spring 2015 physician newsletter update

Physician Update 2015

HIGHLIGHTS AT A

GLANCE

Mil Gracias,

2420 Fenton Street · Suite 100 · Chula Vista · California · 91914 · TEL 1 (800) 640-4662 · www.chgsd.com

Norma Diaz Chief Executive Officer

May 28, 2015 marked Community Health Group’s 33 year anniversary. It is hard to believe how fast time flies and much things have changed since the beginning. We want to take a moment to thank you, our part-ners for the quality care you provide our members, your patients. With-out your participation we could not serve the 250,000 members we proudly call Community Health Group members. It is important to us that our organization is non-profit and local. It allows us to work within the community we serve and to give back. Our dedicated team members are continuously looking for ways to im-prove our service to our customers and exceed their expectations. Our commitment to providing exceptional service manifests in the investment we make to training our staff, staffing levels in our customer service cen-ter and through providing coverage 24 hours a day 7 days a week. It is imperative you and your patients can reach our team to have questions answered and for us to provide the necessary service. This past year we have seen a lot of growth in our membership through the Cal MediConnect program and the expansion of Medi-Cal eligibility. As we celebrate our 33rd year as an organization serving San Diego Medi-Cal and Medicare recipients we look forward to the next chapter in our long history. It is an exciting time to be providing health care in San Diego. Thank you for the bottom of our hearts for the hard work you and your team do each and every day.

Plan Operations Meeting, July 23rd

Report Fraud—call CHG’s toll-free Compliance Hotline (800) 651-4459.

A Message from the CEO

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COMMUNITY HEALTH GROUP COMMJNITY SERVICES (619) 498-6457 CONTACTS FOR PHYSICIANS NOREEN KOIZUMI, DIRECTOR, HEALTH CARE OPERATIONS (619) 498-6476 COLLEEN MORAN, DIRECTOR, HIGH RISK CASE MANAGEMENT (619) 498-6489

SPRING 2015

Compliance Website

Now Available! Adult BMI Assessment

(ABA) Adult BMI Assessment (ABA) is the per-centage of members 18-74 years of age who had an outpa ent visit and whose body mass index (BMI) was doc-umented during the measurement year or the year prior to the measure-ment year. When coding for an outpa ent visit, also include ICD-9-CM Diagnosis: V85.0 – V85.5 (codes to iden fy BMI). This will give you a posi ve hit for this HE-DIS measure and lessens the amount of intrusion to your office by our HEDIS staff.

We are glad to announce that we now have a Compliance tab within our CHG website. We have plenty useful resources available for our vendors and providers. You can go to www.chgsd.com click on the “Compliance” tab to view our Hot-line informa on, FWA a esta on, code of conduct, trainings, educa-

onal tools and many other Compli-ance resources available to our pro-viders, vendors, and members. Please provide us with feedback re-garding this new available tool to our Compliance Manager - Roberto Fierro-Chavez at [email protected] Thank you once again, Community Health Group’s Compliance Team h p://chgsd.com/compliance.aspx

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COMMUNITY HEALTH GROUP COMMUNITY SERVICES (619) 498-6457 CONTACTS FOR PHYSICIANS NOREEN KOIZUMI, DIRECTOR, HEALTH CARE OPERATIONS (619) 498-6476 COLLEEN MORAN, DIRECTOR, HIGH RISK CASE MANAGEMENT (619) 498-6489

Important News Flash!!!

Community Health Group wants to ensure that our healthcare providers are ready for the October 1, 2015 implementation of ICD-10 diagnosis codes. As you are probably already aware, the Centers for Medicare and Medicaid Ser-vices (CMS) will require that all billing/encounter data be submitted in this new format as of October 1, 2015.

As a result, Community Health Group will ONLY accept authorization requests and claims submitted with ICD-10 diagnosis codes for dates of service October 1, 2015. As we prepare to transition to the ICD-10 codes, we want to ensure our provid-ers are able to comply with this requirement. If you have questions related to the implementation, coding or specific requirements please reference the following links for the Centers for Medicare and Medi-Cal Services and the California Medical Society. https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10Resources.pdf https://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/11b1_2011_ICD10CM_and_GEMs.asp http://www.cmanet.org/news/detail/?article=cms-to-conduct-icd-10-claims-testing-for

If you have any questions or concerns, please feel free to contact Charisa Johnson at (619) 498-6485 or [email protected]

SPRING 2015

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Provider Satisfaction Survey Results

Each year Community Health Group conducts a Provider Sa sfac on survey to receive feedback on our services, opera ons and level of service you and your team are receiving. Our independent consultant completed the analysis of our results in late February and we wanted to share with you some of the highlights from the responses. There were three areas where the sa sfac on scores increased: Procedure for Obtaining no-formulary drugs Provider Manual (Online) CHG Internet Website

The areas noted with the room for improvement included:

Helpfulness, a tude and support of various CHG Staff Ability to resolve problems on a mely basis Trainings and informa onal forums provided to your staff

Addi onally, we think it’s important to share with you some of the challenges we faced over the past year and a half as well as some of the changes we have made to address the changes we have encountered. In 2014 we experienced membership growth of 54% in our Medi-Cal prod-

uct. Our overall membership grew 56%. To handle the increased membership we hired new employees in the are-

as driven by volume; member services, claims, referrals and pharmacy. Implementa on of Cal MediConnect began April 2014 and mandatory en-

rollment of dual eligible members into Medi-Cal managed care through the Coordinated Care Ini a ve.

Implementa on of Medi-Cal expansion childless adult members Expansion of mental health benefits began January 2014

SPRING 2015

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SPRING 2015

Provider Satisfaction Survey Results (continued)

Some of the changes we have made recently to be er serve you and your team include:

We have created a Customer Service Center with expanded staffing and

training. This has reduced call me on hold and increase response me. We have created a Community Services Department which combined our

Marke ng/Outreach team with Provider Rela ons staff. This increased our ability to resolve your issues in a melier manner and each primary care site has an assigned representa ve.

Our on-line referral module and process has been streamlined with a goal

of turning around referrals within 24 hours of receipt. Our claims payment me of clean claims has been reduced to 20 calendar

days. We have expanded our on-line claim lookup period to 12 months. We have created a task force to address the areas where there is room for

improvement to develop a correc ve ac on plan.

We thank you for taking the me to provide feedback to our team about our ser-vice. We look forward to working with you and your team to provide the highest level of quality service possible.

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SPRING 2015

Eye Exam Benefits Matrix- 2015

If you need help making an appointment or have any ques ons, please call our Customer

Service Department at 1-800-224-7766.

They are available to help you, 24 hours a day, 7 days a week.

Line of benefits

Type of Visit

Applies to Services must be rendered with:

Addi onal Benefit

Coverage

Medi-Cal Exam and Glaucoma Screening

Adults with a diagnosis of Diabetes

Vision Service Plan (800) 438-4560 h ps://www.vsp.com

None

Cal MediConnect

Exam and Glaucoma Screening

Adults with a diagnosis of Diabetes

Vision Service Plan (800) 438-4560 h ps://www.vsp.com

$100 plan coverage for eye glasses every two years

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SPRING 2015

CHG’s HEDIS Online Web Portal! The great benefit about CHG’s online Web Portal is that it allows you to view your missing HEDIS services by site, measure, and member. You are able to access and print your HEDIS reports via our Web Portal. These reports list those patients who, according to our records, are miss-ing HEDIS services required in calendar year 2015. Our reports are updated monthly to ensure you have a current list of your patients missing HEDIS required services. Our staff will send you a friend-ly reminder so you can download your reports and schedule visits for those patients who are missing services. You can access our Web Portal at https://extra.chgsd.com/login.asp. If you do not have access or need assistance, please contact Jonathan Vega, Community Services Supervisor, at (619) 240-8878 or via email at [email protected]. We thank you for your cooperation and support and look forward to re-ceiving your corrected/missing HEDIS encounter data.

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SPRING 2015

Initial Health and Home Environment Assessments

Community Health Group (CHG) is celebrating our second year of participating as a Medicare Medicaid Demonstration. We are excited about our Cal MediConnect line of business and appreciate the assis-tance many of you have provided to help in growing this new product. One benefit we want to remind you of is the Initial Health and Home Environment As-sessment (IHA) that is provided to all new Cal MediConnect members shortly after enroll-ment. The assessment is conducted by a contracted physician. The intent of the assessment is to document advanced disease level status and member knowledge of his/her current medical condition. The assessment also provides CHG’s disease and high-risk case management nurses a head start for understanding the individual needs of these mem-bers. The results of the IHA, along with any recommendations, are forwarded to the member’s primary care physician for placement in the member’s chart. The findings assist the pri-mary care physician with the member’s overall treatment plan. When primary care physicians receive these reports, we ask for help with the following:

1) Review any recommendations;

2) Ensure the medical record reflects the findings of

the IHA;

3) Develop and implement a treatment plan;

4) Adjust the treatment plan as needed;

5) Request assistance of CHG Case and Disease

Management staff for hard to manage

members;

6) Use standing referral process for members who

may have ongoing needs; and

7) Share pertinent findings with involved specialists

We thank you in advance for your assistance in working with our members through this process. We believe that the data gained through the IHAs will enable all of us to better manage our new members.

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SPRING 2015

Medication for Treating Hypertension

Doctors once hesitated to prescribe medication until a patient’s blood pressure reached 160/100. Anything below that level was deemed mild hypertension and not considered dangerous, so many doctors worried that the drug’s potential side effects might out-weigh their benefits. These perceptions turned out to be false. Research has firmly established the value of treating stage 1 hypertension (140/90 to 159/99 mm Hg) with drugs, if neces-sary. Experts recommend starting any antihyperten-sive drug at the lowest possible dose and grad-ually increasing it until blood pressure sinks to a normal level. If the drug causes troublesome side effect, it should be re-placed with a different medication. The usual course of treatment for stage 1 hypertension is to begin with one drug and add a second if the blood pressure does not fall to desired levels (usually less than 140/90 mm Hg, or less than 130/80 mm Hg for those with diabetes or chronic kidney disease). The treatment for stage 2 often begins with a two-drug combination. Addi-tional drugs may be added if the blood pressure does not drop to an ac-ceptable level. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of Hypertension (JNC) found that blood pressure can be ade-quately controlled, in most people with hypertension, but many individuals will need two or more medications to get their blood pressure in check. Poor blood pressure control can result if doctors do not encourage life-style changes, prescribe adequate doses of medications, or add addition-al medications as needed.

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SPRING 2015

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Inappropriate antibiotic treatment is of concern because misuse and overuse contrib-ute to antibiotic resistance. As you are aware, empiric antibiotic treatment is not indi-cated for acute bronchitis. Yet, according to our performance on this measure, many of our members are receiving antibiotics for acute bronchitis. The current Healthcare Effectiveness Data and Information Set (HEDIS) standards allow for members with acute bronchitis (466.0) to receive antibiotic treatment when there is a co-morbid condition present. The co-morbid conditions are specific by diag-nostic code and are listed in the table below for your reference.

A poorly coded encounter could inaccurately give an impression of a poorly treated patient. A potential coding error is to code chronic bronchitis as acute bronchitis on your claim or encounter form. It is also important to note any of the underlying condi-tions listed above, when applicable. Doing so would justify the treatment of acute bronchitis with antibiotics and would have a positive impact on your HEDIS score. We are aware that some encounter forms list only acute bronchitis. We encourage you to add the code for chronic bronchitis to your “superbill” so that the most appropriate diagnosis can be easily selected. Please call Gabriela Rubalcava at (619) 498-6535 if you have any questions about this or any other HEDIS measures.

Descrip on

HIV disease; asymptoma c HIV Cys c fibrosis

Disorders of the immune system Malignancy neoplasms

Chronic bronchi s Emphysema

Bronchiectasis Extrinsic allergic alveoli s

Chronic airway obstruc on, chronic obstruc ve asthma

Pneumoconiosis and other lung disease due to external agents

Tuberculosis Other diseases of the respiratory system

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SPRING 2015

Use of High Risk Medications in the Elderly The use of high-risk medications in the elderly is well documented in med-ical literature. Inappropriate use of these high risk medications can lead to increased morbidity and mortality as well as increased and avoidable health care costs. The Healthcare Effectiveness Data and Information Set (HEDIS®) measure “Use of High-Risk Medications in the Elderly” targets safe use of medications in patients ages 66 and older. The measure as-sesses the percentage of Medicare members who received at least one drug to be avoided in the elderly and the percentage of Medicare mem-bers who received at least two different drugs to be avoided in the elderly. A lower rate represents better performance. Medications on the list are based on the Beer’s list, the recognized consensus standards for Medica-tion use in older adults. The medications on the list have been determined to be harmful, regardless of medication dose, frequency, or patient’s un-derlying health status. The table on the following page lists high-risk drugs that our CommuniCa-re Advantage Members over 66 received within 2015. The table also lists formulary alternatives. We ask that you review the list and prescribe a saf-er alternative to your members over 66, when applicable. The list of mem-bers on high-risk medications has been shared with Outcomes, our Medi-cation Therapy Management vendor. An Outcomes pharmacist may be contacting you and your members who are taking a high-risk medication on a chronic basis to discuss switching to a formulary alternative.

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SPRING 2015

* Covered through the Medi-Cal portion of the benefit The complete list of high-risk medications is available at: http://www.ncqa.org/Portals/0/Newsroom/SOHC/Drugs_Avoided_Elderly.pdf For questions regarding this measure, please contact Noreen Koizumi, PharmD at (619) 498-6476.

Generic Descrip on Brand Name Formulary Alterna ve

BELLADONNA ALKALOIDS/PHENOBARB* Donnatol cimetadine, rani dine, famo dine, niza dine, Lotronex, Ami za

CARISOPRODOL Soma zanidine

CODEINE/PROMETHAZINE HCL* Phenergan w/Codeine guiafenesin (with or without codeine)

CYCLOBENZAPRINE HCL Flexeril zanidine

DIAZEPAM* Valium buspirone, paroxe ne

DIPHENHYDRAMINE HCL Benadryl loratadine, ce rizine, fexofenadine, zaleplon, zolpidem

DIPHENOXYLATE HCL/ATROP SULF Lomo l loperamide

DIPYRIDAMOLE DIPYRIDAMOLE Aggrenox

D-METHORPHAN HB/PROMETH HCL* Phenergan DM Dextromethorphan, benzonatate, pseudoephedrine/guaifenesin/ dextromethorphan

ESTROGENS,CONJUGATED Premarin Evista, alendronate, Actonel

HYDROXYZINE HCL Atarax loratadine, ce rizine, fexofenadine, buspirone, paroxe ne

HYDROXYZINE PAMOATE Vistaril loratadine, ce rizine, fexofenadine, buspirone, paroxe ne

METHOCARBAMOL Robaxin zanidine

NITROFURANTOIN/NITROFURAN MAC Macrodan n, Macrobid trimethprim, SMZ/TMP, methenamine hippurate

PHENOBARBITAL* PHENOBARBITAL carbamazepine, divalproex sodium, gabapen n, lamotrigine, leve racetam, Lyrica, oxcarbazepine, topiramate, valproate sodium, valproic acid, zonisamide, primidone, Dilan n, ethosuximide

PROMETHAZINE HCL Phenergan loratadine, ce rizine, fexofenadine, zaleplon, zolpidem

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SPRING 2015

Quality Measure for Weight Assessment of Children

Did you know that between 1980 and 2000, the number of overweight children has doubled in the 6 to 11 year old range and tripled among adolescents? These statistics are even higher for the Latino popu-lation. In response to these startling numbers, Community Health Group has adopted a new HEDIS measure to address childhood obesity. HEDIS stands for Healthcare Effectiveness Data and Information Set and is a standardized set of performance measures used to report quality of care provided by managed care organizations (MCOs) such as Community Health Group. The new weight assessment measure empha-sizes the importance of calculating the Body Mass Index (BMI) percentile for children and providing counseling on nutrition and physical activity. This measure is a quality measure for Community Health Group. For our providers giving care to chil-dren and adolescents, please remember to complete the following:

Calculate the BMI and BMI percentile for children ages 3-17. The percentile is determined by plotting the BMI on the growth-age chart. Document the date and BMI percentile in the chart or on the PM160 (for CHDP exam).

Provide counseling on nutrition and physical activity. This counseling can be brief and take as little as 1 to 3 minutes. Any one of the following will count, but it is important to docu-ment the date and action in the chart or use the V-code below:

Discuss and document current eating and exercise behaviors of the child

o Use a checklist to indicate discussion about nutrition and physical activity.

o Document that a referral was made for nutrition education and physical activity.

o Give educational materials and document with specific mention of nutrition education and physical activity.

o Document anticipatory guidance on these topics, with specific mention of nutrition edu-cation and physical activity.

The Staying Healthy Assessment form can be used to document counseling, educational materials and referrals with a brief notation. Age-specific Staying Healthy Assessment forms can be found on our web-site at www.chgsd.com. If you have questions regarding this measure, you may contact Charlene Wilburn, RN, Corporate Quali-ty Analyst at (619) 498-6497. V Codes for BMI and Counseling The following codes can be used on the PM160 for CHDP and for Community Health Group claims outside of the CHDP periodicity schedule to indicate that BMI percentile and counseling were performed on children ages 3 to 17.

BMI Measurement: V85.51 = BMI < 5th percentile V85.52 = BMI 5th to less than 85th percentile V85.53 = BMI 85th to less than 95th percentile V85.54 = BMI 95th percentile or greater

Nutrition Counseling: V65.3 Physical Activity Counseling: V65.41

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SPRING 2015

Prevention and Screening Services for CommuniCare Advantage Members

We would like to thank our primary care physicians who continue to provide care to our Cal MediConnect members. To keep you informed of changes with Medicare require-ments, we are sharing key information on Medicare Star Ratings. The Centers for Med-icare and Medicaid (CMS) monitors health plans’ administrative data addressing ac-cess to preventive health services. We appreciate the partnership we have with prima-ry care physicians to promote health and well being. In accordance with the latest rec-ommendations from the United States Preventive Services Taskforce (USPSTF), guidelines recommend plans and providers work together to promote access to pre-ventive health services, with special emphasis on the following: Annual flu vaccines

Pneumonia vaccines

Colorectal cancer screening

Osteoporosis management

Controlling blood pressure

Testing to confirm diagnosis of COPD

Improving/maintaining physical health

Improving/maintaining behavioral health

Please screen your patients and offer these screenings during routine office visits. You may coordinate the testing with our contracted laboratory provider, Quest, and diag-nostic services through our contracted free standing facilities. To access information on our contracted network, please access our home page at www.chgsd.com. For any questions on claims submittal or coding, please contact Jonathan Vega, Community Services Supervisor, at (619) 240-8878.

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SPRING 2015

Community Health Group Formularies

Community Health Group maintains a formulary for each line of busi-ness. The Formularies are reviewed and revised at least quarterly and the most up-to-date versions are posted on our website (www.chgsd.com). To access the formularies, click on the link for Pro-viders. The formularies can be viewed or printed and retained for your records. For those who do not have Internet access, you can request a copy of the formularies by contacting our Customer Service Department at (800) 224-7766.

Additions, changes or updates arising from Community Health Group’s Pharmacy and Therapeutics Committee meetings are included in the Medi-Cal Formulary just before the Index. Future Part D formulary changes are posted on our Cal MediConnect web page. The Cal Medi-Connect web page also includes the most current prior authorization and step therapy criteria.

Our Pharmacy and Therapeutics Committee, which is comprised of plan providers and pharmacists, meets four times each year. Formu-lary recommendations may be submitted to the Committee by mail: At-tention: P&T Committee, 2420 Fenton Street, Suite 100, Chula Vista, CA 91914; fax: (619) 407-4648; telephone: (619) 498-6476; e-mail: [email protected]; or in person (same as mailing address). The Committee reviews all recommendations based on current formulary medications and membership needs.

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Model of Care for CommuniCare Advantage

Cal MediConnect Members Community Health Group’s CommuniCare Advantage Cal MediConnect care model assesses and addresses the needs of our dual eligible Medicare members. Our prima-ry goal is to improve the care for beneficiar-ies with Medicare and Medi-Cal through im-proved coordination and continuity of care in a way that is seamless to our members. The Centers for Medicare and Medicaid Services (CMS) requires health plans to provide annual training to practitioners on our model of care. We are required to maintain records to demonstrate that con-tracted practitioners receive training each year. Our training module for 2015 is posted on our practitioner extranet. This will allow you to log in when your schedule permits to re-view the module and complete a short ques-tionnaire. Upon receipt of your completed questionnaire, we will document that you have received your training for 2015, and you will be done until next year. To access the training material, use your assigned username and password log on to Commu-nity Health Group’s extranet site at http://www.chgsd.com/documents/MOC/MOCTraining.pdf and click on “Model of Care Training.” If you do not have an ac-count, please contact our Community Ser-vices Department at (619) 240-8878 or by email [email protected].

Community Health Group’s Affirmative Statement about

Financial Incentives

Community Health Group affirms that: Utilization Management (UM) decision-

making is based only on appropriate-ness of care and service, and exist-ence of coverage.

We do not specifically reward practi-

tioners or other individuals conducting utilization review for issuing denials of coverage, service, or care.

Financial incentives for UM decision-

makers do not encourage decisions that result in underutilization.

For more information about Community Health Group’s UM decision-making pro-cess, please contact Colleen Moran, RN, BSN at (619) 498-6423.

SPRING 2015

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SPRING 2015

CHG’s Operations Meeting

Date: Thursday, July 23, 2015 Time: 12:00 p.m. to 1:30 p.m. Where: CHG Paul Dato Conference Room 2420 Fenton Street, Suite 100 Chula Vista, CA 92914 Please submit your RSVP no later than July 21st. RSVP to Community Services at (619) 498-6457

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spring 2015 physician newsletter update

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