News from NEPHO – JUNE 2021 Edition

NEW PROVIDERS

SAVE THE DATE

NECOMG 2021 ANNUAL MEETING SUMMARY

The NECoMG 2021 Annual Meeting was held on Thursday, June17th at 7:00a.m. The meeting was held virtually via GoogleMeet. The meeting details include the following:

• There were over 120 attendees
• The following physicians have been voted to another 3 year term as Board of Directors:
  • Dr. Kathryn Hollett
  • Dr. Richard Mugge
  • Dr. Eric Sleeper

Our guest speaker was Dr. Leslie Sebba, retired Chief Medical Officer of Beth Israel Lahey Health Performance and former Medical Director for the NEPHO.

Dr. Sebba presented on the Current State of Clinically Integrated Networks in Massachusetts. He discussed the increasing healthcare costs for Massachusetts families and the pressure for providers to lower healthcare costs and improve quality performance.

He discussed Physician Group margins for 2020 as well as Hospital margins after COVID relief fund distribution. Dr. Sebba highlighted the importance of working as a system for infrastructure support, technical assistance and coordination with providers.

He stated that BILHPN is well positioned to perform well in risk based contracts and shared an overview of the new structure and resources dedicated to contracting and performance improvement. 

The Annual Meeting attendance was tracked using an online evaluation form that was sent to all physicians after the meeting. The evaluation form included a section to allow for questions and sharing updates about practice changes. NEPHO will analyze all responses and follow up on the questions.

PHILIPS ISSUES RECALL NOTIFICATION

Philips issues recall notification* to mitigate potential health risks related to the sound abatement foam component in certain sleep and respiratory care devices. 

To read the Press Release, click here.

*    This is a recall notification for the US only, and a field safety notice for the rest of the world

NEW PPE GUIDANCE

DPH issued this guidance document that discusses the universal use of facemasks, eye protection, isolation gowns, and more. The state expects facilities to implement the changes no later than July 1.

Among the changes, eye protection is no longer needed for every patient encounter but is limited to circumstances where healthcare personnel are caring for confirmed or suspected COVID-19 cases. DPH also clarifies facemask use for source control and transmission-based precautions.

PODS AND IPA MEETING KEY TAKEAWAYS

 Quality

• Data on NEPHO performance on the BILH System Diabetes Composite was shared, along with the ongoing interventions targeted to improve performance.
  • The diabetes composite includes annual eye exam, A1c < 9, and BP<140/<90.
  • The goal is to have all 3 in control by August 31.
• EPIC users: There is an updated smartphrase to document home BPs: .BPREMOTEDOCU
  • Office colleagues other than clinicians can call the patient and record the information (the clinician does not need to be the documenter).

Patient Experience

• A 3 part webinar patient experience refresher series is being offered for providers during June and July.
• The webinars are approved for risk management training.
• The webinars will be recorded and available for distribution.
• Refresher course for office colleagues is being explored as a next webinar series.

Provider Experience

• A summary of April Practice meetings was shared.
• Discussion was invited on which provider experience improvement tasks are achievable, and the scope and timeline for actionable tasks.

Pharmacy

• A case based discussion on inhalers was shared along with tools to identify coverage and assist with inhaler selection.

Informational

• Detail on types of discharges that qualify for Transitional Care Management (TCM) Visits/coding was shared.
• This is part of an ongoing effort to share FAQs and answers from pods and IPA meetings.

PAYOR UPDATES

PROVIDER RELATIONS

Things are constantly changing within NEPHO practices – it truly is inevitable. As a reminder, please reach out to the Provider Relations Department periodically to request updates or assistance in creating provider lists. Examples of frequent outreach we receive include and are not limited to:

• Primary Care Providers with open panels for patients transitioning out of Pediatric care
• Primary Care Providers with open panels for Special Needs patients transitioning out of Pediatric care
• NEPHO PCP practice rosters used to update EMR mapping tied to billing/ referral network identification

Please do not hesitate to reach out to Alycia.Messelaar@lahey.org for such requests. We are here to help bring ease to both the practices and the patients you serve.

REFERRAL MANAGEMENT

Tufts Health Plan reinstates referral requirements July 1, 2021

Tufts Health Plan has stated that referral requirements will be reinstated for all products as outlined below:

• Tufts Health Commercial Plan: Effective for dates of service on or after July 1, 2021
• Senior (Tufts Medicare Preferred and SCO) Products: Upon the end of the Federal public health emergency
• Tufts Together: Effective for dates of service on or after August 7, 2021

• Note:  Tufts Health Together* and Tufts Health Direct* do not require in network referrals.
  * please refer to health plan directory for in network specialist participation

As a reminder BILHPN Referral Simplification for Tufts HMO/POS, BCBS HMO/POS, HPHC HMO/POS remains in place and eliminates the need for an administrative  referral from PCPs in the BILHPN network for specialty office visits within the Northeast PHO/BILHPN network.

• Any referrals to a Specialist outside the Northeast PHO (NEPHO) network will need to be reviewed by the Medical Director.

Please continue to fax or submit your out of PHO referrals through your EMR system to the NEPHO for review.

Out of PHO referrals require 5-7 days for review.

Please review the list of contracted health plans included within the referral simplification program.

• US Family Health* and Tufts Freedom Plan* are excluded from Referral simplification and will require referrals to in- network specialists
  * please refer to health plan directory for in network specialist participation

The PHO Referral Management team is here to help with specialty referrals. As a reminder, referral requests outside of the Northeast PHO should be reviewed by our team. We have many new specialists in the Northeast PHO and we are learning more about the new specialists coming into the BILH network. We can help you find the appropriate provider to care for your patients.

Please send all out of PHO referral requests to our dedicated fax line at 978-236-1611. If you have any questions or need an urgent referral to a specialist, please contact Ann Cabral, Referral Manager at Ann.Cabral@Lahey.org or 978-236-1758.

PHARMACY

There are two BILHPN Pharmacy Newsletters this month.

Please click here to be directed to the BILHPN June 2021 Newsletter “Inhaler Resources”.

Please click here to be directed to the BILHPN June 2021 Newsletter “Inhalers: More Info, UPDATED: T2DM Medication Coverage Chart and MassHealth RX Copay Changes”.

For more information or questions, please contact Carol Freedman, NEPHO Pharmacy Manager at carol.freedman@lahey.org or 978-380-4089.

QUALITY

The BILH system ambulatory quality goal is a composite measure to improve the care of patients with diabetes. The three measures in the composite are diabetic eye exams, blood pressure at goal (less than 140/less than 90), and A1c less than 9.

Why is this goal worth paying attention to?

The evidence behind the goal is compelling: Studies have shown that risk factor control is highly effective in reducing cardiovascular events in patients with Type 2 diabetes (BARI 2D, JACC 2015). Studies have also shown the excessive cardiovascular risk that is associated with the number of risk factors outside of target ranges (NEJM, 2018; 379:633-634).

Our local data shows we have room for improvement: Preliminary data for 2021 shows that only 9% of BCBS HMO patients tracking to NEPHO providers currently have all 3 risk factors in the diabetes composite met or in control.

The BILH system timeline is to get patients in control/to goal before August 31st. Below are a few tips to help your patients meet their goals. Please reach out to the NEPHO Quality team if you have additional suggestions or would like more information.

• Primary Care Providers
  • Use your PHO EMR alerts – PHO analysts have identified which risk factor(s) your patients need to get into control.
  • If the EMR alert says they are due for an eye exam, please encourage your patient to schedule the exam.
  • If it is clinically appropriate, consider medication adjustments for patients who have not met their blood pressure or A1c targets, and schedule them before they leave your office for an early follow up visit.
  • Some patients may value your written instructions. Consider “prescribing” diabetes eye exam AND extracting a commitment from your patient for when they will schedule the exam (“I would like you to call today to schedule the appointment, are you able to do that?”)
• PCP Office Managers and Key Quality Contacts
  • Check your “Needs Appointments” lists: PHO analysts are leveraging Arcadia reporting weekly to identify diabetes patients who need appointments and sending these names to office managers and key contacts. Try to book these patients for office visits prior to August 31st if possible.
  • Alert your MAs and nurses that patients who have BPs readings above 140/above 90 should get a second reading, preferably towards the end of the visit.
• For Ophthalmology/Endocrinology/Cardiology/Nephrology practices
  • Please obtain and document second BP for your patients who have above 140/above 90 initial readings.
  • Please reach out to patients who miss their appointments to re-schedule.

POPULATION HEALTH

Reminder Diabetic Eye Exams

The BILH Ambulatory DM Composite Measure includes diabetic eye exams. Please see the Quality Section of this newsletter for an explanation of the DM Composite Measure.

The NEPHO Quality Team has taken the following steps to help improve our DM Eye Exam compliance rate:

CODING TIP OF THE MONTH

OPTUM Newsletter – June 2021 | Dementia and Alzheimer’s Disease

Medical Necessity Helps Support Evaluation and Management (E/M) Leveling

It has been 6 months since the new Evaluation and Management (E/M) updates became effective. Providers no longer have to include history and exam components in documentation to determine the E/M code level for the office/outpatient CPT codes 99202-99215. Instead they are now using updated guidance for determining the level of service based on either time or Medical Decision Making (MDM).

Though E/M guidelines have changed, medical necessity has not. The importance of supporting medical necessity by documentation is still an element of E/M coding guidelines. Although the history and physical exam are no longer required to level the visit, they are still important components in establishing medical necessity, supporting medical decision making, and providing quality care. Documenting these components helps maintain continuity of care and assists other providers in management of patient care.

Medical necessity determines coverage and level of reimbursement from Medicare and the other payers:

Medicare

• requires that the level of service provided must be supported by medical necessity. 
• defines medical necessity as health-care services or supplies needed to diagnose or treat an illness or injury, condition, disease, or its symptoms and that meet accepted standards of medicine. 
• determines, on a case-by-case basis, if the method of treating a patient is reasonable and necessary.

Payers 

• provide coverage for care, items and services that they consider to be medically necessary. 
• limit coverage, even if a service is reasonable and necessary, if the service is provided more frequently than allowed under a national coverage policy, a local medical policy, or a clinically accepted standard of practice. 
• use National Correct Coding Initiative (NCCI) claim edits to ensure that payment is made for specific procedure codes when provided for a patient with a specific diagnosis code or predetermined range of ICD-10-CM codes. ICD-10-CM codes should support medical necessity for any services reported. 

As we move forward with the implementation of the new E/M updates for outpatient services it is important to remember how medical necessity must be supported by documentation. This includes services based on time and on the MDM. To better support medical necessity for services reported, the following principles should be followed:

• List the principal diagnosis, condition, problem, or other reason for the medical service or procedure
  • Example: Chief Complaint/Reason for Visits
• Assign the diagnosis code to the highest level of specificity
  • Example: Diabetes with Complications should be coded to the highest specificity
• For office and/or outpatient services, never use a “rule-out” statement (a suspected but not confirmed diagnosis); a clerical error could permanently tag a patient with a condition that does not exist
  • Example: Patient seen in ED for racing heart– this is a new condition but ED provider added anxiety diagnosis to chart and prescribed Zoloft. Patient followed up with PCP and it was found the patient had a mini stroke. The anxiety is a suspect condition captured in the ED. Anxiety should not be captured on the problem list as a chronic treated condition. Anxiety is a suspect condition.
• Distinguish between acute and chronic conditions, when appropriate
  • Example: Acute conditions are severe and sudden in onset. This could describe anything from a broken bone to an asthma attack. A chronic condition, by contrast is a long-developing syndrome, such as osteoporosis or asthma.
• Identify how injuries occur
  • Example: Patient fell off bike and fractured hip

As we move forward into 2021 keeping medical necessity as a driving component when leveling E/M services ensures new guidelines are being followed and captured compliantly.

Please reach out to Shawn Bromley at 978-236-1704 or shawn.m.bromley@lahey.org if you have additional questions related to medical necessity and importance it has in supporting E/M leveling for outpatient services.

PATIENT EXPERIENCE COMMENTS

Blackburn Primary Care, Gloucester – 1 Blackburn Drive

• Dr. Jay Isaac and Beth are the best doctors ever. They care about their patients.

Danvers Family Doctors PC, Danvers 140 Commonwealth Avenue

I Love Dr. Subroto Bhattacharya. Great and respectful staff. He gives me peace

Lahey Primary Care, Beverly – 30 Tozer Road

• Dr. Tina Waugh is an incredible diagnostician and is able to know me very well. She is always prompt and super caring.

Lahey Primary Care, Beverly – 100 Cummings Center

• Dr. Khalil Shahin listened to my concerns and responded with options that made me feel I could take part in my health care.

Lahey Primary Care, Beverly – 900 Cummings Center

• Dr. Daniel McCullough is a true gentleman and is certainly on top of his game concerning health issues.

Lahey Primary Care, Danvers – 5 Federal Street

• Dr. Mauri Cohen is a doctor that is very easy to talk to about any medical conditions. There are doctors that want to talk more than listen, but Dr. Cohen definitely listens which makes me feel comfortable.
• Very good experience with Dr. Brent Fryling.

Lahey Primary Care, Manchester – 192 School Street

• Dr. Matthew Plosker is very competent and personable. I trust him implicitly and have recommended him.

PRACTICE RECOGNITION

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 winner is:

Regina Moormann, Danvers Family Doctors.

Regina Moormann, Danvers Family Doctors, was recognized for efforts to support NEPHO and other practices learn about practice management systems.

Regina Moormann, Danvers Family Doctors

Please let us know if you would like to nominate a team member in your practice or another practice for the recognition program. We will deliver gift cards to the winners each month, and they will be announced here and in our website “Hot Topics” section.

Please be sure to look for the new winners in next month’s issue!