DISEASE MANAGEMENT – IMPROVING MEMBERS’ HEALTH
Disease Management is a no-cost, voluntary program to assist members with specific chronic conditions. A member is assigned a disease nurse manager who can help the member with:
• Education and understanding of his or her specific
condition
• Identification of adherence barriers and ways to overcome them
• Individualized lifestyle modification suggestions to improve daily life
• Self-management of the member’s condition to improve health outcomes
• Motivational coaching to encourage members when they face difficulties
• Improved communication with the member’s primary care provider and health care team
Disease Management can assist your members with the following conditions:
• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• Coronary artery disease (CAD)
• Depression
• Diabetes
• Hypertension
• Obesity
• Smoking cessation
For more information, or to refer a member to Disease Management, please call us at 1-877-393-3090.
Disease Management –
Improving Members’ Health ...Page 1 Provider Satisfaction Survey ...Page 1 Medicare Quality Overview ...Page 2 We Are Building a Website That
Works for You ...Page 2 Better Quality Is Our Goal ...Page 3 Updating Provider Directory
Information ...Page 3 Q2 2016 Provider Formulary
Update ...Page 3 Coding Corner ...Page 4 Healthy Rewards Program ...Page 5 How Care Management Can Help
Your Patients ...Page 5 How to Improve Patient Satisfaction and CAHPS® Scores, Part 1 of 3 ...Page 6 Provider Resources ...Page 7
PROVIDER NEWSLETTER
Kentucky | 2016 | Issue II
IN THIS ISSUE
PROVIDER SATISFACTION SURVEY
WellCare is conducting the annual Provider Satisfaction Survey, May – July, in all WellCare markets. Administered by SPH Analytics, the survey targets health care providers to measure satisfaction with WellCare, as well as support NCQA Standards for Health Plan Accreditation. PCPs, Specialists and Behavioral Health providers are randomly selected and surveyed by mail, internet, and phone. Your participation is encouraged and appreciated.
WE ARE BUILDING A WEBSITE THAT WORKS FOR YOU
WellCare recently launched a redesigned public website. Now we’re redesigning our secure provider portal, where you can log in to complete tasks such as:
• Check member eligibility and co-payment information
• Submit authorization requests and check status
• Submit claims and check status
• View open care gaps and access reports
• Access a personal inbox with direct messages from WellCare What’s next?
We are visiting some of you, our providers, to find out how we can improve our website tools. We are planning to talk to people in billing, admissions, care coordination and more. Your feedback will help shape our new portal!
Stay tuned for updates on the project.
MEDICARE QUALITY OVERVIEW
QUALITY IMPROVEMENT PROGRAM GOALS WE ACCOMPLISHED IN 2015 INCLUDE:
• Completed assessments for members who are part of the WellCare D-SNP population
• Completed individualized care plans for D-SNP members
• Conducted inter-disciplinary care teams with providers and health plan care managers to ensure that quality care is provided
• Reviewed data on quality outcomes for diabetes, congestive heart failure, chronic obstructive pulmonary disease and mental health diagnoses to ensure members receive high quality care
• Deployed Clinical HEDIS Practice Advisors to assist providers in improving health care outcome rates
• Enhanced Case and Disease Management Programs by adding Health Coaches and expanding field based resources
• Continued to implement and expand the Community Advocacy Team throughout WellCare markets to ensure all members and provider share access to community resources
OUR CONTINUED GOALS FOR 2016 INCLUDE:
• Improving the WellCare D-SNP Model of Care program to assist with members receiving the right care at the right time in the right setting
• Reviewing and measuring the quality of care and services that our members receive
• Working with providers as a team to help meet members’ health care needs
• Working with providers to organize care so that together we can coordinate our members’ health care and improve their quality of service
• Contracting with and maintaining High Performance Provider Networks
• Reviewing and updating our guidelines to ensure that a safe and healthy environment for care is maintained
• Focusing on performance indicators as an organization to achieve quality excellence
WellCare appreciates our providers’ partnership in ensuring our members receive the best care. To receive a copy of our Medicare Quality Improvement Annual Evaluation and/or the D-SNP Model of Care Evaluation, please call Customer Service.
MEDICARE
MEDICAID
BETTER QUALITY IS OUR GOAL
Our Quality Improvement (QI) program is dedicated to finding ways to help deliver better care and services to our members, in collaboration with our providers.
SOME 2015 QI PROGRAM GOALS WE ACCOMPLISHED INCLUDE:
• Ensuring members’ health care needs were met through an expanded coordinated effort
• Responding to feedback and implementing improvements to our services
• Continuing to review and update our guidelines providing a safe and healthy environment for member care OUR GOALS FOR 2016 INCLUDE:
• Improving collaborative partnerships to ensure your voices/perspectives are heard and you have a meaningful role in shaping WellCare’s delivery model
• Enhancing the quality of services provided in the areas of claims processing and prior authorization
• Continuing to enhance members’ health and quality of life by collaboratively improving the quality of services provided
We look forward to continuing to partner with you to ensure our members get the best care.
For more information about the QI Program, please contact your Provider Relations representative or email:
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 OR CHANGE IN PANEL STATUS:
MEDICAID
Send a letter on your letterhead with the information being updated to KY_ProviderCorrection@wellcare.
com. Please include contact information if we need to follow up on the update with you.
MEDICARE
Call 1-855-538-0454
Thank you for helping us maintain up-to-date directory information for your practice.
Q2 2016 PROVIDER FORMULARY UPDATE
MEDICAID:
The WellCare Medicaid Preferred Drug List (PDL) has been updated. Visit www.wellcare.com/
Kentucky/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/Kentucky/
Providers/Medicaid to view more information regarding WellCare’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/Kentucky/Providers/Medicare/
Pharmacy.
You can also refer to the Provider Manual available at www.wellcare.com/Kentucky/
Providers/Medicare to view more information regarding WellCare’s pharmacy UM policies and procedures.
CODING CORNER
NOTIFICATION OF CLAIM EDITING UPDATE
The information outlines updates to claim editing that were effective as of 02/01/2016.
CLAIM EDITING
UPDATE DESCRIPTION OF SERVICE UPDATES EFFECTIVE
Multiple Initial Hospital Care within 3 Days
According to WellCare’s policy, an initial hospital care service (CPT 99221- 99223) billed within 3 days of a prior initial hospital care service for the same diagnosis should be billed with a subsequent hospital care service (CPT 99231-99233), not an initial hospital care service code, because the services rendered for the same diagnosis represent a continuation of the same episode of care.
Effective 02/01/2016, WellCare Health Plans will deny claims for an initial hospital care service, if an initial hospital care service has been billed in the previous 3 days with the same diagnosis by the same provider. Medical necessity dispute rights will be provided.
Arthrocentesis
According to CMS policy, there are specific diagnoses that are appropriate indications for arthrocentesis,
aspiration or injection of a major joint (20610 or 20611).
Effective 02/01/2016, WellCare Health Plans will deny claims for arthrocentesis, aspiration or injection of a major joint when submitted without an appropriate diagnosis code. Medical necessity dispute rights will be provided.
Screening
Electrocardiogram (ECG) for Coronary Disease in
Asymptomatic Adult Patients
According to the U.S. Preventive Services Task Force (USPSTF), an electrocardiogram should not be performed routinely on asymptomatic adults who are at low risk for
coronary heart disease. The USPSTF has determined that the incremental information provided by the resting electrocardiogram (beyond that obtained with conventional risk factor assessment) is not likely to alter risk stratification or improve clinical outcomes. USPSTF recommends against using electrocardiogram to screen for coronary disease in asymptomatic adults who are at low risk for coronary disease.
Effective 02/01/2016, WellCare Health Plans will deny claims for 93000 (electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) when billed in the office setting, for patients 18 and older, without an appropriate diagnosis. Medical necessity dispute rights will be provided.
Duplex Scan for Carotid Artery Stenosis (CAS) in Asymptomatic Adult Patients
According to the USPSTF, it is not appropriate to screen for coronary disease in asymptomatic adult patients.
Therefore, WellCare will not pay for a duplex scan of extracranial arteries (CPT 93880 or 93882) when it is billed in the office setting (POS 11) for a patient age 18 or older without a supporting carotid artery stenosis symptom diagnosis.
Effective 02/01/2016, WellCare Health Plans will deny claims for duplex scans of extracranial arteries when billed in the office setting when the patient age is older than 18 and a diagnosis of carotid artery stenosis symptom is not present. Medical necessity dispute rights will be provided.
NOTIFICATION OF NCD AND LCD POLICY UPDATE
POLICY UPDATE:
Kentucky Medicare and Health Insurance Exchange Lines of Business Professional Claims NCD and LCD Policy Update DESCRIPTION OF UPDATE:
Kentucky Medicare and Health Insurance Marketplace lines of business will apply National Coverage
Determinations (NCDs) and Local Coverage Determinations (LCDs) based on Kentucky Part B contractor CGS to all professional claims. No changes will be made to the existing Facility NCD and LCD edit. For more information on NCDs and LCDs, please go to CGS at www.cgsmedicare.com/
UPDATE EFFECTIVE 03/15/2016:
WellCare will apply the NCD and LCD policy to all professional claims. Medical necessity dispute rights will be provided.
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 prenatal visits, preventive dental visits, and certain health checkups, members can earn rewards that are placed on prepaid debit cards. Members can use these cards at a variety of locations to purchase healthy items they use every day. The more services members complete, the more they can earn.
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.
MEDICAID
HOW CARE MANAGEMENT CAN HELP YOUR PATIENTS
Care Management helps members with special needs. It pairs a member with a care manager. The care manager is a registered nurse (RN) or licensed clinical social worker (LCSW) who can help the member with issues such as:
• Complex medical and behavioral health needs
• Solid organ and tissue transplants
• Chronic illnesses such as asthma, diabetes, hypertension and heart disease
• Children with special health care needs
• Lead poisoning
This no-cost program gives access to a registered nurse or licensed clinical social worker Monday–Friday, 8 a.m.
to 5 p.m. For more information about Care Management, or to refer a member to the program, please call us at 1-866-635-7045. We’re here to help you!
HOW TO IMPROVE PATIENT SATISFACTION AND CAHPS
®SCORES, PART 1 OF 3
WHAT IS THE CAHPS?
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys ask patients to evaluate their health care experiences. WellCare conducts an annual Child CAHPS survey, which asks parents or guardians to rate experiences with their child’s healthcare providers and plans.
As a WellCare provider, you can provide a positive experience on key aspects of their child’s care; we’ve provided some examples of best practices to help with each of the sections.
KNOW WHAT YOU ARE BEING RATED ON: TIPS TO INCREASE PATIENT SATISFACTION:
1. Getting Needed Care
• Ease of getting care, tests, or treatment child needed.
• Obtained child’s appointment with specialist as soon as needed.
• Help patients by coordinating care for tests or treatments, and schedule specialist appointments, or advise when additional care is needed to allow time to obtain appointments.
2. Getting Care Quickly
• Child obtained needed care right away.
• Child obtained appointment for care as soon as needed.
• Educate your patients on how and where to get care after office hours.
• Do you have on-call staff? Let your patients know who they are.
3. How Well Doctors Communicate
• Child’s doctor explained things in an understandable way.
• Child’s doctor listened carefully.
• Child’s doctor showed respect.
• Child’s doctor spent enough time with your child.
• The simple act of sitting down while talking to patients can have a profound effect.
• Ask your patients what is important to them;
this helps to increase their satisfaction with your care.
4. Shared Decision Making
• Doctor/health care provider talked about reasons you might want your child to take a medicine.
• Doctor/health care provider talked about reasons you might not want your child to take a medicine.
• Doctor/health care provider asked you what you thought was best for your child when starting or stopping a prescription medicine.
• Use of office staff other than physicians to distribute decision aids could help more patients learn about the medical decisions they are facing or simply to address medications
• Decision making tools and quick reference guide are available at: www.ahrq.gov/
professionals/education/curriculum-tools/
shareddecisionmaking/tools/index.html.
• Ask your patients, “What should I know about you that may not be on your medical chart?”
5. Coordination of Care
• In the last 6 months, did your child’s doctor seem informed and up-to-date about the care your child got from other health care providers?
• Your office staff needs to offer to help your patient schedule and coordinate care between providers.
Make sure both you and your medical team know the questions your practice is being rated on. Knowledge is power.
For more information and research on ways to improve patient satisfaction, see “Flipping Health Care: From
‘What’s the Matter?’ to ‘What Matters to You?’” You can access this article and a video at the websites below.
Sources and References:
www.ihi.org/Topics/WhatMatters/Pages/default.aspx Christina Gunther-Murphy-What Matters Office Practice Setting IHI www.ihi.org/resources/Pages/AudioandVideo/WIHIWhatMatters.aspx
2016 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey
6. Rating of Personal Doctor
• Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your child’s personal doctor?
• Studies have shown that patients feel better about their doctor when they ask patients,
“What’s important to you?”
7. Rating of Specialist
• Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?
• Help your members value their visit to the specialists, be informed of their visit and their advice.
PROVIDER RESOURCES
WEB RESOURCES
Visit www.wellcare.com/Kentucky/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/Kentucky/Providers/
Medicare or www.wellcare.com/Kentucky/Providers/Medicaid.
Live webinar demonstrating the provider portal every 4th Thursday at 3 p.m.: www.webmeeting.att.com, 1-888-278-0296, Code 1526526.
PROVIDER NEWS
Remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com/Kentucky/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 WellCare located in the column on the right.
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/Kentucky/Providers/Clinical-Guidelines.
WellCare of Kentucky, Inc.
13551 Triton Park Blvd.
Suite 1800
Louisville, KY 40223
WELLCARE OFFICE LOCATIONS
WellCare has various offices throughout Kentucky where you will find your local Provider Relations and Health Services team members.
Ashland
1539 Greenup Avenue 5th Floor
Ashland, KY 41101-7613
Main Office Number: 1-606-327-6200 Bowling Green
922 State Street Suite 300
Bowling Green, KY 42101-2216 Main Office Number: 1-270-793-7301 Hazard
479 High Street 2nd Floor
Hazard, KY 41701-1701
Main Office Number: 1-606-436-1500
Lexington
2480 Fortune Drive Suite 200
Lexington, KY 40509-4168
Main Office Number: 1-859-264-5100 Louisville
13551 Triton Park Boulevard Suite 1800
Louisville, KY 40223-4198
Main Office Number: 1-502-253-5100 Owensboro
The Springs, Building C 2200 E. Parrish Ave., Suite 204 Owensboro, KY 42303-1451
Main Office Number: 1-270-688-7000
Important reminder
You can use the member’s Kentucky Medicaid ID number when the WellCare member ID number is not available when billing a claim.
Please remember to use the Kentucky MMIS, www.kymmis.com, as your primary source of Managed Care Organization (MCO) assignment and eligibility for WellCare members.
We encourage all providers to use KYMMIS as their primary source as it contains the most updated eligibility and MCO assignment information on each individual member.
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