A New Providers listing will be published after the
August 21st New Physician Orientation.
- Michael Moharan, DPM of Addison Gilbert Podiatry Clinic has resigned
- Forrest Schwartz, MD of Sports Medicine North has resigned
- Peter Rapoza, MD of Ophthalmic Consultants of Boston will no longer be seeing patients at the
104 Endicott Street Suite 303 Danvers, MA 01923 location effective 10/4/2019 and will resign from NEPHO
- John Boyle, MD will be retiring effective 7/31/2019
- Effective 8/1/2019 the practice of Thompson Medical Associates, Dr. Candace Thompson, will be relocating from 242 John Wise Ave Essex, MA 01929 to 9 E Dr Osman Babson Rd. Gloucester MA 01930
- Effective 9/1/2019 the practice of Robert O’Brien Jr., M.D.& Associates, P.C. – Drs. Robert O’Brien, Benjamin Solky and Joshua Shofner will be relocating from 83 Herrick Street Suite 3000 Beverly, MA 01915 to 140 Commonwealth Ave Suite 201 Danvers, MA 01923
SAVE THE DATE
IPA / POD MEETINGS SUMMARY
- Dr. Peppe shared and collected feedback on the LCPN new dashboard which provides cost, utilization and quality metrics specific to each PCP’s population and comparisons to the LCPN network.
- Feedback included:
- Helpful to see the comparison to peers
- Separating out Adult/Pedi will be useful
- Clear take home message is helpful
- Important to see quality section and the patient detail tracking to this area
- Add filter for deceased patients
- PCPs also commented that it will be useful to see this information periodically
Quality: Low Back Pain
- The Imaging for Low Back Pain measure was reviewed. 2019 performance is behind 2018 performance suggesting that early imaging is being performed for the evaluation of uncomplicated low back pain.
- The Basics and Beyond the Basics format was introduced for the low back pain measure and as a format for future measures.
- The Basics format keeps messaging to the point while Beyond the Basics format adds more detail about the measure and includes current measure performance, findings of chart reviews and coding opportunities, and discussion of clinical scenarios.
Quality: Patient Lists
- Updated patient Integration Reports for PCPs were distributed and reflects care that needs to be provided before year end.
- Logistics regarding the upcoming NP/PA meeting in September were shared. Dr. Amalanshu Jha from Essex Surgical Associates will be presenting on Abdominal Surgery Overview.
Rapid Meeting Assessment
- Meeting attendees were asked to complete a Rapid Meeting Assessment to help gather feedback on content, discussion, materials, and structure of the meeting.
HARVARD PILGRIM 2019 QUALITY GRANT RECIPIENTS
Harvard Pilgrim 2019 Quality Grant Recipients
NEPHO would like to share this year’s Harvard Pilgrim 2019 Grant Recipients. The NEPHO Telehealth Pilot Program is listed on line 7 and is one of 8 Massachusetts organizations selected. We are completing the first quarter of the grant award timeline that is from May 2019 to June 2020. NEPHO will provide quarterly updates on progress made through the year. Click here to see the listing of Harvard Pilgrim 2019 Quality Grant Recipients.
AllWays Health Partners (AHP)
Have you ever filed an appeal because a prior authorization (PA) was denied? Of course, you have. AHP receives an average of 60 appeals requests per month. Many of these appeal requests, especially the ones for prescription drugs, don’t require an appeal for a favorable outcome. In fact, at least half of all prescription drug PAs that are denied for not meeting medical criteria were subsequently approved once AHP receives additional necessary information.
Your options before filing an appeal
- Requesting an appeal as an immediate response to a denial limits the review opportunities for you and your patient.
- Once an appeal is filed, the formal appeals process must be followed, which can be unnecessarily time consuming, especially for someone who needs a service or a medication quickly. If the service or medication is denied on appeal, and the member would like to dispute that decision, their only recourse would be to go through an independent external review.
- Additionally, choosing to initiate an appeal as a first attempt immediately following a denial, bypasses two opportunities that can result in a timelier favorable outcome for your patient.
Option #1: Re-review
Instead of requesting an appeal after an initial denial, simply ask for help from AHP customer service or, in the case of a prescription denial, CVS customer service. AHP can help identify the reason for the denial, including what key information may be missing. In many cases, you simply need to provide additional information to have your PA approved without an appeal.
Option #2: Reconsideration
To initiate this option, simply contact AHP to request the reconsideration. You can speed up the reconsideration by including additional relevant information with your request. Reconsideration is less formal and less time consuming than an appeal. There is also an opportunity in this step for a peer to peer discussion between your requesting provider and an appropriate clinician to determine medical necessity coverage. You can learn more about reconsideration in the initial denial letter sent by AHP or CVS.
3 tips to avoid denial
The best outcome for you and your patients is a PA that’s approved on first submission – no need for reconsideration or appeal. Here are 3 tips to help you get your PAs approved quickly:
- Include as much detail and relevant clinical documentation as possible
- Submit the request before you provide a service
- Check a member’s eligibility and benefits before you request a PA. Check the authorizations page on our website to determine medical criteria for intended service,• medication, or durable item
MassHealth Newborn Enrollment —(Update from MHA)
Massachusetts Health and Hospital Association (MHA) and Boston Children’s Hospital recently testified on priority legislation regarding newborn enrollment in MassHealth. H.1153 /S.679 (Rep. Higgins/Sen. DiDomenico) would require MassHealth to enroll newborns born to mothers under managed care plans in the fee-for-service program for the first forty-five days of their life.
MHA, Accountable Care Organizations (ACOs), and providers have long raised concern with MassHealth auto-assignment rules for newborns who are often inappropriately assigned to an ACO or Managed Care Organization (MCO) that does not include the baby’s pediatrician. With the introduction of the new MassHealth ACO program in March 2018, many more managed care offerings are now available — thereby spreading enrollment across more health plans. Beyond the expansion of the number of managed care offerings, the ACO program also introduced a key policy change affecting member assignment to plans. Individuals in MassHealth managed care are required to have a primary care physician (PCP). Under the new ACO program, PCPs participating in a MassHealth ACO are now exclusive to a single ACO. With this change, the likelihood that a newborn’s pediatrician is not in the mother’s managed care plan has increased significantly given the new PCP exclusivity for pediatricians participating in ACOs.
H.1153/S.679 provides a substantive solution to this problem, allowing families and provides a reasonable time period to select the appropriate plan that includes a baby’s pediatrician. This week, MassHealth reported that it will seek to adopt this type of approach in January of 2021, with the fee-for-service time period to be determined (no more than 45 days). Families will be able to enroll a baby in an ACO or MCO earlier if they so choose. In the meantime, MassHealth reported it will work to improve efforts to reduce payment denials for these instances including requiring MCOs to provide a 30 day continuity of care protection for newborns. MassHealth will also be making further improvements to the newborn auto-assignment process and notice of birth (NOB) forms that will improve the enrollment of newborns into appropriate health plans. Further details will be forthcoming.
Cervical Cancer Screenings
A Pap test can detect cervical cancer early. It can also detect pre-cancers, which can be treated to keep cervical cancer from forming.
The American Cancer Society, the American College of Obstetricians and Gynecologists and the US Preventative Services Task Force recommend the following guidelines for women who are not at high risk for cervical cancer:
- Women aged 21–29 years should have a Pap test alone every 3 years. HPV testing is not recommended
- Women aged 30–65 years should have a Pap test and an HPV test (co-testing) every 5 years
Under these guidelines a woman 30 years or older who had a negative Pap test and a negative HPV test in 2015 would not be due until 2020. The following websites provide additional resources:
The best choices for disposal of unused or expired medicines are:
Medicine take-back options:
Encourage patients to dispose of unused or expired medications the safe way, by bringing them to an approved collection site. To find a location visit https://nabp.pharmacy/initiatives/awarxe/dispose-safely/
Disposal in the household trash:
If a drug disposal site or mail-back program is not available in your area, it is best to follow Food and Drug Administration (FDA) guidelines for the safe disposal of unused or unwanted medications at home; including when to flush medication and patches.
- Check the label on your medication and follow any instructions for safe disposal provided.
- A small number of medications need to be flushed down the toilet if a disposal box is not immediately available. These drugs include fentanyl, hydrocodone, and methadone, among others. The list of drugs that should be flushed when take-back options are unavailable is available on the FDA website.
- If there are no take-back programs available in your area and there are no specific instructions, such as flushing, take your medication out of the container and mix them with an undesirable substance, such as dirt, used coffee grounds, or cat litter. Next, seal the mixture in a sealable bag, can, or container and place the container in the garbage.
- If disposing of sharps, place the used sharps immediately in a sharps disposal container, which are often available through pharmacies, medical supply companies, etc. If a disposal site is not available, you may use a heavy-duty household container, such as a laundry detergent container to dispose of the sharps.
Cigna Specialty Meds
Earlier this year Cigna announced Accredo, part of Express Scripts’ services, as their preferred specialty pharmacy provider. Effective July 13, 2019 Cigna Specialty pharmacy has added approximately 60+ new medications. The list can be accessed at CignaforHCP.com >Resources>Pharmacy Resources>Specialty Pharmacy> Limited Distribution Drugs List. To ensure a smooth transition, in August 2019, Cigna Specialty Pharmacy will begin transferring current specialty drug refills to Accredo. Affected customers will be notified in advance of the transfer and made aware of their next refill will be available from Accredo. Practices with patients who have open refills through Cigna will receive a letter when the refill has been transferred to Accredo. A complete transition to Accredo will be completed by the end of 2019.
CODING TIP OF THE MONTH
OPTUM Newsletter – July focus is High Blood Pressure and Stroke
Accurate Coding of Opioid Diagnoisis Improves Risk Adjustment Capture
ICD-10 gives us the opportunity to improve public health intervention related to drug abuse. Where are the other links between mental illness and drug use, abuse, or dependence? It’s about finding and targeting the root cause of drug problems, and coded data can help us get answers. The major changes for the CMS HCC 2019 Risk Adjustment Model included the addition of four new risk-generating HCCs in chronic conditions related to substance abuse and mental health, and severity of chronic kidney disease.
- The four new HCCs include:
- HCC 56: Drug Abuse, Uncomplicated, Except Cannabis
- HCC 58: Reactive and Unspecified Psychosis
- HCC 60: Personality Disorders
- HCC 138: Chronic Kidney Disease, Moderate (Stage 3)
- Statistical data depends on coded data, and coded data depends on documentation specificity. Encourage physicians to:
- Document the intent of the overdose carefully
- Choose one term (use, abuse, or dependence) to use throughout the note consistently
- Document any complications
- Identify any and all other drug use, abuse, or dependence
- Document any manifestations and link them to the drug use (when appropriate)
- According to the ICD-10 coding guidelines for coding opioid use, abuse and dependence, when the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis) only one code should be assigned to identify the pattern of use based on the following hierarchy:
- If both “use” and “abuse” are documented, assign only the code for abuse.
- If both “abuse” and “dependence” are documented, assign only the code for dependence.
- If “use,” “abuse,” and “dependence” are all documented, assign only the code for dependence.
- If both “use” and “dependence” are documented, assign only the code for dependence.
- The diagnosis of Opioid Use Disorder can be applied to someone who has a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
- Taking more opioid drugs than intended.
- Wanting or trying to control opioid drug use without success.
- Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs.
- Cravings opioids.
- Failing to carry out important roles at home, work, or school because of opioid use.
- Continuing to use opioids, despite use of the drug causing relationship or social problems.
- Giving up or reducing other activities because of opioid use.
- Using opioids even when it is physically unsafe.
- Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway.
- Tolerance for opioids.
- Withdrawal symptoms when opioids are not taken.
HCC ICD-10 Codes
|F11.10||Opioid abuse, uncomplicated|
|F11.11||Opioid abuse, in remission|
|F11.120||Opioid abuse with intoxication uncomplicated|
|F11.121||Opioid abuse with intoxication, delirium|
|F11.122||Opioid abuse with intoxication with perceptual disturbance|
|F11.129||Opioid abuse with intoxication, unspecified|
|F11.14||Opioid abuse with opioid-induced mood disorder|
|F11.150||Opioid abuse with opioid-induced psychotic disorder with delusions|
|F11.151||Opioid abuse with opioid-induced psychotic disorder with hallucinations|
|F11.159||Opioid abuse with opioid-induced psychotic disorder, unspecified|
|F11.181||Opioid abuse with opioid-induced sexual dysfunction|
|F11.182||Opioid abuse with opioid-induced sleep disorder|
|F11.188||Opioid abuse with other opioid-induced disorder|
|F11.19||Opioid abuse with unspecified opioid-induced disorder|
| Opioid Dependence
HCC ICD-10 Codes
|F11.20||Opioid dependence, uncomplicated|
|F11.21||Opioid dependence, in remission|
|F11.220||Opioid dependence with intoxication uncomplicated|
|F11.221||Opioid dependence with intoxication, delirium|
|F11.222||Opioid dependence with intoxication with perceptual disturbance|
|F11.229||Opioid dependence with intoxication, unspecified|
|F11.23||Opioid dependence with withdrawal|
|F11.24||Opioid dependence with opioid-induced mood disorder|
|F11.250||Opioid dependence with opioid-induced psychotic disorder with delusions|
|F11.251||Opioid dependence with opioid-induced psychotic disorder with hallucinations|
|F11.259||Opioid dependence with opioid-induced psychotic disorder, unspecified|
|F11.281||Opioid dependence with opioid-induced sexual dysfunction|
|F11.282||Opioid dependence with opioid-induced sleep disorder|
|F11.288||Opioid dependence with other opioid-induced disorder|
|F11.29||Opioid dependence with unspecified opioid-induced disorder|
Opioid Use, Unspecified HCC ICD-10 Codes
|F11.920||Opioid use, unspecified with intoxication, uncomplicated|
|F11.921||Opioid use, unspecified with intoxication delirium|
|F11.922||Opioid use, unspecified with intoxication with perceptual disturbance|
|F11.929||Opioid use, unspecified with intoxication, unspecified|
|F11.93||Opioid use, unspecified with withdrawal|
|F11.94||Opioid use, unspecified with opioid-induced mood disorder|
|F11.950||Opioid use, unspecified with opioid-induced psychotic disorder with delusions|
|F11.951||Opioid use, unspecified with opioid-induced psychotic disorder with hallucinations|
|F11.959||Opioid use, unspecified with opioid-induced psychotic disorder, unspecified|
|F11.981||Opioid use, unspecified with opioid-induced sexual dysfunction|
|F11.982||Opioid use, unspecified with opioid-induced sleep disorder|
|F11.988||Opioid use, unspecified with other opioid-induced disorder|
|F11.99||Opioid use, unspecified with unspecified opioid-induced disorder|
PATIENT EXPERIENCE COMMENTS
Addison Gilbert Primary Care – 298 Washington Street, Gloucester
• Dr. Karen Damico is the best. She is always helpful and takes all the time I need.
Beacon Family Medicine – 130 County Road, Ipswich
• Dr. Curtis Ersing is a very pleasant person to deal with and always has useful and practical advice.
• I have nothing but the best care with Dr. Aimee Hromadka.
Cummings Center Medical – 900 Cummings Center, Beverly
• Dr. Andrew Lenhardt provides excellent medical care, is open minded, and a good listener – I feel
• fortunate to have this care.
Garden City Pediatric Associates – 83 Herrick Street, Beverly
• We’ve been bringing our children to Dr. Sheryl Silva for 13+ years –she’s wonderful – we tell everyone
• about her.
• The entire staff is excellent! They are also very efficient. Dr. Eric Sleeper always takes enough time with
• us to answer all our questions.
Lahey Primary Care, Danvers – 5 Federal Street, Danvers
• Dr. Mauri Cohen is very professional, caring, very complete and thorough.
• Dr. Steven Keenholtz has exceptional talents as a primary care doctor. He has “it” when it
• comes to his patients.
Lahey Primary Care, Hamilton – 12 Railroad Avenue, So. Hamilton
• Dr. William Medwid provides phenomenal care. He always makes me feel comfortable and well cared for.
• Dr. Gordon Laurence is wonderful I have total confidence in him. Excellent doctor!
Thomas Pearce, MD – 279 E. Main Street, Gloucester
• Dr. Thomas Pearce is knowledgeable, caring and thorough.
The Northeast PHO recognizes colleagues who provide a positive experience for our patients, help us keep care local and meet our quality targets.
This month’s winners are:
Deb Houde, Patton Park Medical, was recognized for her excellent patient outreach efforts scheduling needed appointments.
Nancy Worsencroft, Family Medicine Associates – Manchester, A Member of Lahey Health was recognized for her efforts collaborating with the NEPHO Referral Team in re-directing patients to in-PHO Specialists.
We appreciate their efforts in supporting the PHO goal to provide high quality, community health care. We will deliver gift cards to the winners each month, and they will be announced here in the newsletter.