News from NEPHO – November 2018 Edition

NEPHO NEWS
November 2018 Edition
November Newsletter – click here to print
Please note: Due to a system-wide glitch not all links will function
in the print version of this newsletter.  IT is working on the problem.
OPTUM Insider Newsletter: November Focus – National Diabetes Month

PHYSICIAN and PRACTICE CHANGES/UPDATES

Practice Changes/ Updates

• Zaven Jouhourian, MD has announced his retirement effective 11/30/2018
• Michael Newman, MD of North Shore G.I. will be terminating his affiliation with the Northeast PHO effective 12/31/2018
• Sandra Hu-Torres, MD of North Suburban Eye will be terminating her affiliation with the Northeast PHO effective 12/30/2018
• Jeanne Gose, MD of Asthma and Allergy Affiliates has retired effective 9/28/2018
• Kenneth Shieh, MD of North Shore G.I. will be terminating his affiliation with the Northeast PHO effective 1/31/2019
• Emily Chin, MD of Lahey Primary Care, Beverly – 900 Cummings will be terminating her affiliation with the Northeast PHO
  effective 2/15/2019
• Victor Carabba, MD of Lahey Health Primary Care, Gloucester – 4th Floor has closed his panel, except to existing
  patients effective 11/1/2018
• Robert Tufts, MD of the Sleep Center has two new referral  sleep consult locations: LOCD and AGH in Gloucester. 
  Click here for a referral example in EPIC
• Bruce Barlam, MD has announced his retirement effective 12/15/2018
  

SAVE THE DATE

Office Manager Meeting
Date: December 12, 2018
Place: 500 Cummings Center, Suite 6500
Good Harbor Room
Beverly, MA  01915
RSVP: Judy O’Leary at Judith.O’Leary@Lahey.org   or 978-236-1739

MD OrientationDate:  December 13, 2018 @7:30 A.M.
Place: 500 Cummings Center, Suite 6500
Good Harbor Conference Room
Beverly, MA  01915
RSVP: Alycia Messelaar at Alycia.Messelaar@Lahey.org   or 978-236-1784

MassPAT Changes  

The Department of Public Health (DPH) released a memo on November 1, 2018 to all Massachusetts licensed providers
detailing a change in the state law that requires prescribers to check MassPat, the Commonwealth’s prescription
monitoring program before issuing every benzodiazepine prescription. Previously, DPH regulation required MassPAT
to be checked prior to issuing a prescription for benzodiazepines to a patient for the first time.

The DPH also suggests clinicians consider prescribing naloxone to patients when prescribing a benzodiazepine.
To view the DPH memo please click here.

PAYOR UPDATES

MassHealth Managed Care Organizations

• Per the recent state regulations, MassHealth Managed Care Organizations (MCOs) are required
  to pay providers at 100% of the current MassHealth rates effective 3/1/2018.

Boston Medical Center HealthNet and Tufts Health Public Plans
implemented these rate changes after the 3/1 start date. This will lead
to claims adjustments from both plans to process claims at the lower  rate.BCBS

• Effective 1/1/2019, our BCBS HMO contract will change from a 10% withhold to an 8% withhold.
• We will publish the 2019 BCBS fee schedule on our website when it becomes available.

Tufts Health Plans 

• Payment Policy Update: Preventive Services
  To view the complete policy click here:

Harvard Pilgrim Health Care
Updated Medical Policy: Mammography  

• Updated policy includes making changes to age for screening coverage.
• Harvard Pilgrim Health Care (HPHC) considers annual screening mammography as medically necessary for members when medical record documentation confirms ALL of the following conditions: Member is at least forty years in age but no more than seventy-four years in age.
• To view the complete policy click here:

Updated Payment Policy: Vaccine and Immunization

• The Plan has added to CPT 90750 reimbursed for ages 50 and older, administrative edits. To view the complete policy click here:  

Diabetes Prevention
Harvard Pilgrim has wellness programs designed to promote healthy lifestyles, helping members reduce their risk factors for conditions like diabetes in a variety of ways.

• The approach includes, among other things:
  • telephonic support in which a dedicated team of certified health coaches/nurse educators work with members and their families to help them make informed decisions about lifestyle opportunities like nutrition management, physical activity, and weight management
  • online wellness resources like self-paced educational workshops, fitness logs, and trackers that sync with more than 80 personal tracking devices, as well as recipes and a meal planner

To get a personal health coach, members simply sign on to HPHConnect and indicate on the confidential health questionnaire that they would like to work with a coach.  To review Harvard Pilgrim’s Diabetes Management Program please click link: Harvard Pilgrim’s Diabetes Management Program.

• Members who are at moderate or higher risk are additionally referred to our High-Risk Diabetes Programand receive outreach and personalized care from a Harvard Pilgrim nurse care manager.
• To refer a patient for diabetes nurse care management services, call 1-866-750-2068. The US. Department of Health and Human Services offers this helpful toolbox for providers.

POPULATION HEALTH

Population Health Focus for December: Diabetic Eye Exams
Diabetic retinopathy is a leading cause of blindness in American adults and is the most common diabetic disease.
An estimated 40 to 45% of diabetic Americans experience some stage of diabetic retinopathy.
No Warning Signs – 50% of patients are not getting their eyes examined or are diagnosed too late for treatment to be effective.

• Patients normally don’t experience symptoms until their vision is already damaged.
• Vision loss and blindness – Diabetic retinopathy usually affects both eyes by damaging the retina.
• Over time, the blood vessels protecting the retina become blocked causing vision blurriness or loss. If left untreated, it could ultimately lead to blindness.
• Annual comprehensive eye exams are crucial – A dilated eye exam allows for an eye care professional to notice the early warning signs for this disease and prevent vision loss. Timely treatment and appropriate follow-up care can reduce the risk of blindness by 95%.
• Refer your patients to an eye care provider today – You can find a detailed list of in-network providers via https://www.nepho.org/provider-directory/

Diabetic eye disease can affect many parts of the eye, including the retina, macula, lens and the optic nerve.

IPA / POD MEETING SUMMARIES 

Efficiency – Imaging

MRI Services Medical Director Dr. Peter Curatolo presented guidelines for ordering imaging, including when
to choose MRI vs CT, ordering contrast, and general pricing guidelines.

Quality – Year End Push

• Liz Isaac, Director of Quality and Performance Improvement, reviewed the current PHO scorecard
  and action plans for focus items until year end.
• Strategies for spotlight measures, DM HTN, HTN, Well Visits, and Chlamydia were discussed.
• Data on the number of hypertension patients by provider who are at or close to 140/90 was reviewed.
• Carol Freedman reviewed data on current Acute Bronchitis measure performance and shared tips for
  coding Acute Bronchitis when appropriate.

Patient Experience – 2018 MHQP Preliminary Results

• Liz Isaac shared that the 2018 MHQP practice results that will be
  posted online early next year have been sent to practices.
• Meetings have begun to review the results with practice administrators
  and individual providers.
• Meeting discussions will drive next steps for improvement opportunities.

Reporting

• Attendance records through October PODs were shared.

QUALITY

Quality Focus for December: Maximizing Opportunities during the Final Push for AQC

The final weeks of the 2018 AQC campaign are upon us.  Many opportunities to improve your standing in the Blue Cross Quality measures are still available:

• Grab the low hanging fruit in the blood pressure measures. The last blood pressure documented in the patient chart is what will be submitted to Blue Cross for 2018. Patients with a current reading at 140/90 or just above are good candidates to bring in for a BP check.  Remember that the goal BP is less than 140/less than 90.
• Let’s get physicals…well-child visits and chlamydia screenings. Every visit and screening that is performed counts. Many college kids are home during the weeks prior to the holidays.  Try to fit them in for a physical if you can.
• Tis the season…the Acute Bronchitis season that is. Use the acute bronchitis diagnosis when appropriate and remember, do not prescribe an antibiotic for acute bronchitis alone.
• Take a deep breath…it’s the Asthma Medication Ratio measure. This measure can be tricky, but it does offer opportunities to improve performance through the end of the year. Remember to refill your patients’ long-acting asthma controller when refilling their rescue inhaler.

Should you have any questions about these or any of the AQC measures, please contact the PHO Quality Team.  We will be glad to provide you with your patient lists too!

PHARMACY UPDATES

BCBS  Proton Pump Inhibitors (PPIs) No Longer Covered
Since most PPIs are available over-the-counter (OTC), BCBS will no longer cover these medications under the pharmacy benefit,* effective January 1, 2019.

• NEPHO providers wrote PPI prescriptions for over 470 BCBS patients in the May – September 2018 timeframe.

* BCBS will be sending affected patient’s letters about the exclusions and the options available.

Some tips for patients affected by BCBS new PPI policy

• If patients can benefit from dose-reductions or medication discontinuation, deprescribing guidelines are available to assist in this process. Some options for deprescribing include decreasing to a lower dose or stop and use on demand strategies. Patients and/or caregivers are usually more successful when engaged in the process and have an understanding of the rationale for deprescribing (e.g. risks of continued PPI use etc.)

• Patients can use Good Rx coupons for most generic prescription PPIs and pay about $5 to $25 for a month supply. (GoodRx.com)
• OTC PPIs are available from various locations (Walmart, Amazon, COSTCO) at reasonable costs ($12 – $15 per month).
• For more information on this new policy or deprescribing strategies, please contact
  Carol Freedman RPh at Carol Freedman@lahey.org or 978-236-1774.

E-Cigarettes and Vaping

• Earlier this year the FDA released information about their Youth Tobacco Prevention Plan program in an effort to eliminate youth e-cigarette use.
• In addition, plans for a total ban on sale of “flavored e-cigarettes “are being proposed. Reports indicate current use of POD e-cigarettes such as Juul and Vuse account for as much as 70% of e-cigarette sales.
• Please see the attached Prescriber / Pharmacist Letter on E-Cigarette and Vaping FAQs for more information on this important topic.

CHECK OUT OUR NEW WEBSITE SECTION – CODING TIP OF THE MONTH

NEPHO is happy to announce the newest section on our website focused on coding.
This section will be updated with the most up to date information related to medical coding.

• Information will help support efforts to capture codes that Risk Adjust.
• Provide providers with CMS updates that impact reimbursement.
• Offer guidance to stay in compliance with billing and coding requirements.

To be directed to this section please click the following link
https://www.nepho.org/the-coding-corner/

Featured this month are the NEW 2019 ICD-10 CM and CPT Updates.
Please feel to contact Shawn Bromley with questions related to coding at
shawn.m.bromley@lahey.org or 978-236-1704.

NOVEMBER CODING TIP OF THE MONTH

Risk Adjustment Coding is a Joint Effort
Risk adjustment coding requires health plan management, provider group management, physicians, nurse practitioners and physician assistants, and skilled coding professionals to work together to capture the health status of their patients and ensure their documentation complies with the Hierarchical Condition Categories (HCC) reporting requirements on a yearly basis.

Here are some common errors made in coding and documentation. By working to address these, physician practices will have a better opportunity to meet the requirements for Risk Adjustment Coding that will impact the future budget.

PROVIDER RELATIONS

FROM YOUR LIPS TO OUR EARS – NEPHO Provider Relations Meet and Greets

The NEPHO Provider Relations department will be scheduling meetings with each of the PHO practices to help identify opportunities to better serve the practices.  The Provider Relations department is working to implement a program to enhance our partnership with each practice.

The goal is to grow the department in terms of the current assistance we provide that includes:

• Reimbursement/Claim Issues
• Answering General Questions
• Reviewing NEPHO Contracts
• Helping to Understand NEPHO Policies and Procedures
• Performing Research and Problem Resolution Related to Billing and Coding
• Credentialing Paperwork
• Provider Communications
• Verifying Information
• The purpose of these meetings is to ensure each practice has a point person within NEPHO to advocate the practice needs to the PHO and/or hospital.

Please click  Northeast PHO Educational Offerings to see a list of current educational offerings and potential new initiatives that are in development. Feel free to reach out to Alycia Messelaar if you would like to request a meeting   as soon as possible, 978-236-1784 or Alycia.Messelaar@lahey.org

We look forward to meeting you!

Alycia Messelaar Manager,
Provider and Payor Relations

Janelle Jensen
Provider Relations and Credentialing Coordinator

REFERRAL MANAGEMENT

It is always a pleasure to communicate that your efforts are working in reducing the number of patients seeking care outside of the Northeast PHO network.  Please refer to the Northeast PHO Referral Management Policy and BCBS, Harvard Pilgrim, Tufts, Tufts Medicare Preferred payor policies to ensure we continue to maintain improved performance of out-of-network referrals.

The following criteria must be documented in patient’s chart in order for an out of PHO referral request to be approved:

• Pre-existing relationship– Clinical notes will be required to authorize a pre-existing relationship.
  • One Calendar Year
  • Follow up to current surgery or complication of current surgery or therapy
• Access to Care – refer to NEPHO Physician Access Standards
• Services not in PHO network –Clinical notes will be required to support this request
  • Patient to be directed to Preferred Tertiary provider
• Coordination of Care –Clinical notes will be required to support this request
• ER follow up – Clinical notes will be required to support this request
  • Must have seen Specialist in ER
  • One visit only and will be re-directed back to Northeast PHO or Lahey specialist as appropriate.
• Second Opinion – requires Medical Director review and documentation
  • Required in Northeast PHO ; if not available in Northeast PHO second opinion should be directed to a Preferred Tertiary specialist
  • Restricted to 1 visit

Reminder
In PHO Orthopedic Policy members must see a Northeast PHO Orthopedic Specialist prior to being referred to an Out of PHO (OOPHO) or Preferred Tertiary Orthopedic Specialist.

Pediatric Orthopedic referrals must be in PHO excluding the following reasons:

• Scoliosis
• Club Feet
• Malignant Tumors
• Growth Plate Fractures for Patients under 24 month
• Congential anolmalies / issues

Pediatric Referral Rules
Referrals for the following pediatric specialties will be approved without PHO review:

• Cardiology
• Endocrinology
• Gastroenterology
• Nephrology
• Neurology/Neurosurgery
• Pulmonary
• Rheumatology
• Urology

PRACTICE  RECOGNITION

PATIENT EXPERIENCE COMMENTS

Center for Healthy Aging, Danvers

• Dr. Kevin Ennis provides a very good experience – every time.

Danvers Family Doctors

• Dr. Subroto Bhattacharya is one of the most knowledgeable doctors I have had.
  He is so thorough and also kind and caring!

Family Medicine Associates, Hamilton – A member of Lahey Health – 15 Railroad Avenue

• Dr. Laurence Gordon is a great doctor. The staff and people working there are excellent.
• FMA and Dr. William Medwid have provided excellent care during all my appointments these past years.

Garden City Pediatrics

• Dr. John Dean is an amazing person who shows compassion for every patient he sees.
  We are lucky to have him as our doctor!
• Dr. Sheryl Silva is always attentive and helpful and concerned about my health.

Lahey Health Primary Care,Beverly – 30 Tozer Road

• Been seeing Dr. Tina Waugh for many years. She and her staff are terrific!

Lahey Health Primary Care, Beverly – 100 Cummings Center

• Excellent medical office from doctor to everyone in the office.
• They have always treated me with respect not like a number.

Lahey Health Primary Care – Danvers – 480 Maple Street

• Everyone in this office is always friendly, helpful and concerned
• The nurses were fantastic! “Wonderful Staff!”