your FSR immediately to terminate Web access for an employee in your office. We’ll inactivate his or her access to member data and your provider accounts. Medical policy changes Please remember to view the Recent Changes section on the left side of the online Provider Manual page for updates to medical policies and billing information. Operational information Coding specificity does make a difference It’s important for providers to document each condition as specifically as possible. Correct ICD-9 coding relies on providers to clearly detail the type of condition, complications or manifestations of a condition, and outcomes from testing relating to a condition. Documenting the specific condition also impacts the diagnosis code chosen. When documentation is generic, coders are not able to select the most specific diagnosis code. In these cases, coders may select the “unspecified” or “unknown” diagnosis code when there is a more specific diagnosis code that could be used. For example:
Remember to link the two conditions with terms such as “due to,” “associated with,” and “with” to indicate that the conditions are related to one another (indicating that both conditions exist does not “link” the conditions as related). For example:
Clinical Support
Pre-diabetes coverage Priority Health covers pre-diabetes education classes, which are focused on healthy eating and daily activity. Glucose monitors are covered for this diagnosis under the DME benefit, or commercial members may obtain them for free from Accu-Chek or OneTouch. The test strips are covered under the DME benefit (any brand) and pharmacy benefit (Accu-Chek and One Touch brands only). Under the pharmacy benefit, Accu-Chek and OneTouch strips are available with a generic copay, which is more often less costly than using the DME benefit. NOTE: this does not apply to PriorityMedicare members. Contact the Provider Helpline at 800 942-4765 for coverage information on plans other than commercial and Medicare. Flu season: Plan and prepare Plan for the Novel H1N1 Influenza The CDC is urging medical offices to develop a business continuity plan, so you can manage an increased demand for services in the midst of an H1N1 outbreak. Visit the CDC’s Resources for Clinicians at cdc.gov/h1n1flu/clinicians to find 10 Steps You Can Take: Actions for Novel H1N1 Influenza Planning and Response for Medical Offices and Outpatient Facilities and the most up-to-date guidance on vaccines and treatment. The CDC has announced five priority target groups to receive the H1N1 flu vaccine, when it becomes available:
Seasonal Influenza We encourage our members to get their seasonal flu vaccines from participating providers and pharmacies. Most of our members (99.92%) have vaccine coverage, however a small group of self-funded plans don't have vaccine coverage and aren't eligible for this benefit. Here’s what you can do for seasonal influenza:
Although research has consistently shown that antibiotics have no benefits for the management of viral URIs, inappropriate use of antibiotics continues to be widespread. Overuse or inappropriate use of antibiotics can lead to the development of antibiotic-resistant microbial strains. Steps your office can take to ensure appropriate use include:
Reference: "Guidelines for the Use of Antibiotics in Acute Respiratory Tract Infections," American Family Physician, September 15, 2006. Physical exam reminder calls to your Priority Health Medicare patients If your office has received phone calls from your Priority Health Medicare patients asking for a comprehensive physical exam, it’s most likely a result of reminder phone calls from Priority Health’s Medicare health improvement nurse. The courtesy calls are a proactive approach to assist you in encouraging patients to not only schedule a physical exam, but to verify current health conditions in their medical records. This is part of our “stimulus package” of $25 per patient, Priority Health’s Medicare Complexity of Care pilot program for 2009. Next steps for members will include:
If the purpose of a colonoscopy or sigmoidoscopy is preventive (i.e., for colorectal cancer screening), then the procedure is paid under the preventive benefit provisions of the member’s coverage. The table below shows common colorectal cancer screening procedures and the corresponding CPT and ICD-9 codes that are considered preventive.
** Tests for purposes other than preventive colorectal cancer screening require different diagnostic coding. This is true even when polyps are removed during the screening colonoscopy or sigmoidoscopy procedure. However, the pathology tests on any polyps found are considered diagnostic and will be subject to a deductible. Explaining the follow-up testing procedures and costs to members will help them understand charges they may be responsible for. If you believe that a deductible has been incorrectly applied to the screening, please send us the medical record indicating the purpose of the test, and the claim will be reviewed and adjusted if appropriate. Print our Provider Dispute Resolution form. Sedation choices The preventive health benefit for colonoscopies assumes conscious (moderate) sedation as the standard of care. If general anesthesia is used as part of the procedure, it is considered to be an additional service beyond the “preventive” component of care and is subject to the deductible. If a patient has a condition which indicates that general anesthesia is required for a successful procedure, then it’s important to include documentation in the medical records supporting that need and to ensure the patient understands the associated out-of-pocket costs. Lead testing Elevated blood lead levels can lead to serious health consequences and developmental delays. Protect your young patients by screening children at ages 12 and 24 months who fall into any of these high-risk categories:
Priority Health makes it easier to stay on top of the lead testing status of your patients by reconciling member claims data on lead testing with additional data from MCIR. We notify members who are due or overdue for a lead test and request that they schedule a test with their PCP. In addition, we prepare reports for each practice listing screening rates and the members who are due for a test. As of October 2009, MDCH will require that at least 80% of Medicaid-enrolled children be current on their lead test by age 2. We are adjusting our reports to make it easier to see how your practice is performing against this benchmark. For additional information, please contact your PAE. Patient-Centered Medical HomeAugust 4 meeting focused on PCMH Priority Health continues its support of the patient-centered medical home model. On August 4, members of the Community Medical Directors Committee, physician hospital organization administrators and employers heard more on this topic from Chief Medical Officer Jim Byrne, MD. Dr. Byrne noted Priority Health continues to look at payment reform issues. He also noted the Michigan Primary Care Consortium Payer Partnership is working to develop consistency across plans and payers on reimbursement tied to adopting the medical home model. TransforMED CEO & President Terry McGeeney, MD, MBA, spoke on the topic of health care reform and the medical home. Internist Terri Osborne, MD, of MMPC/Lake Drive, addressed the topic from the provider’s perspective. Her practice is one of the Priority Health pilot sites. “The role of the provider is to remember the patient,” she said. Patient-centered medical home grants total $1.25 million Priority Health awarded $1.25 million in grants to fund 10 projects representing primary care practices across the state of Michigan. The projects will assist the practices in the transformation to patient-centered medical homes. In all, 21 grant applications were received. Awardees are:
PharmacyGeneric drug news Generic Ortho Tri-Cyclen Lo (norgestimate/ethinyl estradiol) is now available! Generic Ortho Tri-Cyclen Lo is indicated for the prevention of pregnancy. Asthma long-term controllers moving to generic copay Effective Sept. 1, 2009, Pulmicort and QVAR inhalers became available on the Priority Health commercial formulary (HMO, PPO, POS) for a generic copay! It’s a win-win for members and providers:
Positive changes to more than 100 drugs We’re making changes to more than 100 drugs that will positively impact providers and members. These changes are in addition to the more than 50 positive changes we made in 2008. Changes were effective September 1, 2009. A complete list of the changes is available online. Here are the highlights:
The Pharmacy and Therapeutics (P&T) Committee met on July 21, 2009, and reviewed several new drugs. The following information summarizes the recommendations made at the P&T meeting.
ST = Step Therapy + Indicates the change applies to this formulary * Indicates drug is covered under the medical benefit Step therapy Priority Health has some drug categories that require a therapeutic trial of a specific drug or drug(s) before authorization will be granted for other medications. This process is commonly referred to as step therapy. Here are some examples of common drug classes for the commercial formulary (HMO, PPO, POS) that require step therapy:
Questions or concerns regarding processes or utilization management decisions made by Priority Health can be referred to your PAE or the Health Management department at 800 942-4765. Physician and pharmacist reviewers can be used to assist you. Behavioral HealthHIPAAPriority Health has always been committed to protecting the confidentiality of our members’ personal and medical information in all settings. We have a special committee dedicated to monitoring all of our processes and procedures to protect this important information. Our Notice of Privacy Practices online, or is available upon request.The Department of Health and Human Services (HHS) issued the Standards for Privacy Individually Identifiable for Health Information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to provide the first comprehensive federal protection for the privacy of personal health care information. HIPAA privacy regulations went into effect on April 14, 2003. Health plans and health care providers are all affected by the regulations. This means we must all evaluate how we obtain, store, retrieve and communicate personal health information about members and patients. While the privacy regulations are more complex than can be addressed in one article, here are some helpful hints for using passwords to protect the security, privacy and integrity of patient records kept in computer systems. Passwords are not specifically required under HIPAA, but are commonly recommended by HIPAA experts. When setting a password, keep the following tips in mind:
Clinical practice guidelinesClinical practice guidelines are developed in collaboration with area physicians based on standards established by national organizations. Each guideline addresses a specific condition, diagnosis, therapeutic intervention, patient education/follow-up, continuity and coordination of care. Guidelines are available for ADHD, alcohol/substance use, depression, pain management and many other topics. Review the clinical practice guidelines.Mental health parityIntegrating medical and behavioral health care is a primary objective at Priority Health. The Mental Health Parity and Addiction Equity Act of 2008, which was passed last fall, supports this goal. We’re well positioned to comply with this federal law.What is mental health parity? The Mental Health Parity and Addiction Equity Act of 2008 ensures that Americans have access to non-discriminatory mental health and substance abuse coverage through their health insurance plans. This act significantly expands the Mental Health Parity Act of 1996. Detailed implementation regulations will be issued by the Department of Labor, Health and Human Services and the Internal Revenue Service by October 3, 2009. However, health plans must comply with the act by that same date (whether or not the regulations have been issued). What the act requires The law requires parity (equal treatment) between behavioral health benefits (mental health/ substance use disorders) and medical/surgical benefits.
Who it impacts This law applies to both fully funded and self-funded group health plans with more than 50 employees. Group size is determined using Internal Revenue Code “controlled group” rules. When it goes into effect The requirements apply to new contracts and renewals on or after October 3, 2009. The effective date for groups with union contracts could be delayed until the contract is terminated. Frequently asked questions Is compliance with mental health parity required for all groups and members? No. This law applies to groups with more than 50 employees (including Priority Health Medicare offered as a group plan). Priority Health will assume that all groups with 51 or more employees (all employees, not just eligible employees) are required to comply unless a group tells us otherwise. Small groups (50 employees or less) and individual plans are exempt from these requirements. Group size is determined using Internal Revenue Code "controlled group" rules. Will mental health and substance abuse benefits change? Yes, but only for groups affected by this law.
Here are the basics of the mental health parity benefit design for groups of 51 or more employees:
Does this law take benefits away from members? No. It does require some changes in the way financial limits and treatment limits are applied. Does mental health parity mean that members will have unlimited mental health and substance abuse benefits? No. Although day and visit limits are removed, the health plan can still manage these benefits under its medical criteria policies. Coverage limitations and/or non-covered services will be outlined in the Certificate of Coverage or Insurance Policy for fully funded members and the SPD for self-funded members. Questions?If you have questions about information in this edition of Physician and Practice Information, call your physician account executive, field services representative or the Provider Helpline at 616 942-4765 or 800 942-4765.
Last modified
10/30/09
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September/October 2009
Physician and Practice Information
