ANNUAL PROVIDER SATISFACTION SURVEY

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ANNUAL PROVIDER SATISFACTION SURVEY

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 underway 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, 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.

IN THIS ISSUE

Annual Provider Satisfaction Survey ....Page 1 Expanded Evicore Services ...Page 2 Updating Provider

Directory Information ...Page 3 Availability of Review Criteria ...Page 3 Access to Utilization Staff ...Page 3 New Pharmacy Benefit Manager ...Page 3 Depression Prevention Program ...Page 4 Balance Billing Guidelines ...Page 4 Communication With Behavioral

Health Members ...Page 5 Healthy Rewards Program ...Page 6 Clinical Practice Guidelines ...Page 8 Q1 2016 Provider Formulary Update ....Page 9 Provider Resources ...Page 9

PROVIDER NEWSLETTER

Florida | 2016 | Issue I

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EXPANDED EVICORE SERVICES

WellCare currently collaborates with eviCore healthcare (formerly CareCore National) to provide prior

authorization for certain outpatient diagnostic imaging procedures. With your support, this collaboration ensures our commitment that members receive medically necessary covered services at the appropriate time and in the appropriate setting.

WellCare has expanded our relationship with eviCore effective Dec. 10, 2015, to include prior authorization requirements and post-service reviews for the following outpatient procedures:

Applicable to Medicare Only Applicable and Medicare and Medicaid Radiation Therapy

• EBRT

• Brachytherapy • IMRT

• IGRT

• Proton Therapy

• Stereotactic Radiosurgery

Outpatient Therapy Services

• Occupational and physical therapy visits for all outpatient rehabilitation and habilitation services

• Authorization will be required for payment of claims for a limited range of CPT and HCPCS codes used for these services.

Note: Prior authorization is not required for these services when performed in an emergency room/

department, observation unit, urgent care facility, or during an inpatient stay.

THE CLINICAL REVIEW PROCESS

Physicians should request authorization directly from eviCore prior to rendering these services, by phone at 1-888-333-8641, Monday–Friday, 7 a.m. to 7 p.m. or online via www.evicore.com.

Your time is valuable! Please take advantage of eviCore’s online authorization service. Most cases can be completed online within four minutes and the online service is available 24 hours a day, seven days a week for your convenience.

Please contact our Provider Help Desk at 1-866-270-5223, Monday–Friday, 7 a.m. to 5:30 p.m. with any questions.

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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 Provider Relations 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 or Change in Panel Status:

MEDICAID

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.

Please send the letter by either of these methods:

• Email: [email protected] • Fax: 813-865-6764

This contact information is only for the updates mentioned above in bold. Any other correspondence sent through these channels will not be reviewed or processed.

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/Florida/Providers/

Medicaid or www.wellcare.com/Florida/

Providers/Medicare.

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/Florida/Providers/Clinical- Guidelines/CCGs.

NEW PHARMACY BENEFIT MANAGER

Please remind patients who have a prescription benefit through WellCare Health Plans, Inc. to bring their new ID card to the pharmacy. Please also refer to www.wellcare.com/Florida/Providers and select

“Pharmacy” from the “Providers” drop-down menu 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 audiotapes. 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.

com/Florida/Providers/Medicaid or www.wellcare.

com/Florida/Providers/Medicare.

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BALANCE BILLING GUIDELINES

Participating providers are required to accept payment directly from 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 eligibles 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 WellCare, resulting in the incorrect classification of a member as self-pay, which in turn generates a bill to the 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 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.

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, WellCare has established a Depression Prevention Program.

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. 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 WellCare website at www.wellcare.com/Florida/Providers.

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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/Florida/Providers/Clinical-Guidelines/CPGs

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HEALTHY REWARDS PROGRAM

The Healthy Rewards Program rewards members for taking small steps that will help them live healthy lives. For simple tasks like completing primary care provider (PCP) visits, prenatal visits, and certain health checkups (see the table below), members can earn rewards that are placed on reloadable Visa® cards. Members can use these cards at a variety of locations to purchase items including milk, bread, diapers and over-the-counter (OTC) items from a pharmacy. The more behaviors members

complete, the more they can earn.

Healthy Rewards Program Reward Type Reward Amount Reward Criteria Medically Approved Smoking

Cessation Program Healthy Rewards discount card

Reward varies based on member usage; target 5-20% discount on select healthy lifestyle items.

Attendance and completion of a smoking cessation program

Medically Directed Weight

Loss Program Healthy Rewards

discount card

Enrollment with a Health Coach

Medically Approved Alcohol or Substance Abuse

Recovery Program

Healthy Rewards discount card

Self-identification, provider identification or HRA responses indicating need, and agreeing to receive educational materials New Member Healthy Actions

Health Risk Assessment Completion

Reloadable restricted

Visa card $10 Health Risk Assessment

Completion within the first 90 days of enrollment

Initial PCP Visit Reloadable

restricted

Visa card $10 Initial PCP Visit within 90 days of

enrollment

Completion of either Healthy Rewards discount card

Completion of HRA or PCP Visit

Children’s Healthy Actions Well Child Visit:

0-15 months

Visa card $10 0-15 months: Well child visit

per periodicity schedule (reward for each visit, up to 6 visits) Child Health Checkup:

3-6 years

Visa card $10 3-6 years: Child health

checkup visit (EPSDT) (reward for each visit) Adolescent Checkup:

7-21 years Reloadable

restricted

Visa card $20 7-21 years: Adolescent checkup

visit (reward for each visit)

(Continued on next page) Providers can encourage their patients to participate in the Healthy Rewards Program by signing and including their provider ID on applicable activity reports.

For more information on WellCare’s Healthy Rewards Program, please contact your Provider Relations representative or call one of the Provider Services phone numbers at the end of this newsletter.

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Healthy Pregnancy Actions Prenatal Visits

Reloadable

restricted Visa card plus stroller or portable playpen

$20 plus a stroller or

portable playpen 6 prenatal visits before the birth of baby

Postpartum Visit Reloadable

restricted

Visa card $10 1 postpartum visit 21-56 days

after the birth of baby

Completion of both Reloadable restricted Visa card

Members who complete both receive $30 incentive plus a stroller or portable playpen

Completion of prenatal +

postpartum visits = total incentive Well Woman Healthy Actions

Screening Mammogram Reloadable restricted

Visa card $20 Completion of screening

mammogram (ages 40-65) Dental Healthy Actions

Preventive Dental Visits Reloadable restricted

Visa card $10 1-20 years: any dental care visit

with a dentist Diabetes Healthy Rewards Program

Eye Exam Reloadable

restricted

Visa card $10 Complete eye exam (enrollees

with diabetes ages 18-75)

HgbA1C Control Reloadable

restricted

Visa card $10 Goal achievement for HgbA1C (8)

LDL Control Reloadable

restricted

Visa card $10 Goal achievement for LDL

level (100)

* Rewards card cannot be used for the following: Gambling, alcohol, tobacco, or drugs (except for over-the-counter drugs). The value of the card cannot exceed $50.

HEALTHY REWARDS PROGRAM

(Continued from previous page)

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CLINICAL PRACTICE GUIDELINES

Clinical Practice Guidelines (CPGs) are best practice recommendations based on available clinical outcomes and scientific evidence.

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/Florida/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

Depressive disorders in children and adolescents

Major depressive disorders in adults

Persons with serious mental illness and medical comorbidities

Schizophrenia

Substance use disorders

Substance use disorders in high-risk pregnancy

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Q1 2016 PROVIDER FORMULARY UPDATE

MEDICAID:

The Staywell Preferred Drug List (PDL) has been updated. Visit ahca.

myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/fmpdl.

shtml to view the current Staywell PDL and pharmacy updates. Visit www.wellcare.com/Florida/Providers/Medicaid/Pharmacy for the Healthy Kids PDL and pharmacy updates. You can also refer to the Provider Manual available at www.wellcare.com/Florida/Providers/

Medicaid to view more information regarding WellCare’s pharmacy Utilization Management (UM) policies and procedures.

MEDICARE:

There have been updates to the Medicare formulary. Find the most up-to-date complete formulary at www.wellcare.com/Florida/

Providers/Medicare/Pharmacy. You can also refer to the Provider Manual available at www.wellcare.com/Florida/Providers/Medicare to view more information regarding WellCare’s pharmacy UM policies and procedures.

PROVIDER RESOURCES

WEB RESOURCES

Visit www.wellcare.com/Florida to access our Preventive 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/Florida/Providers/Medicaid or www.wellcare.

com/Florida/Providers/Medicare.

PROVIDER NEWS

Remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com/Florida 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 WellCare located in the right-hand column.

ADDITIONAL CRITERIA AVAILABLE

Please remember that all Clinical Coverage Guidelines detailing medical necessity criteria for several medical procedures, devices and tests are available on our website at www.wellcare.com/Florida/Providers/Clinical- Guidelines/CCGs.

WE’RE JUST A PHONE CALL OR CLICK AWAY!

Medicare:

1-855-538-0454

Staywell 1-866-334-7927

Staywell Kids

1-866-698-5437 www.wellcare.com/Florida