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The InsIde sTory - Fall 2015 www.swhp.org 1
Provider Relations Provider Interactive Voice Response (IVR) System .................................................. 2 ICD-10 Helpful Documents ............................................................................................... 2 Prescriber Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs ................................................................................................. 3 Balance Billing Scott & White Health Plan Members .............................................4
Quality Improvement (QI) Chronic Obstructive Pulmonary Disease ..................................................................... 5 Best Practices for ADHD Care in Children ...................................................................6 Asthma Medications .......................................................................................................... 7 Adolescent Well-Care Visits ............................................................................................8 Colorectal Cancer Screening Best Practices ...............................................................9 Cardiovascular Best Practices ....................................................................................... 10
Care Coordination Division (CCD) Scott & White Health Plan Medical Coverage Policies Update ............................11 SWHP/ICSW Utilization Management Criteria for Inpatient Services and Selected Benefit Coverage Determinations 2015 .......................................12
The Inside Story Staff ..............................................................................................................14
In This Issue
Thesecondhalfof2015isprovingtobejustasbusyasthefirsthalfwasforScott&WhiteHealthPlan(SWHP).OurnewProviderInteractiveVoiceResponse(IVR)Systemwentliveon08/14/2015.TheProviderIVRwasimplementedtoofferafasterwayforyoutoobtaininformationaboutmemberenrollmentstatus,memberbenefits,andclaimsstatus. WealsoworkeddiligentlytopreparefortheconversionfromICD-9toICD-10thatoccurredon10/01/2015.SWHPteamedwithseveralproviders,clearinghouses,andvendorstoconducttesting.Inaddition,weconductedtwoICD-10TrainingSeminarsandcreatedanICD-10FrequentlyAskedQuestionsandICD-10TrainingPowerPointthatarecurrentlyavailableontheSWHPwebsite. SWHPiscurrentlyworkingonanewwebsitedesignthatisscheduledtolaunchinNovember
Volume 21 Issue 3 FALL 2015
2015.Weareveryexcitedtoofferanenhancedanduser-friendlydigitalexperiencetoourmembersandproviders! Asweapproachthenewyear,SWHPisimplementingvarioustools,processes,andpoliciesandprocedurestoensureweareincompliancewithalloftheupcomingregulatoryrequirementsthatgointoeffectthroughout2016,includingAffordableCareActAdministrativeSimplification,providerenrollmentrequirementsforwritingprescriptionsforMedicarePartDdrugs,providerdirectoryaccuracyrequirements,andetc. Welookforwardtoourongoingpartnershipswithallofourprovidersaswecollaboratetocontinuetoprovidehigh-qualityandcost-effectivecaretoourSWHPmembers.
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Provider Relations
PROVIDER INTERACTIVE VOICE RESPONSE (IVR) SYSTEM
ICD-10 HELPFUL DOCUMENTS
Scott&WhiteHealthPlan(SWHP)isexcitedtoannouncethatournewProviderIVRwentliveon08/14/2015.TheProviderIVRwasimplementedtoofferafasterwayforyoutoobtaininformationaboutmemberenrollmentstatus,memberbenefits,andclaimsstatus.ByutilizingtheProviderIVR,younolongerhavetowaitonthephonetospeakwithaCustomerServiceAdvocate(CSA).Please note that the information received from the Provider IVR is generated from the same system that the CSAs use. Therefore, there is no need to wait to speak with a CSA on the phone to validate the information received from the Provider IVR. Werealizethatyouarebusydeliveringhealthcareservicestoourmembers,sowewanttoofferyoutoolstoobtaintheinformationyouneedefficiently.
YoucanaccesstheProviderIVRdirectlybydialing1-800-655-7947orbycallingtheSWHPCustomerAdvocacyDepartmentphonenumberat1-800-321-7947andselectingoption1.TheProviderIVRisavailable24hoursaday,7daysaweek.Ifthesystemisunavailableorishavingtechnicaldifficulties,thenyouwillberoutedtoaCSAforassistance.
SWHPvaluestherelationshipsthatwehavewithourproviders,andwearecommittedtoprovidingyouwiththehighestlevelofservice.
Scott&WhiteHealthPlan(SWHP)valuestherelationshipsthatwehavewithallofourparticipatingprovidersthatdeliverhigh-qualityandcosteffectivehealthcaretoourSWHPmembers.Welookforwardtocontinuingourpartnershipwithyouasweworkcollaborativelytomeetthevariousfederalandstaterequirementsthatarebeingmandated.Assuch,wehavecreatedsomehelpfuldocumentstoanswermanyofyourquestionsandprovideyouwithvaluableinformationregardingtherecenttransitiontoICD-10onOctober1,2015.Wewanttoprovideasmuchassistanceaswecantoourproviderpartnerstoensureeveryonehasasuccessfulconversion,withourtopprioritybeingtoavoiddisruptioninservicestoourSWHPmembers.To access the ICD-10 PowerPoint Training and ICD-10 Frequently Asked Questions (FAQs) documents that we have available, please visit the SWHP website at https://swhp.org/providers/training-education.
IfyouhaveanyquestionsorneedassistancelocatingtheICD-10materialsonourwebsite,pleasedonothesitatetocontacttheSWHPProviderRelationsDepartmentat1-800-321-7947,ext.203064or254-298-3064.
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Provider Relations
PRESCRIBER ENROLLMENT REQUIREMENTS FOR MEDICARE
PART D DRUGSTheCentersforMedicareandMedicaidServices(CMS)finalizedruleCMS-4159-FonMay23,2014,whichrequiresphysiciansandothereligibleprofessionalswhowriteprescriptionsforPartDdrugstobeenrolledinanapprovedstatusortohaveavalidopt-outaffidavitonfilefortheirprescriptionstobecoveredunderMedicarePartD.CMSoriginallyplannedtoenforcethisrequirementbeginningDecember1,2015.However,CMSmaderevisionstoruleCMS-4159-FonMay6,2015.TherevisedruleispublishedasCMS-6107-IFC,whichwentintoeffectonJune1,2015.
UndertherevisedruleCMS-6107-IFC,CMSisdelayingenforcementoftheprescriberenrollmentrequirementsuntilJune1,2016.TherevisedrulealsoencouragesPartDsponsorsandpharmacybenefitmanagers(PBMs)tobeginoutreachactivitiestoMedicarePartDprescribersnolaterthanJanuary1,2016.Therefore,prescribersmaybecontactedmultipletimesfromthevariousPartDsponsorsandPBMswithwhomtheyparticipate.
CMS strongly encourages prescribers of Part D drugs to submit their Medicare enrollment applications or opt-out affidavits to their Medicare Administrative Contractors (MACs) before January 1, 2016. This will provide the MACs with sufficient time to process the prescribers’ applications or opt-out affidavits and avoid prescription drug claims from being denied by the Part D plans, beginning June 1, 2016.
Formoreinformation,pleasevisittheCMSPartDPrescriberEnrollmentwebsiteat:http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Prescriber-Enrollment-Information.html.
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Provider Relations
Balance Billing the PatientScott&WhiteHealthPlan(SWHP)doesnotallowcontractedproviderstobalancebillpatientsforcoveredservices.
BalancebillingisthepracticeofbillingthepatientforthedifferencebetweenwhatSWHPpaysforcoveredservicesandthe"retail"priceyouchargeuninsuredpatientsforthoseservices.
Review Your Participating Provider Agreement for DetailsInyourparticipatingprovideragreement(contract)withSWHP,itstatesthatyoushallnotlooktoSWHPmembersforpaymentforcoveredservices,excepttotheextentthattheapplicablePlanspecifiesacopayment,coinsurance,ordeductibleortheserviceisnotacoveredbenefit.
Balance Billing Rules under MedicareTheCenterforMedicareandMedicaidServices’(CMS)MedicareManagedCareManual,Chapter4,Section170,statesinpart,“MedicareAdvantagemembersareresponsibleforpayingonlytheplan-allowedcost-sharing(copaymentsorcoinsurance)forcoveredservices.”
Ifamemberinadvertentlypaysabill,whichisSWHP’sresponsibility,youmustrefundtheamounttotheenrollee.
Foradditionalinformationorquestions,pleasecontacttheSWHPProviderRelationsDepartmenttoll-freeat1-800-321-7947,ext.203064orlocallyat254-298-3064.
Balance Billing Scott & White Health Plan Members
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Quality Improvement (QI)
AccordingtotheCentersforDiseaseControlandPrevention(2015),6.8millionadultswerediagnosedwithChronicObstructivePulmonaryDisease(COPD)duringthepastyear,equaling2.9%oftheadultpopulation.WithCOPDbeingstatisticallyprevalent,itisimperativethatpatientsreceiveappropriatetestingtoconfirmthediagnosisofCOPD.
SpirometryplaysavitalroleindeterminingtheseverityofCOPD,butcanalsoplayaroleindeterminingtheseverityofotherconditionslikeasthma.Spirometrycandetermineexactlyhowsevereeachrespectiveconditionisandcanhelpdeterminetheultimatecourseoftreatment.
Scott&WhiteHealthPlan(SWHP)monitorsaHealthcareEffectivenessDataandInformationSet(HEDIS)measurededicatedtotheUseofSpirometryTestingintheAssessmentandDiagnosisofCOPD(SPR).SPRisbrokendownbydeterminingifamemberreceivedappropriatetestingtoconfirmthediagnosisofCOPDwithinsixmonthsofthediagnosisdate(HEDIS2015).
WhendiagnosingsomeonewithCOPD,pleaseremembertoordertheappropriatetestingtoconfirmthediagnosisandtodeterminetheseverityoftherespiratorycondition.
References
CentersforDiseaseControlandPrevention.(2015).ChronicObstructivePulmonaryDisease(COPD): ChronicBronchitisandEmphysema.Retrievedfromhttp://www.cdc.gov/nchs/fastats/copd.htm.
HEDIS2015TechnicalSpecificationsforHealthPlan(Volume2).(2014).Washington,D.C.National CommitteeforQualityAssurance.
Chronic Obstructive Pulmonary Disease
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Quality Improvement (QI)
Best Practices for ADHD Care in ChildrenAttentionDeficitDisorder(ADD)andAttentionDeficitHyperactivityDisorder(ADHD)arecommondiagnosesinchildren(www.nimh.nih.gov).Parentsoftenbringtheirchildrentoadoctorforanevaluationwhenfocusingatschoolandathomebecomeanissue.HyperactivityispresentinsomebutnoteverychildwithADHD.Teachersarefrequentlythefirsttonoticefocusproblemsinschoolagechildren.“SymptomsofADHDmayinclude:stayingfocusedandpayingattention,difficultycontrollingbehaviorsandhyperactivity”(www.nimh.nih.gov).
VariousmedicationscanbeusedtotreatADHDinchildrenbasedontheindividualchild’ssymptoms.TheseincludeCNSStimulants,Alpha-2Receptoragonists,andotherADHDmedications.Thesemedicationscanhavevarioussideeffectsthatneedtobemonitoredtoachievethetreatmentresponseneeded.
Scott&WhiteHealthPlan(SWHP)workswithBaylorScott&WhiteHealth(BSWH)physiciansandtheNationalCommitteeforQualityAssurance(NCQA)tomonitorthetreatmentandtheprescribingofmedicationsforschoolagechildrenwithADHD,ages6to12yearsofage.PrescriptioncomplianceismonitoredperprescriptionrefillsbytheSWHPClaimsDepartment.
SWHPisincomplianceifthepatienttakesADHDmedicationfor10monthswithonlyamaximum45daygapbetweendays31and300.Themeasureallows10monthsofmedicationperyearsincemanyparentstaketheirchildrenofftheADHDmedicationontheweekendandduringthesummermonths.
Follow-upcareisessentialintreatingchildrenwithADHD.IntheInitiationPhase,childrenareprescribedanADHDmedication.ThenintheContinuationandMaintenance(C&M)Phase,patientsarerequiredtohaveatleastthreefollow-upvisitsperyear(HEDISManual2015).
WhileADHDisoftenthoughtofasachildhooddisorder,itcanlastintoadulthood.ADHDinchildreniscommonlyassociatedwithothermentalhealthconditionsinadulthood,soitisveryimportantforthechildtogettheproperdiagnosisandtreatmentattheearliestagepossible(www.cdc.gov/ncbddd/adhd).
References
NIH.(n.d.).NIMH-Attention Deficit Hyperactivity Disorder (ADHD).RetrievedJune25,2015,from http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
NCQA.(2014).BehavioralHealth.HEDIS 2015 Technical Specifications for Health Plans(2015ed.,pp.172-176). Washington,DC:NationalCommitteeforQualityAssurance.
www.cdc.gov/ncbddd/adhd
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Quality Improvement (QI)
AccordingtotheCentersforDiseaseControlandPrevention(2008),over1.2millionadultsandover590,000childreninTexaswerediagnosedwithasthmain2008.AsthmaisstatisticallyprevalentinTexas,anditisimperativethatmembersdiagnosedwithasthmahavetheappropriatemedicationstohelpmanageandcontrolvariousstagesofasthmaorasthma-relatedconditions.
First,therearerescuemedications,whicharespecificallydesignedtoprovideimmediatereliefforasthmasymptomsastheyoccur.Itisimportanttomakesurethatrescuemedicationsarenotoverused.Second,therearecontrollermedications,whicharespecificallydesignedtoworkoveraperiodoftimetohelpalleviateinflammationintheairwaysoverthecourseoftime.
AccordingtotheMayoClinic(2012),ifanindividualdoesnotusetheircontrollermedicationsasprescribedbytheirprimarycarephysician,thatindividual’sasthmacanpotentiallybecomeuncontrolledandincreasetheirriskofamajorasthmaattack.
TheScott&WhiteHealthPlan(SWHP)monitorsaHealthcareEffectivenessDataandInformationSet(HEDIS)measurededicatedtoMedicationManagementforPeoplewithAsthma(MMA).MMAisbrokendowntoindividualsthatwereonanasthmacontrollermedicationforatleast50%andatleast75%ofthetreatmentperiod(HEDIS2015).
IndividualsdiagnosedwithpersistentasthmaareincludedintheMMAmeasure.Persistentasthmaisdefinedas:oneEDvisitwiththemaindiagnosisofasthma,oneinpatientencounterwiththemaindiagnosisofasthma,fouroutpatientvisitswithdifferentdatesofservice,andtwoasthmamedicationdispensingeventsorfourasthmamedicationdispensingevents.Pleaserememberthatanymemberthatisdiagnosedwithpersistentasthmashouldbeprescribedanasthmacontrollermedication.
References
AsthmainTexas.(2008).Retrievedfromhttp://www.cdc.gov/asthma/stateprofiles/asthma_in_tx.pdf
HEDIS2015TechnicalSpecificationsforHealthPlan(Volume2).(2014).Washington,D.C.National CommitteeforQualityAssurance.
MayoClinicStaff.(September8,2012).Asthmamedications:Knowyouroptions.Retrievedfrom
http://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma-medications/art-20045557?pg=1
Asthma Medications
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Quality Improvement (QI)
Adolescenceisoneofthemostdynamicstagesofhumandevelopment.Adolescenceisatimewhenteensexperiencedramaticphysical,cognitive,social,andemotionalchanges.Itisatthistimewhenmanyphysicalandmentalhealthconditions,substanceusedisorders,andhealthriskbehaviorsfirstbegintoappear.Infact,threeoutoffouradolescents,ages12–19,reportengaginginatleastonetypeofriskybehavior,suchastheuseandabuseofalcoholandothersubstances,unprotectedsex,pooreatingandexercisehabits,andphysically-endangeringbehaviors(DHHS,2014).
HealthyPeople2020notedthat“theleadingcausesofillnessanddeathamongadolescentsandyoungadultsarelargelypreventable”(Hensley-Quinn&Osius,2008).Infact,$700billionisspentannuallyoncostsdirectlyandindirectlyassociatedwithpreventableadolescenthealthproblems(Hensley-Quinn&Osius,2008).AccordingtoHealthyPeople2020,“behavioralpatternsduringthesedevelopmentalperiodshelpdetermineyoungpeople’scurrenthealthstatusandtheirriskofdevelopingchronicdiseasesinadulthood”(Hensley-Quinn&Osius,2008).TheCentersforDiseaseControlandPrevention(CDC)estimatesthat16%ofhighschoolstudentshaveseriouslyconsideredsuicidewith13%reportingthattheyhadactuallycreatedaplantodoso(CDC,2015a).Also,theCDCstatesthatalmost9outof10cigarettesmokerstriedtheirfirstcigarettebytheageof18(CDC,2015b).
Acomprehensivewell-carevisitforadolescents,ages12to21,canprovidethescreening,healthcounseling,andtreatmentnecessarytoaddressfivekeyareasofadolescenthealth: 1. Mentalandbehavioralhealth 2. Tobaccoandsubstanceuse 3. Violenceandinjuryprevention 4. Sexualbehavior 5. Nutritionalhealth
Itisextremelyimportantthatadolescentsreceiveannualwell-carevisitsforearlyidentificationandappropriatemanagementandinterventionforconditionsandbehaviorsthat,ifnotaddressed,canbecomeseriousandpersistintoadulthood.
What Counts as a Well Care Visit?
Awell-carevisitoccurswithaPCPorOB/GYNinaclinicalsettingduringthecalendaryear.Thefollowingdocumentationmustbenotedinthemember’smedicalrecord: 1. Healthhistory 2. Physicalandmentaldevelopmenthistory 3. Physicalexam 4. Healtheducation/anticipatoryguidance
Asickvisitandawell-carevisitcanbebilledatthesametime,butallthecomponentslistedabovemustbeincludedinthemember’smedicalrecord.Sportsphysicalsarealsoagreattimetocompleteawell-carevisitaslongasallthecomponentsofthewell-carevisitarenotedinthemedicalrecord.
References
CDC.(2015a,March).SuicidePrevention:YouthSuicide. Centers for Disease Control and Prevention.
CDC.(2015b,July).YouthandTobaccoUse.Centers for Disease Control and Prevention.
DHHS.(2014,February).PavingtheRoadtoGoodHealth:StrategiesforIncreasingMedicaidAdolescentWell-CareVisits, Department of Health & Human Services.
Hensley-Quinn,M.andOsius,E.(2008,May).SCHIPandAdolescents:AnOverviewandOpportunitiesforStates.State Health Policy.
Adolescent Well-Care Visits
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Quality Improvement (QI)
Althoughtheincidenceofcolorectalcancer(CRC)intheU.S.hasbeendecliningby2%to3%peryearoverthepast15years,itcontinuestobethesecondleadingcauseofcancer-relateddeaths(Randel,2012).Because90%ofallcasesofCRCoccurinpeopleover50yearsofage,theAmericanCollegeofGastroenterology(ACG)continuestorecommendtheuseofacolonoscopyasthepreferredstandardforscreeningevery10yearsbeginningatage50(Rex,2009).However,theACGalsorecognizesthatmanypatientsarenotwillingtoundergoacolonoscopyforavarietyofreasons.Assuch,theACGguidelinesstatethatinthesecases,analternatemethodoftestingshouldbeusedtoscreenforCRC.Thisincludesflexiblesigmoidoscopy(FlexSig),computedtomography(CT-scan),guaiac-basedfecaloccultbloodtests(GFOBT),andimmunochemicalbasedfecaloccultbloodtesting(FIT)untilthememberisover75yearsofageorhasanestimatedlifespanoflessthan10years.ThisleavesbothourprovidersandourpatientsaskingwhattestIshouldhave,when,whataretherisks,andwhatarethebenefits.Toaidinthediscussionofacareplan,Iofferthebelowtable.
Again,weashealthcareprovidersknowtherisksandbenefitsofeachofthesetests.However,ourmembersaretheoneswhomustbewillingtocompletetheprep,spendtheirtimetogetthetestdoneorsubmitasample.Bydiscussingalltheoptionswithourmembers,theycanchoosethemethodofCRCscreeningthatworksbestforthem.ThiswillincreaseourcomplianceratesandallowScott&WhiteHealthPlantocatchthiskillerearly.Whileourmembersseethisaspatient-centeredcare,wewillreapthebenefitsofsignificantcostsavingsinthelongrun.
References
Randel,A.(2012).ACPReleasesBestPracticeAdviceonColorectalCancerScreening.American Family Physician,86(12),1153-1154.
Rex,D.K.,Johnson,D.A.,Anderson,J.C.,Schoenfeld,P.S.,Burke,C.A.,&Inadomi,J.M.(2009).ColorectalCancerScreening. American Journal of Gastroenterology,104,739-750.
Colorectal Cancer Screening Best Practices
TestSensitivity / Specificity
Cost Frequency Barriers Risks
Colonoscopy High High 10yearsBowelPrep,Cost,Limited
Availability
Postpolypectomomybleeding,perforation,diverticulitis,severe
abdominalpain,death
FlexSig Medium High 5years BowelPrep,CostPerforation/bleeding,false
negatives
CTScan Medium High 5years BowelPrep,Cost
Low-doseradiationexposure,additionaldiagnostictestingandproceduresmaybeneedforlesionsthatmightnotbe
clinicallysignificant
Guaiac-BasedOccultBlood
TestingVariable Low Annual
2-3samplesfromconsecu-tivestoolsathome
FalseNegatives
FITTesting High Low Annual1samplefromastool
samplecollectedathomeNomajorrisks
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Quality Improvement (QI)
Cardiovascular Best PracticesNumerousresearchstudieshaveshowntimeandtimeagainthatwhenitcomestothebestpracticesforprotectingtheheart,theanswerisassimpleasourABCs: • Aspirin(asappropriate) • BloodPressureControl • CholesterolManagement • SmokingCessationStill,“thesocialandenvironmentaloriginsofCVD[cardiovasculardisease]havelongbeenrecognizedasmediatedinlargepartbylifestylesandbehaviorsthataremodifiable.Cardiovascularhealthinchildrenpredictssubsequentcardiometabolichealthinadulthood,affirmingtheimportanceofmaintaininghealthylifestylebehaviorsfromearlyinlife”(Pearsonetal,2013,p.1732).Thequestionthenbecomes,“howdowebestmodifythesebehaviors?”Bandura’sSocialLearningTheoryposesthatwelearnthelifestylebehaviorsthroughmodelingofsociallyacceptablebehaviors.FactistheNationalInstituteofHealth(NIH),CentersforMedicareandMedicaidServices(CMS),CentersforDiseaseControlandPrevention(CDC),AmericanCollegeofCardiology(ACC),AmericanAcademyofFamilyPhysicians(AAFP),andtheAmericanHeartAssociation(AHA)arealllookinginthesamedirection;improvingindividualhealthbyimprovingcardiovascularhealthandeducationatthecommunitylevel.InSeptember2011,theDepartmentofHealthandHumanServices(HHS)launchedtheMillionHeartsInitiativewiththegoalofpreventing1millionheartattacksandstrokesby2017.OneinnovationtheypresentedwasthatofHeart360.MemberswereencouragedtorecordhomeBPreadingsatleast3-4timesperweekandsharethemwiththeirpharmacist.PharmacistswereempoweredtomakeadjustmentstoRxdosagesbasedonthesereadings.Attheendofthe6-monthpilot,57%ofthepreviouslyuncontrolledHTNpatientswerenowcontrolledascomparedtothecontrolgroupusingstandardoffice-basedcare’s37%.Asimilarprogram,theAmericanPharmacists’AssociationFoundation’sAshevilleProject,alsoallowedforpharmacy-basedmedicationtherapymanagement(MTM)forpatientswithHTNordyslipidemia.Again,pharmacistswereinvolvedinbothmembereducationandadjustmentsofmedications.Overthecourseof6years,thisprogramactuallyreducedcostsforasthma,CVD,depression,anddiabetesbyover$1200permemberperyearandyet50%moremembersmetgoals.
AnotherstudywaslaunchedtolookattheeffectsofculturallycompetentcareforAfrican-AmericanswithHTN.Thisprogramentailedtrainingthenurses.Again,patientswereencouragedtotakehomeBPreadingsandreportthemtothenursingstaff.ThenurseswerealsotrainedtoanswerpatientquestionsregardingBPmonitoring,medicationadherence,andotherareasofculturallycompetentcare,aswellas,torelayBPreadingstotheproviders.Attheendofthestudy,nursehealthcoachingwithculturallycompetenteducationresultedina36%increaseinHTNcontrolratesascomparedtothebaselineofoffice-basedvisits.Meanwhile,theCDCandCMSteameduptoimprovecommunitybasedunderstandingoftheneedtoimproveantihypertensivemedicationadherencethroughtheEpi-Exchange.Simplyput,theyworkedtogethertooptimizememberaccesstobothpublichealthandclinicalresources.Intheprocesstheynotonlyincreasedtransparencyabouthowtoaccessresourcesandinformation,butconfirmedthatwhenevidence-basedbestpracticeswerecollaboratedthroughdata-sharingacrossdisciplines,patientcomplianceratesincreaseddramatically.Onecaneasilyfindnumerousotherstudies,butitissufficienttosaytheyallhaveonethingincommon.Theyhaveallchangedtheirfocusfromtreatmentbasedsolelyonofficevisitstopatient-centeredcarebasedonindividuallifestylesandcommunitybasedresources.Howcanwemakeourbestpracticesuserfriendlyforthecommunity?Theanswerremainsthesame,weuseourABCs:Aspirin,HomeBPMonitoring,CholesterolManagement,andSmokingCessation,butwithatwist.Wenowfocusonthememberasawholeandnotjustwhatweseeatoneofficevisit.Whentheentirehealthcareteamcollaboratestosendaconsistentmessageinanenvironmentofpatient-centeredcare,onlythencanwesaywehaveachievedtheCVDbestpractices.
ReferencesCDC.(2015).Million Hearts; Innovatiuons & Progress Notes.RetrievedSeptember2,2015fromhttp://millionhearts.hhs.gov/about_mh.html.
Pearson,T.A.,Palaniappan,L.P.,Artinian,N.T.,Carnethon,M.R.,Criqui,M.H.,Daniels,S.R.,Turner,M.B.(2013).AmericanHeartAssociationGuideforImprovingCardiovascularHealthattheCommunityLevel,2013Update;AScientificStatementforPublicHealthPractitioners,HealthcareProviders,andHealthPolicyMakers.Circulation,127,1730-1753.doi:10.1161/CIR.0b013e31828f8a94.
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Care Coordination Division (CCD)
Scott & White Health Plan Medical Coverage Policies UpdateScott&WhiteHealthPlan(SWHP)ispleasedtoannouncethereleaseofthefollowingMedicalCoveragePolicies.Youcanfindthesepoliciesonourwebsiteathttps://swhp.org/providers/policies.
Number Title CommentR003 OccupationalTherapyR007 AutologousChondrocyteImplantationR010 HearingAids-Bone-AnchoredR011 BotulinumToxinInjectionforChemodenervationR014 ApolipoproteinEGenotypeofPhenotypeR015 Non-InvasiveNerveConductionTestingR018 IMRTforBreastCancerR101 RegionalSympatheticBlocksR112 SpeechTherapyR129 OrganTransplantationR130 VagusNerveStimulationR213 CoverageDeterminationFinalUpdate043 INRHomeTestingUpdate208 PrivateDutyNursingR012 CompressionGarmentsR074 OccipitalNerveStimulationR082 PhonophoresisR099 PulsedDyeLaserTreatmentR110 SleepApneaR141 InfertilityR201 VentricularAssistDeviceR205 DeepandDoubleBalloonEnterscopyR214 ChiropracticServicesR215 MedicationsCoveredUnderMedicalPolicyR037 GeneticTestingR044 HyperbaricOxygenTherapyR078 SpinalCordStimulatorsR084 VertebroplastyKyphosplasySacroplastyR028 DurableMedicalEquipmentR029 AlzheimersDiseaseBiochemicalMarkersR030 OsteoporosisBoneTurnoverMarkersR031 EpiduralAdhesiolysisR035 ColdTherapyDevicesR036 GastricElectricalStimulationR045 ImmuneGlobulinTherapyR048 IncontinenceAlarmsR050 CancerVaccinesR067 NeutralizingAntibodyTestinginMultipleSclerosisR064 GenderReassignment
TheSWHPMedicalCoveragePoliciesarereviewedonanannualbasistoassurecontinuedrelevanceandtokeepthemcurrent.ThisreviewisconductedbySWHPMedicalDirectors.Eachpolicyisreviewedusinganumberofresources,suchas:1. Medicalliterature2. InterQual®guidelines3. SWTechnologyAssessmentDeterminations4. SpecialtySocietyorothernationalguidelines
OncepolicieshavebeenreviewedbytheSWHPMedicalDirectors,theyaresentforspecialtyreview.RecommendationsfromthespecialtyreviewersareconsideredatasubsequentMedicalDirectorCommitteeMeeting,andafinaldecisiononthecontentofthepoliciesunderconsiderationismade.
Thereviewprocessfortheabovepolicieshasbeencompleted,andtheyhavenowbeenpublishedtothewebsite.YourcommentsandsuggestionsregardingtheMedicalCoveragePoliciesarealwayswelcomeandmaybeforwardedto:[email protected].
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Care Coordination Division (CCD)
TheScott&WhiteHealthPlan(SWHP)/InsuranceCompanyofScott&White(ICSW)InsurancePolicyalsoreferredtoasEvidenceofCoverage(EOC)orStandardPlanDocument(SPD)isthecontractforcoverageofthehealthcareservicesthatanindividualpurchasedoranemployerpurchasedfortheiremployees.SWHP/ICSWprovidesavarietyofbenefitplanstomeetpurchaserneeds.
BenefitplansincludebenefitsrequiredbylawtobeofferedbytheSWHP/ICSW,aswellas,purchaserpreference(ASO).ThepurposeofSWHP’sUtilizationManagement(UM)ProgramistomanageservicesaccordingtothetermscontainedintheInsurancePolicy.Allbenefitplansrequirecoveragetobecontingentuponmedicalnecessity.SWHP’sUtilizationManagementCommitteeadoptsordevelopsevidence-basedcriteriatodeterminemedicalnecessity.Annually,SWHPprovidesproposedcriteriatophysiciandirectorsofBaylorScott&WhiteHealth’sMedicalServicesDivisionsandcontractednetworkphysiciansforreviewandfeedback.SWHP/ICSWMedicalDirectorsevaluateallfeedbackprovided.TheresultingapprovedfinalcriteriasetsandtheHealthCareManagementGuidelines(targetlengthofstay(LOS))areforwardedtotheSWHP/ICSWUMCommitteeforreviewandapproval.
2015criteriaincludeInterQual®,internalpolicies,targetLOS,criteriadevelopedandapprovedduringTechnologyAssessmentmeetings,andmedicalcoveragepolicies.
TheapprovedcriteriaareusedbytheUMStaffasaguidelineonly.SWHP/ICSWMedicalDirectorsmakealldenialofcoveragedeterminations.AnypersonmakingdecisionsonUM,includingformularycoveragedeterminationsarebasedonmeetingcriteriaforappropriatenessofcareandservicesandaresubjecttothetermsandlimitationsoftheInsurancePolicy.SWHP/ICSWdoesnotofferincentives,includingcompensationorrewards,toPractitionersorotherindividualsconductingutilizationreviewtoencouragedenialsofcoverageofservicesorofferfinancialincentivesthatencouragedecisionsthatresultinunderutilizationofservices.SWHP/ICSWdoesnotuseincentivestoencouragebarrierstocareandservices.
MedicalDirector(s)compensationisnotbasedonutilizationofservicesdenials.SWHP/ICSWdoesnotmakedecisionsregardinghiring,promotingorterminatingitspractitionersorotherindividualsbaseduponthelikelihoodorperceivedlikelihoodthattheindividualwillsupportortendtosupportthedenialofbenefits.
SWHP/ICSWmonitorsforevidenceofunderutilization,overuse,andmisusethroughtheQualityImprovement(QI)Committee’sreviewofMEDInsightreports,HEDIS®measures,QITeammeasuresandcomplaintdata.Evidenceofunderutilization,overutilizationandmisusewillbediscussedwiththeindividualphysician,aswellastargetedMemberoutreachasappropriate.Individualcoveragerequestsarediscussedwiththeindividualphysicians/providersmakingtherequestonbehalfofaMember.
SWHP/ICSWUMStaff,includingMedicalDirectors,areavailablebytelephone24hoursperday,7daysperweekorbyappointmentat1-254-298-3088ortollfreeat1-888-316-7974.Thestaffisavailable
SWHP/ICSW Utilization Management Criteria for Inpatient Services and Selected Benefit Coverage Determinations 2015
The InsIde sTory - Fall 2015 www.swhp.org 13
Care Coordination Division (CCD)
todiscussUMand/orcoveragedeterminations,includingbenefitprovisions,guidelines,criteriaortheprocessesusedtomakedeterminations.TheSWHP/ICSW“oncall”nursewhohasaccesstoaSWHP/ICSWMedicalDirectoroncallisavailableafterhours.
Appealrights,includingexpeditedappeals,reconsiderationrightsand/orIndependentReviewOrganization(IRO)optionsarealwaysprovidedwithanydenialissued.Practitionersmayrequesttoreviewcriteriaatanytimeincludingatthetimeofacase-specificdetermination.Criteriawillbeprovidedbyfax,phone,andemailorthroughanonsiteappointmentwiththeCareCoordinationDivision(CCD)managementstaff.CCDcanbereachedbycallingthetollfreenumberat1-888-316-7947ordirectlyat1-254-298-3088. Inanefforttoimprovecommunicationwithnon-EnglishspeakingMembers,SWHP/ICSWusestheinterpretiveservicesofAT&T.Membersdonothavetocallaspeciallineforthisservice.WhencontactingSWHP/ICSW,MembersmaynotifytheCCDstaffand/orCustomerAdvocatesoftheirprimarylanguageandthecallwillbecompletedwiththehelpofanAT&TinterpreteratnochargetotheMember.CCDStafffollowsestablishedinternalSWHP/ICSWpoliciesrelatedtoprovisionofinterpretiveservicesforSWHP/ICSWMembers. SWHP/ICSWutilizesatollfreeTTYnumber1-800-735-2989toassistwithcommunicationservicesforMemberswithhearingorspeechdifficulties.TheTTYnumberislistedontheSWHPwebpageatwww.swhp.organdisalsoincludedinyourMembercorrespondenceandMemberpublicationmaterials.
14 www.swhp.org The InsIde sTory - Fall 2015
1206 West Campus DriveTemple, TX 76502
INSIDE STORY STAFFOperational Staff
Chief EditorOmegia Walker
Publishing Coordinator & DistributionErica Martin
Graphic DesignConnie Horak
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