First Quarter 2013

Provider Newsletter

Cultural Communication and Interpreter Services Cultural and linguistic differences can create barriers between providers and patients. These barriers may hinder healthcare professionals from understanding patient needs. Providers can positively enhance a patient-physician relationship by:

• Being focused on the patient during the visit

• Asking clear and concise questions

• Following up with additional questions to ensure the member understands the provider’s instructions

For members that are hearing impaired or not proficient in English, MedStar Family Choice will provide telephonic interpretation services and/or professional on-site interpreters. Please contact our Care Management department at 800-905-1722 to schedule telephonic translation services or call Provider Relations at 800-905-1722, option 6, to coordinate an in-office interpreter. Please be aware that Provider Relations will need no less than five business days prior to a member’s appointment to coordinate an on-site interpreter. Providers who are interested in learning more about cultural diversity and literacy can take online training courses. For example, ThinkCulturalHealth.org provides training, as well as free CME credits for completing education modules on this topic.

Excluded Parties Listing–Payment BandThe Health and Human Services Office of the Inspector General (HHSOIG) publishes a list of providers that are excluded from receiving payments from the Medicaid program for any and all reimbursable items or services. The list was created to support and prevent fraud and abuse of the Medicaid program. The “payment ban” includes contractors, providers, employees of providers, etc. Providers should be aware of and screen all employees and contractors for exclusion since payments may be retracted if reimbursement is directly or indirectly related to the excluded parties for items/services received by a Medicaid recipient. A searchable list can be found on the List of Excluded Individuals/Entities (LEIE) on the HHSOIG website, as well as a separate look up for Maryland Sanctioned Providers and Entities Excluded from participation in the Medicaid program. Visit: OIG.HHS.gov/Fraud/Exclusions.asp for all lists. Both lists should be utilized and checked regularly. Questions and concerns regarding the LEIE can be directed to the chief compliance officer, Office of the Inspector General, at 410-767-5784.

Maryland HealthChoice Program

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Avoid Timely Filing DenialsA clean claim must be received by MedStar Family Choice within 180 days (six months) from the date of service. After 180 days, any claim submitted will be denied as untimely and the claim will not be paid. If the claim is first submitted to another insurance carrier (Commercial, Medicaid fee-for-service, etc.), claims must be submitted within 180 days (six months) from the date of the Explanation of Benefits (EOB) of the primary carrier. It is always required that the provider submit that EOB with the claim once they receive it. If a member has Medicare as a primary carrier, then the timely filing must occur within 18 months from the date of the Medicare EOB. When a claim is submitted, please retain the EOB as your proof of timely filing. It is critical for providers to retain their EOB since this is the only acceptable proof that a claim has been filed. MedStar Family Choice does not accept billing system print outs as proof that a claim was filed in a timely manner. Providers should make every effort to submit their claims as soon as possible. This allows providers additional time to submit corrected new claims within the six month timeframe.

Report Fraud and AbuseMedStar Family Choice and MedStar Health have comprehensive Compliance programs in place to monitor and detect fraud and abuse. Fraud and abuse could be committed by a provider, member or even an employee of the managed care organization. As a MedStar Family Choice provider, it is your responsibility to report fraud and abuse. Providers report fraud by calling the MedStar Family Choice compliance director at 410-933-2283 or the MedStar Health Integrity Hotline at 877-811-3411. You may also contact complianceofficer@medstar.net via email. A strict non-retaliation policy is in place for reporting suspected fraud and abuse. Some common examples of fraud and abuse are:

• Billing for a service that was never performed

• Unbundling of procedures

• Upcoding

• Performing unnecessary procedures

• Altering or forging a prescription

• Allowing others to use a member’s ID card for care

Most billing errors are oversights and not indicators of fraudulent activity. However, fraud and abuse does occur and MedStar Family Choice is responsible for monitoring, identifying and deterring these types of activities. As a result, we regularly monitor and audit claims submissions and encounter data. In addition, MedStar Family Choice performs routine and random chart audits as a part of the Compliance program. Providers are subject to comply with these audits. If overpayments related to fraudulent or abusive billing have been identified, we may retract those payments made to providers. In addition, under certain circumstances (Maryland Medicaid MCO Transmittal No. 82), MedStar Family Choice may be required to notify the Department of Health and Mental Hygiene (DHMH) Office of Inspector General and Medicaid Fraud Control Unit (MFCU) of the retraction. DHMH or the MFCU may perform its own investigation. Penalties such as fines, loss of licensure or imprisonment can occur for providers found guilty of fraudulent activity.

Required EPSDT MaterialsEffective Jan. 1, 2012, pediatric providers were required to implement developmental screening tools for children ages nine and 18 months, as well as 24 to 30 months of age. There are six approved developmental tools recommended by the HealthyKids program that Maryland providers may choose to purchase. These tools include:

• Ages and Stages Questionnaire (ASG): Recommended by the Healthy Kids program

• Battelle Developmental Inventory Screen Tool, Second Edition

• Brigance Screens-II

• Early Screening Inventory Revised

• First STEP Preschool Screening Tool

• Parents’ Evaluation of Developmental Status (PEDS) +/- Peds: DM: Recommended by the Healthy Kids program

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• A blood lead level performed at age 12 and 24 months

• A lead risk assessment survey completed at EVERY well-child visit from age six months to six years

• A blood level check for any patient with any item positive on a lead risk assessment survey

Children whose lead levels are above 5mg/dL are to be retested within three months. The child must be retested and the family should receive lead and nutritional education along with an assessment for other likely causes of lead exposure.

In order to help providers meet these mandates, there are a few options for having the lead levels for MedStar Family Choice members tested. Providers may use LabCorp, MedTox and CLIA Waived Devices.

LabCorp: Lead testing supplies can be ordered at no cost. These supplies are listed on the LabCorp requisition form. When a pediatric lead test is ordered, it requires a tan top tube. When an adult lead test is ordered, it requires a royal blue tube. Specimens are then sent to LabCorp for testing.

MedTox: Effective Jan. 25, 2012, primary care providers can use MedTox for MedStar Family Choice members. MedTox will provide filter paper lead supplies and pre-assembled comprehensive collection kits to providers at no charge. Postage paid and pre-addressed envelopes are included in the kits. Once the samples are placed in the pre-addressed envelopes and sent to MedTox, the results are reported back to the provider and the state within 72 hours. Account set up can be completed by faxing an account set-up form to Mark Johnson at 651-633-1071 or by calling 888-834-8315.

CLIA Waived Devices: Effective Nov. 27, 2011, primary care providers who purchased and are using CLIA waived devices in their office for blood lead testing can submit claims for CPT 83655 to MedStar Family Choice for processing. Reimbursement for CPT code 83655 is paid at the MedStar Family Choice fee schedule.

Please contact MedStar Family Choice Provider Relations at 800-905-1722 with questions and or inquiries.

Since there is an up-front cost to obtain the forms, providers will receive reimbursement for utilizing the screening tools by billing CPT code 96110 on the HCFA 1500 Form as each individual form is used. Another screening tool that pediatric providers must utilize is the M-CHAT. This is the modified checklist for autism in toddlers. The M-CHAT is free of charge and can be photocopied. This tool cannot be modified and should be used at ages 18 months and 24 to 30 months. Providers are reimbursed for completing the M-CHAT by using CPT 96110. If the M-CHAT is performed on the same day as a developmental tool mentioned above, bill the CPT code 96110 for both and use modifier 59 to report the CPT codes as separate and distinct screenings performed on the same day. Visit MCHATScreen.com for more information regarding the M-CHAT. The new developmental tools do not replace development surveillance, which is currently on the age-specific EPSDT forms used during well-child visits. These EPSDT forms remain free of charge and continue to assist providers in meeting all the program elements required by the state of Maryland. Visit DHMH.State.MD.US/EPSDT/HealthyKids for up-to-date forms, schedules and clinical guidelines, as well as a copy of the provider manual. If your office does not have Internet access, hard copies of current EPSDT forms and related materials can be requested from MedStar Family Choice Provider Relations by calling 800-905-1722. For assistance in training or the implementation of the developmental screening tool that is best for your practice, please contact the Maryland Healthy Kids program at 410-767-4804.

Lead Testing OptionsAs a provider, it is important to follow the lead testing schedule as it applies to Medicaid recipients. As per federal and Maryland state law, it is the responsibility of healthcare providers to ensure that all applicable children receiving Medicaid get:

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EPSDT Updates to the Healthy Kids Preventative ScheduleIn December, the Maryland Department of Health and Mental Hygiene sent out a notification to EPSDT Healthy Kids providers that included important updates and clarifications made to the Healthy Kids Preventative Schedule that became effective on Jan. 1, 2013.

Healthy Kids health schedule updates and clarifications included:

• The Maryland Department of Health and Mental Hygiene added two additional well-child examination encounter forms to the Healthy Kids preventative schedule. The encounter forms added are Pediatric Visit 3 to 5 Day and Pediatric Visit 30 Months. Provider offices should begin using the new forms immediately.

• Providers must begin referring members for dental services at 12 months of age.

• Autism screening tools must be completed at the ages of 18 and 24 to 30 months.

• Standardized, validated developmental screening tools must be completed at ages 18 and 24 to 30 months.

• Lead testing must be performed at 12 and 24 months of age. Children with a lead level > 5 mg/dL must be retested within 30 months of initial test. Providers must also provide additional lead and nutrition education for families with a child(ren) with the increased lead level.

To view and/or print a copy of the updated Healthy Kids Preventative Schedule, additional forms and additional clarifications and billing standards, please visit the Maryland Healthy Kids website at: DHMH.Maryland.gov/EPSDT/HealthyKids/SitePages/Home.aspx.

For questions regarding the EPSDT updates, please contact Lesa Watkins in the Maryland Medical Assistance Healthy Kids Unit at 410-767-1836 or lesa.watkins@maryland.gov.

2012 EPSDT Results – Calendar Year 2011Each year, the Maryland Department of Health and Mental Hygiene (DHMH) evaluates the quality of care (QOC) provided to Maryland Medical Assistance recipients enrolled in a HealthChoice Managed Care Organization (MCO).The DHMH contracts with The Delmarva Foundation to serve as the External Quality Review Organization (EQRO). In 2008, beginning with calendar year 2007 services, Delmarva began performing an annual medical record review of preventive services performed according to the calendar year’s Schedule of Preventive Health Care for HealthChoice children under the age of 21.

The five components reviewed were: health and developmental history, comprehensive physical examination, laboratory tests/at risk screenings, immunizations and health education/anticipatory guidance.

MedStar Family Choice scored above the minimum performance score of 75 percent for each component. In addition, MedStar Family Choice is at, or above, the Maryland aggregate score for all components with the exception of health education/anticipatory guidance, which scored two percentage points below the Health Choice aggregate. The MedStar Family Choice score in the component laboratory tests/at-risk screenings decreased slightly from the previous year but remained above the Health Choice aggregate. In addition, scores for health and development History and immunizations improved over the previous year. The composite score for MedStar Family Choice for calendar year 2011 was (89 percent), which equals the Health Choice aggregate score.

MedStar Family Choice continues to request that providers encourage parents to schedule appointments for well-child visits and take their children for their laboratory tests. MedStar Family Choice has requested that providers continue to use the EPSDT screening forms, (a small supply of the EPSDT forms are available to the MedStar Family Choice providers from the Provider Relations department upon request) or they can be obtained online at DHMH.Maryland.gov/EPSDT. Use of the tools continue to have positive impact on the scores.

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First Annual Youth Fitness and Health ExpoThe MedStar Family Choice Annual Youth Fitness & Health Expo was held on Nov. 17, 2012 at M&T Bank Stadium, Baltimore, Maryland. The population targeted for this event was the teen population. Families of our members were welcome and a total of 1,022 guests attended the expo. The goal of the Expo was to provide easy access to physical exams, provide education on health/fitness and to have fun!

Prior to the event, we contacted our non-compliant members who either were not able to schedule their physical for 2012 due to scheduling conflicts with their primary care physician (PCP) or the member was not yet established with a PCP. Immunizations were not given during these physicals and members were instructed to receive immunizations at their PCP office. Members who received their physical exam were eligible to receive a $35 Wal-Mart gift card and were also entered into a drawing for a $50 Target gift card.

Three of our MedStar Physician Partners volunteered for the day and completed the physical exams at the Expo. The physicians were Dr. Richard Walsh, Dr. Elaine Wilson-Colbert and Dr. Danielle Brown. Multiple vendors donated their time as well. The Expo would not have been as successful without them!

The day was packed with educational information, games and prizes. For example, Dr. Steven Bentsen, medical director for Value Options, gave a special presentation on substance abuse, including the abuse of prescription drugs and the steps to prevention. Following Dr. Bentsen’s presentation, Mario Barrett, entertainer, and founder from the Do-Right Foundation conducted a question and answer session via Skype regarding the impact of substance abuse in the community.

We are planning a 2nd Annual Youth Fitness & Health Expo in 2013. The date has not yet been determined. If you are interested in learning more or have ideas for the 2013 Expo, you can contact your provider relations representative at 800-905-1722, option 6.

Again … MedStar Family Choice would like to thank Dr. Richard Walsh, Dr. Elaine Wilson-Colbert and Dr. Danielle Brown for everything they did at the Expo!

“Picture this: a brisk November afternoon at the M&T Bank Stadium, large crowds, and beautiful cheerleaders. No, I wasn’t at a Ravens game, but I was at the next best thing - The MedStar Family Choice Annual Youth Fitness and Health Expo. I volunteered to help perform physicals on MedStar Family Choice members and had a great time providing some health education to patients who were really motivated to learn. The MedStar staff was supportive and ran the expo like a well oiled machine. As a MedStar associate, I got to see how MedStar gives back to the community, and my new motto is: Whatever the Team Needs! As you can see, I also had quite a few people cheering me on. “ -Rich Walsh

Just a few vendors who participated in the expo included: Oriole Bird Baltimore Ravens Cheerleaders Baltimore Blast M&T Stadium Tours (including Ravens Locker Room) 92Q radio Rolling Video Games Theater Mario Barrett, Entertainer, Mario Do-Right Foundation Dr. Steven Bentsen, medical director, Value Options Kangaroo Kids Changing faces for Fun (Caricature artist and balloon twisters) Coalition to end childhood lead poisoning House of Ruth Baltimore County Health Department Baltimore City Health Department Baltimore Community City College Ravens Play60 Fitness-Physical Education/Activity National Guard Adventure Dental Dr. Collier, MedStar Union Memorial Dental Fit-N-Fun-Physical Education/Activity Baltimore Ravens Stadium Tour staff DC United-Physical Education/Activity Baltimore City Junior Police Cadets: The Explorers YMCA yoga instructor-Physical Education/Activity

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Value Based Purchasing – Reporting Year 2012 (Calendar Year 2011 Data)In 1999, the Department of Health and Mental Hygiene began working with the Center for Health Care Strategies, a Robert Wood Johnson Granting agency, to develop a Value Based Purchasing (VBP) model for Maryland Medicaid. The goal of this project is to improve enrollee health through improved managed care performance. Improved performance is to be achieved by focusing on a handful of measures selected to focus on core populations served by Medicaid, such as the disabled, children and pregnant women. The program’s design includes outside auditing of the results for validation. Measures were selected to reflect three operational areas: access to care, quality of care and administration. Some of the measures are gleaned from other measurement areas, such as the HEDIS scores. Each of the selected measures has a minimal acceptable performance level (disincentive level) a high performance level (incentive level.) and an average performance level (neutral range). Rewards and fines can be awarded and assessed based on performance. In future years, other measures may be added to this set of 10 or may be rotated with measures in the set. The flexibility of this strategy provides the opportunity to change measures based on evolving priorities and healthcare needs.

The 10 VBP performance measures for reporting year 2012 (services provided during calendar year 2011) were:

1. Well-Child Visits for Children Ages 3 through 6

2. Adolescent Well Child

3. Ambulatory Care Services for SSI Adults

4. Ambulatory Care for SSI Children (Disabled)

5. Postpartum Care

6. Cervical Cancer Screening for Women Ages 21 to 64

7. Lead Screening for Children Ages 12 to 23 Months

8. Eye Exams for Diabetics ages 18 to 75

9. Childhood Immunization Status (Combo 3 only)

10. Use of Appropriate Medications for Asthma

This year, MedStar Family Choice had four scores in the incentive range as compared to the two last year. The four measures in the incentive range were: childhood immunization status (combo 3), eye exams for diabetics, cervical cancer screening for women ages 21 to 64 and use of appropriate meds for asthma. There were no scores in the disincentive range. The remaining six measures scored in the neutral range.

MedStar Family Choice was above the Maryland MCO average in all but two areas. Therefore, our opportunities for improvement for reporting year 2013 (calendar year 2012 services) will be in the areas of well-child visits 3, 4, 5 and 6 lead screening. MedStar Family Choice will continue to focus efforts on all the VBP measures. There continues to be coordination of MedStar Family Choice staff in outreach, case management and QI to assist members in obtaining the services needed, i.e., women’s preventative services, children well visits and immunizations, and management of specific diseases. In addition, there are individually dedicated outreach representatives working on women’s preventative services, well-child visits, eye exams and childhood immunizations/lead screening. For well-child visits, we are proactively contacting the guardian of those members who have not had a well child visit and assisting them in getting an appointment as soon as possible. For lead, monthly reports are run for those members who are turning 20 months of age and who have not had a lead test. MedStar Family Choice is proactively contacting the guardian of those members to assist them in getting an appointment for a lead test before the member turns two years of age.

Provider Satisfaction Survey 2012 (Based on Calendar Year 2011 Data)Each year, the Department of Health and Mental Hygiene contracts with a third party to conduct a provider satisfaction survey for primary care physicians. The provider survey asks the physicians and staff whether they like being a part of the MedStar Family Choice network and how well we work with you to meet your needs. The survey reviews our performance in the below areas:

• No-show appointments

• Finance (claims issues)

• Customer service/Provider relations

• Coordination of care/case management

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• Utilization management

• Overall satisfaction

A random sample of 288 MedStar Family Choice providers was mailed the survey tool between March and June 2012. A total of 68 responses were collected, 39 were returned by mail and 29 were conducted by telephone. The response rate for 2012 decreased slightly from last year but not enough to make a considerable difference in the end results.

MedStar Family Choice increased its scores in the following composite measures: no-show appointments, finance issues, customer service/provider relations, coordination of care and utilization management. We decreased our scores in overall satisfaction. MedStar Family Choice scored significantly higher than the Maryland MCO aggregate in all the composite measures with the exception of no-show appointments and finance issues.

MedStar Family Choice strengths that improved from last year while scoring above the HealthChoice aggregate for 2012 include:

• Accuracy of claims processing

• Timeliness of initial claims processing

• Timeliness of adjustment/appeal claims processing

• Process for obtaining member eligibility information

• Responsiveness and courtesy of the health plan’s provider relations/customer service representative

• Timeliness to answer questions and/or resolve problems

• Quality of written communications, policy bulletins and manuals

• Accuracy and accessibility of drug formulary and formulary updates

• Customer service/provider relations overall

• Telephone system overall

• Specialist network has an adequate number of specialists to whom I can refer patients

• Coordination of care/case management

• Timeliness of obtaining authorization for outpatient services

• Timeliness of obtaining authorization for medication

• Overall experience in obtaining prior authorization for medications

• Overall satisfaction with MedStar Family Choice

• Would recommend to patients

• Would recommend to other physicians

MedStar Family Choice’s performance in 2012 rated above the Maryland HealthChoice aggregate for all of the composite measures. Overall satisfaction was lower than 2011, but higher than the 2012 HealthChoice aggregate. Our focus for 2013 will be:

• Looking for more specialists specifically in dermatology and endocrinology

• Continuing to look at all measures in order to improve in all areas

HealthChoice Member Satisfaction Survey 2012 Final Report (Based on 2011 Data)The HealthChoice program contracts with an independent vendor to conduct a member satisfaction survey once a year. The surveyed members are randomly chosen from three different population groups: adults, children and children with special needs/chronic conditions. The members are asked to rate their satisfaction on the following measures:

• How well doctors communicate

• Shared decision making

• Getting care quickly

• Coordination of care

• Getting needed care

• Customer service

• Health promotion and education

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When comparing the MedStar Family Choice rates from 2011 to 2012, the ratings increased in five out of seven composite measures. Customer service increased significantly in 2012 from the previous year. This is very exciting for MedStar Family Choice as several interventions have been implemented to address this area over the past two years. Compared to the Medicaid MCO aggregate for MCOs operating in Maryland, MedStar Family Choice scored above or equal to all of the composite measures.

MedStar Family Choice continued to receive the highest satisfaction ratings among child members, general population, in 2012 on the following measures:

• Personal doctor

• Health plan overall

• Health care overall

• Specialist

MedStar Family Choice continued to receive the highest satisfaction ratings among children with chronic conditions.

• Personal doctor

• Health plan overall

• Health care overall

• Specialist

Even though our survey results showed an increase in our customer service rates, MedStar Family Choice will be monitoring our vendor throughout the year to make sure we continue to improve in this area.

Update to the MedStar Family Choice Formualry Maryland HealthChoiceUpdates will continue to be available quarterly on our website and more frequently on ePocrates. Paper booklets of the 2013 formulary have been mailed. If you have not received a copy or would like additional copies, please contact your provider relations representative. Details of the prior authorization criteria are available on the MedStar Family Choice website with the other pharmacy protocols. Contact provider relations at 800-905-1722, option 6, if your office does not have access to the Internet and you would like copies of this information.

At the January 2013 Pharmacy and Therapeutics Committee meeting, the following changes were made:

Additions that have or will go into effect in the next few weeks:

• None

Additions with Prior Authorization effective April 1, 2013:

• Synribo (omacetaxine) is indicated for the treatment of accelerated phase and chronic phase chronic myelogenous leukemia in patients who have experienced intolerance and/or resistance to two or more tyrosine kinase inhibitors. Authorization will be for this indication.

• Stivarga (regorafenib) is an oral treatment option for metastatic colorectal cancer in patients who have exhausted all other standard treatment options.

Authorization will be for this indication.

Removals:

• There were no medications removed from the formulary.

Managed Drug Limitations and Step Therapy:

• None

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8094 Sandpiper Circle, Suite O Baltimore, MD 21236 888-404-3549 PHONE

The MedStar Family Choice Newsletter is a publication of MedStar Family Choice.

Submit new items for the next issue to Melanie Bodencak, MedStar Family Choice, melanie.bodencak@medstar.net

Kenneth A. Samet, FACHE President and CEO, MedStar Health

Eric Wagner President, MedStar Family Choice

Melanie Bodencak Editor MedStarFamilyChoice.com

13-MFC-0463.032013