ANNUAL PROVIDER SATISFACTION SURVEY
Harmony-WellCare continues to focus efforts on the experiences of both our members and providers. In order to better understand and remain well-informed about our valued provider network, we conducted the Provider Satisfaction Survey again in 2015. The survey concentrated on a variety of subjects including call center/provider services, provider relations, continuity/
coordination of care, utilization and quality management, finance issues, pharmacy and drug benefits, and overall satisfaction and loyalty.
As in 2014, extensive reviews of our 2015 survey results are under way to ensure that our focus is aligned with the needs of our providers. Current areas of focus include enhancing provider services at the local level, claim processing and issue resolution, enriching administrative tools/capabilities, and continued emphasis on quality.
The organization is continuously engaged with several cross-functional teams working on these initiatives, and others that are aimed at better serving our providers.
We anticipate incremental gains on several initiatives in 2016 and continued improvement beyond.
In early 2016, Harmony-WellCare will conduct the annual Provider Satisfaction Survey to continue measuring progress, as well as better evaluate how we can become more effective and productive business partners.
Your participation is encouraged – and appreciated – as together we strive to positively impact the lives of our members’ overall quality of care.
IN THIS ISSUE
Annual Provider Satisfaction Survey ...Page 1 Clinical Practice Guidelines ...Page 2 Balance Billing Guidelines ...Page 3 Availability of Review Criteria ...Page 4 Updating Provider
Directory Information ...Page 4 Communication With Behavioral
Health Members ...Page 5 How to Submit an Anesthesia
Claim/Encounter With a Patient
Status Modifier ... Page 6 New Pharmacy Benefit Manager ... Page 6 Access to Utilization Staff ... Page 6 Depression Prevention Program ...Page 7 Expanded Benefits for
Harmony Members ...Page 7 Q1 2016 Provider Formulary Update .... Page 8 Provider Resources ... Page 8
PROVIDER NEWSLETTER
Illinois | 2016 | Issue I
CLINICAL PRACTICE GUIDELINES
Clinical Practice Guidelines (CPGs) are best practice recommendations based on available clinical outcomes and scientific evidence.
Harmony-WellCare CPGs reference evidence-based standards to ensure that the guidelines contain the highest level of research and scientific content. CPGs are also used to guide efforts to improve the quality of care in our membership. The CPGs listed below are available at www.wellcare.com/Illinois/Providers/Clinical-Guidelines/CPGs.
GENERAL CPGS
Alzheimer’s disease Asthma
Cancer
Cholesterol management Congestive heart failure Chronic kidney disease COPD
Coronary artery disease Diabetes in adults
Diabetes in children Fall risk assessment
HIV antiretroviral treatment in adults HIV screening
Hypertension
Imaging for low back pain Lead exposure
Motivational interviewing & health behavioral change
Obesity in adults Obesity in children Osteoporosis Palliative care Pharyngitis
Rheumatoid arthritis Sickle cell disease Smoking cessation Transitions of care
PREVENTIVE HEALTH GUIDELINES
Adult preventive health Preventive health pediatric Pregnancy
Preconception and interpregnancy Postpartum guidelines
BEHAVIORAL HEALTH CPGS
ADHD
Antipsychotic drug use in children and adolescents Behavioral health and sexual offenders
Behavioral health conditions in high-risk pregnancy Bipolar disorder
Major depressive disorders in adults
Persons with serious mental illness and medical comorbidities
Schizophrenia
Substance use disorders
BALANCE BILLING GUIDELINES
Participating providers are required to accept payment directly from Harmony-WellCare.
This includes payment in full, with the exception of applicable co-payments, deductibles, coinsurance and any other amounts listed as member responsibility on your Explanation of Payment (EOP). Any bill generated to a member to collect for cost sharing other than those outlined above is prohibited. Balance billing of “zero cost-share” dual-eligible members is prohibited, including co-payments, etc., as listed above.
Please consider the following scenarios that may unintentionally create a balance billing problem:
• You have a billing/practice management system that automatically generates a bill to a member if you have not received an EOP from the plan within a certain time frame or if the expected amount received (in some cases zero, for denials) is less than the remitted amount.
• You have sent a lab test or other services out of network without proper authorization, creating a situation where our member may be inappropriately billed.
• You have not confirmed eligibility with Harmony-WellCare, resulting in the incorrect classification of a member as self-pay, which in turn generates a bill to the Harmony-WellCare member for services rendered. You can avoid this scenario by requiring all patients to present their ID cards at the time of their visit.
The generation of a balance bill to a Medicaid or Medicare managed care enrollee is not only against Harmony-WellCare policy, but is also strictly prohibited according to Centers for Medicare & Medicaid Services (CMS) guidelines.
If you have any questions or concerns regarding claims, please call one of the Provider Services phone numbers at the end of this newsletter or your Provider Relations representative.
Note: A provider may charge a member for services not covered by WellCare only when both parties have agreed prior to the service being rendered that the member is being seen as private pay. The provider must obtain the member’s written consent that he or she will be financially responsible for the non-covered service, and that consent must be signed and dated on or before the date of service.
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UPDATING PROVIDER DIRECTORY INFORMATION
We rely on our provider network to advise us of demographic changes so we can keep our information current.
To ensure our members and Case Management staff have up-to-date provider information, please give us advance notice of changes you make to your office phone number, office address or panel status (open/closed). Thirty-day advance notice is recommended.
New Phone Number, Office Address, Change in Panel Status, and Adding New Providers to an Existing Contracted Group/IPA – Send a letter on your letterhead with the information being updated. Please include contact information if we need to follow up on the update with you.
MEDICAID
Please send the letter by any of these methods:
• Email: [email protected]
• Fax: 312-630-2022
• Mail: WellCare
Attention: Provider Relations 29 N Wacker Drive, Suite 300 Chicago, IL 60606
MEDICARE
Call 1-855-538-0454
Thank you for helping us maintain up-to-date directory information for your practice.
AVAILABILITY OF REVIEW CRITERIA
The determination of medical necessity review criteria and guidelines are available to providers upon request.
You may request a copy of the criteria used for specific determination of medical necessity by calling Provider Services at the number listed on your Quick Reference Guide at www.wellcare.com/Illinois/Providers under either “Medicare” or “Medicaid”.
Also, please remember that all Clinical Coverage Guidelines detailing medical necessity criteria for certain medical procedures, devices and tests are available via the Provider Resources link at www.wellcare.com/Illinois/
Providers/Clinical-Guidelines/CCGs.
COMMUNICATION WITH BEHAVIORAL HEALTH MEMBERS
People with behavioral health issues often feel that health care professionals do not listen to them. More than one third of American adults lack sufficient health literacy to understand and complete needed medical treatments and participate in preventive health. This lack of health literacy is more commonly noted in certain demographic groups such as the elderly, the poor, minority groups, people with limited education and people who do not speak English during early childhood.
Your respectful conduct and willingness to explain treatment is critical to patient success.
Here are some tips and techniques that may improve communication with patients:
Simple tips:
• Warm greeting – Greet patients with a smile and welcoming attitude.
• Eye contact – Make appropriate eye contact throughout the interaction.
• Plain, non-medical language – Use common words when speaking to patients, taking note of what words they use to describe their illness and use them in your conversation.
• Slow down – Speak clearly and at a moderate pace.
• Limit content – Prioritize what needs to be discussed and limit information to 3-5 key points.
• Repeat key points – Be specific and concrete in your conversation and repeat key points.
• Patient participation – Encourage patients to ask questions and be involved in the conversation during visits and to be proactive in their health care.
• Teach-back – Confirm patients understand what they need to know and do by asking them to repeat back directions. This is especially important for medication directions and information on side effects.
Reflective Listening is summarizing what a patient has said. It allows the patient to know you have been listening carefully, that you are interested in their views, and are trying to understand their point of view. It also allows the patient the opportunity to correct your understanding, which increases their sense of involvement.
The Teach Back Method ensures that the patient understands the information the provider has given. During the session, ask the patient to explain the material you’ve just covered. If the patient has trouble explaining or recalling the information, you’ll need to repeat, clarify, or modify it, then reassess their understanding. By enhancing patients’ knowledge, their health care self-management increases and they become more accountable for their own health.
Motivation Interviewing has been shown to improve patient satisfaction, ensuring that patients know we care about them and understand their issues. Evaluate if the counseling is important to the patient, address if the patient feels confident in their ability to change and establish rapport. This technique provides information rather than telling patients what to do with their health.
Sources:
health.gov/communication/literacy/quickguide/factsbasic.htm
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/
healthliteracytoolkit.pdf
www.wellcare.com/Illinois/Providers/Clinical-Guidelines/CPGs
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MEDICAID
NEW PHARMACY BENEFIT MANAGER
Please remind patients who have a prescription benefit through Harmony-WellCare to bring their new ID card to the pharmacy beginning January 1, 2016. Please also refer to www.wellcare.com/
Illinois/Providers and select “Pharmacy” from the “Providers” drop down menu, under either
“Medicare” or “Medicaid” for 2016 formulary and pharmacy network changes.
ACCESS TO UTILIZATION STAFF
The Utilization Management (UM) section of your Provider Manual contains detailed information related to the UM program. Your patient, our member, can request materials in a different format including other languages, large print and audio tapes. There is no charge for this service.
If you have questions about the UM Program, please call Provider Services at the number listed on your Quick Reference Guide located at www.wellcare.
HOW TO SUBMIT AN ANESTHESIA CLAIM/ENCOUNTER WITH
A PATIENT STATUS MODIFIER
Harmony-WellCare encourages providers to submit claims with the correct claims and encounters for the State of Illinois Department of Healthcare and Family Services (HFS).
The Illinois Provider Handbook, which can be found at www2.illinois.gov/hfs/MedicalProvider/
Handbooks/Pages/default.aspx, provides documentation on HFS that the state requires a Patient Status Modifying unit for each anesthesia CTP/HCPCS code submitted on a claim/encounter.
HFS MODIFIER REQUIREMENTS:
Page 46 of the HFS Provider Manual under section A-221.21 General Anesthesia documents the
requirement for general anesthesia; either the major
surgical procedure codes or the anesthesia CPT code must include the physical status modifier (P1–P6) in the modifier field.
PATIENT STATUS MODIFIERS:
• P1 – Normal, healthy patient
• P2 – Patient with mild systemic disease
• P3 – Patient with severe systemic disease
• P4 – Patient with severe systemic disease that is a constant threat to life
• P5 – Moribund patient not expected to survive without the operation
• P6 – Declared brain-dead patient whose organs are being removed for donor purposes HARMONY BILLING EDIT:
Due to encounter rejections from HFS, Harmony deployed an edit to reject anesthesia claims that do not meet the HFS modifier requirement for inclusion of a patient status modifier for anesthesia claims/encounters submitted for Harmony Medicaid members. Please code your anesthesia submissions accordingly to avoid denials.
MEDICAID
EXPANDED BENEFITS FOR HARMONY MEMBERS
Harmony is excited to offer the following expanded benefits and programs to our members (your patients) beginning January 1, 2016:
• FREE GED Exam - Eligible members age 16 and over who don’t have a high school diploma can take the GED exam at no cost
• FREE pair of approved glasses - Members age 21 and over can choose from glasses outside of what is covered by Medicaid
• FREE Weight Loss Program - Harmony has partnered with Curves to offer a three month membership benefit for Harmony members. The goal of the program is to support healthy lifestyles and improve health outcomes. Through 30-minute fitness regimens and one-on-one counseling, Curves Complete members will be encouraged to form healthy lifestyle habits, eat smarter, and get more exercise. A member’s Curves membership can be extended if approved by a Health Coach.
• Discounted Gym Membership to Anytime Fitness or LA Fitness
• Diaper Program - Members who complete their postpartum appointment and recommended baby immunizations can receive up to six packs of diapers
• Healthy Rewards Program - Members will receive a
$20 CVS Select gift card for each healthy behavior completed
• FREE over-the-counter (OTC) supplies - Members can get $15 for OTC items each month through the Harmony +15 program
• No co-pays for doctor visits, hospital visits, or generic drugs
• FREE Healthy Kids Club program – Members ages 4-11 receive health tips and tools to encourage immunizations and checkups
• FREE Dental Cleanings - Members age 21 and older receive free dental cleanings every six months, with no co-pay
• Hypoallergenic Bedding – Qualified members can get hypoallergenic bedding to avoid asthma triggers
For more information on these expanded benefits and programs, please contact Provider Services or your Provider Relations representative.
DEPRESSION PREVENTION PROGRAM
Depression affects more than 6.5 million of the 35 million Americans aged 65 or older. Depression in older persons is closely associated with dependency and disability and causes great distress for the individual and their family. Depression is also closely associated with chronic illness such as diabetes, COPD, CHF, CAD, and stroke. In an effort to foster improved collaboration, continuity and coordination between medical and behavioral health providers, Harmony-WellCare has established a Depression Prevention Program.
Harmony-WellCare encourages providers to screen for depression and discuss with members the importance of appropriate follow-up with the right practitioner when issues and/or problems are identified. Proactive prevention, outreach and education programs are critical mechanisms through which members can obtain the appropriate behavioral health services regardless of age, ethnicity, gender or family background. Harmony-WellCare has created a variety of resources and tools to help providers screen for depression in members with chronic health conditions; these resources can be found on the Harmony-WellCare website at www.wellcare.com/
Illinois/Providers.
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PROVIDER RESOURCES
WEB RESOURCES
Visit www.wellcare.com/Illinois/Providers to access our Preventive, Behavioral Health and Clinical Practice Guidelines, Clinical Coverage Guidelines, Pharmacy Guidelines, key forms and other helpful resources. You may also request hard copies of any of the above documents by contacting your Provider Relations representative.
For additional information, please refer to your Quick Reference Guide at www.wellcare.com/Illinois/Providers/
Medicaid or www.wellcare.com/Illinois/Providers/Medicare.
PROVIDER NEWS
Remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com/Illinois/Providers to find copies of the latest correspondence. Access the secure portal using the “Provider Secure Login” area in the Provider drop-down menu on the top of the page. You will see Messages from Harmony located in the right-hand column.
Q1 2016 PROVIDER FORMULARY UPDATE
MEDICAID:
The Harmony Medicaid Preferred Drug List (PDL) has been updated. Visit www.wellcare.com/Illinois/
Providers/Medicaid/Pharmacy to view the current PDL and any pharmacy updates.
You can also refer to the Provider Manual available at www.wellcare.com/Illinois/Providers/Medicaid to view more information regarding Harmony’s pharmacy Utilization Management (UM) policies and procedures.
MEDICARE:
The Medicare Formulary has been updated. Find the most up-to-date complete formulary at www.wellcare.
com/Illinois/Providers/Medicare/Pharmacy.
You can also refer to the Provider Manual available at www.wellcare.com/Illinois/Providers/Medicare to view more information regarding WellCare’s pharmacy UM policies and procedures.
WE’RE JUST A PHONE CALL OR CLICK AWAY!
Medicare: 1-866-334-6876 Medicaid: 1-800-608-8158 www.wellcare.com/Illinois
