News from NEPHO – OCTOBER 2020 Edition


Xuan “Tony” Wang, MD 
Lahey Cardiology, Beverly
75 Herrick Street -Suite 206
Beverly, MA 01915
978 927-8400   (F) 978-922-1452


  • Philip Thomason, MD of Beverly Radiological Associates has retired effective 10/8/2020
  • Michael Tibbles, MD has terminated his affiliation with Northeast Emergency Associates effective 10/1/2020


ICD-10 CM Updates
Date: Wednesday, November 11 @10:00 – 11:00 am
Location: GoogleMeet Conference Call
RSVP: judith.o’ or 978-236-1739

Date: Thursday, November 12, 2020 @5:30 pm
Location: GoogleMeet Conference Call

RSVP: or 978-236-1784

Please check the meeting calendar on our website to get the latest meeting status, notification of the Coding and Billing webinars,  Specialty Specific meetings, and POD/IPA meetings.


COVID19 Discussion

  • Dr. Peppe invited the meeting attendees to discuss topics of their interest related to COVID 19.


  • Dr. Peppe reviewed BILHPN updates, sharing PCP count by risk unit within the network and funds flow changes.
  • Beginning with Performance Year 2021, quality and TME surplus/deficit funds flow will be allocated separately, with Quality paid primarily to PCPs and with flexibility for hospital/specialists share of earned funds.
  • Earned quality funds will be distributed by payer at the risk unit level.
  • TME surplus/deficit will be settled at aggregate commercial payor level than individual payor level. TME surplus distribution is based on risk adjusted year over year unit trend and budget performance.
  • High performers (measured at BILHPN unit level; NEPHO is a risk unit within BILHPN) are eligible for 100% of earned funds and share in the lowest% of deficit, while low performers are eligible for one-third of earned funds and share in 100% of deficit performance.
  • Dr. Peppe invited discussion from attendees in light of these changes.
  • Dr. Peppe also reviewed proposed PCP meeting attendance requirements for 2021.

Reporting and Quality

  • Liz Isaac shared the revisions to the PCP Report Card for 2020 as approved by the Physician Risk Share Committee. A copy of the Q1 2020 PCP Report was included in the meeting packet and was used as reference. 
  • Liz shared the Home and Ambulatory Blood Pressure Monitoring Reference document which has been updated to include the BCBS BP measure accommodation for patient reported BP readings.
  • Best practice documentation tips for recording patient reported readings was included in the reference sheet, along with a tip sheet on how to include a comment in the BP field in EPIC for patient reported readings.   The reference sheet, sans EPIC Tip sheet is on the NEPHO website.


  • Dr. Peppe shared details on his deep dive findings for Q1 2020 Commercial expenses.  Related to efficiency, Dr. Peppe presented a case and invited attendee discussion of opportunities.
  • Dr. Peppe shared utilization data and clinical guidance on Low Value Care relating to Vitamin D and TSH lab ordering. Next step is to provide provider level data to identify opportunities.

 Population Health

  • Carol Freedman and Lucia Kmiec shared the updated DCCP Pilot metrics; the pilot continues 1 day prior pre-visit planning (PVP) for diabetes patients with upcoming visits.
  • The PVP flags tests that are due so that providers have this information readily available to act on during the visit.
  • The pilot has been received well by providers at FMA Hamilton which is the pilot site; there are hopes to scale to other practice(s) in the near future.
  • Dr. Peppe shared information about the HPHC Serious Illness grant. The grant provides training for 72+ providers through December 2021.
  • Two 90 minute virtual training sessions are offered and are recommended for PCPs, NPs, PAs, and Pulmonary, Cardiology, and Oncology specialties.
  • Included within the meeting packet was details on Serious Illness Conversation flow.


CMS – Medicare

Checking Medicare Eligibility Fact Sheet

A new  Checking Medicare Eligibility Medicare Learning Network Fact Sheet is available to make sure providers bill appropriately for Medicare-covered supplies and services.

Find out how to check eligibility through online tools and services: 1) MAC online provider portal or interactive voice response system; 2) Health Insurance Portability and Accountability Act Eligibility Transaction System; 3) Billing agencies, clearinghouses, or software vendors.

Health Connector

The Health Connector’s Open Enrollment for 2021 coverage begins on Sunday, November 1st.

Open Enrollment is the time of year when individuals and families can enroll in the Health Connector’s non-group health insurance coverage or switch existing coverage for any reason, without needing a qualifying event. This year’s Open Enrollment is scheduled from November 1, 2020 through January 23, 2021.

In order to best help new and existing members with questions about their coverage options, please see the links to resources on the Health Connector website.

  • On November 1st., updated Health Connector materials will be available from the Open Enrollment 2021 renewal page: Bookmark this page for use during Open Enrollment!
  • Directly access many consumer resources and tools from the Health Connector’s Resource Download Center at: This page includes:
    •  2021 ConnnectorCare Plan Shopping Guide:Follow the steps in this guide to help you choose a ConnectorCare health insurance plan through the Massachusetts Health Connector.
    • 2021 Health Connector Plan Shopping Guide:Follow the steps in this guide to help you choose a health insurance plan through the Massachusetts Health Connector.
    • 2021 Consumer Guide to Subsidies:Can you get help paying for health insurance through the Health Connector? Download the guide to find out more.
    • 2021 ConnectorCare Overview:What are ConnectorCare plans? What do they cover? How much to they cost? Who can qualify? Download our Overview to find out about the Health Connector’s the great benefits ConnectorCare offers with low monthly premiums, low co-pays, and NO deductibles.
    • Plan Comparison tool: The Health Connector’s Provider and Prescription medication search is part of the online shopping process available directly through the consumer’s application. It lets you see which plans cover preferred providers, facilities and prescription medications. Detailed prescription medication information is also available, such as if a prior authorization is required and what the retail copay tier will be. This tool lets you do side-by-side plans comparisons while displaying the information you searched for. You can also use this tool outside of someone’s application by clicking on the direct link. When using the tool outside of the online application, you enter limited information about a person’s eligibility such as income and family size to get an estimate of the plans the consumer may be eligible for in their zip code.

Fallon Health

New and Announcements: Paper Claims P.O. Box Issues

When shipping paper claims that are not deliverable to a P.O. Box, (via FedEx etc.), send to the following address: Fallon Health Claims- Smart Data Solutions, 960 Blue Gentian Road, Eagan, MN 55121. For additional information and to view the notification, click here and scroll to related title.

Revised Laboratory and Pathology Payment Policy

The Laboratory and Pathology Payment Policy has been revised. Clarified that serologic testing for COVID-19 (e.g., CPT 86769) should be reported with a unit of one (1); Added requirement for ordering/referring provider’s name, qualifier, and valid NPI. For more information and to view the entire policy, click here.

Revised Radiology/Diagnostic Imaging Procedures Payment Policy

The Radiology/Diagnostic Imaging Procedures Payment Policy has been revised. Added requirement for ordering/referring provider’s name, qualifier, and valid NPI. To view the entire policy, click here.

Harvard Pilgrim Health Care

Introducing New Products for 2021

Harvard Pilgrim is introducing the following four new products in Maine, New Hampshire, and Connecticut, which will be offered to employer groups beginning on Jan. 1, 2021.

  • Maine’s Choice Plus HMO will be sold in Maine and will feature a two-tiered full network.
  • Littleton Options HMO will be sold in New Hampshire and will feature a two-tiered full network.
  • Focus CT HMO will be sold in Connecticut and feature a network of select authorized access providers in Connecticut, with the remainder of Harvard Pilgrim providers across New England considered in-network.
  • Network Choice CT PPO will be sold in Connecticut and will feature a two-tiered full network.

Please refer to our online Provider Directory for information on participating providers and tiering for these new products and benefits. You can recognize members with these products and benefits by their ID cards; for further information, refer to the Member Identification Cards policy in Harvard Pilgrim’s online Provider Manual.

Tufts Health Plan

Medicare’s Annual Election Period (AEP) is here

This provides your Medicare patients an “open enrollment” period to assess their needs and choose the medical and prescription plan that’s best for them. Eligible patients can enroll between October 15 and December 7, 2020 for a plan start date of January 1, 2021.

As a result of the 2020 5-Star rating* given to the Tufts Medicare Preferred HMO plans by Medicare, your eligible patients can enroll in these plans all year long and not just during the AEP window. This means they may select a start date of November 1 or December 1 if they so choose. We are also happy to announce Tufts Health Plan has achieved a 5-Star CMS Quality rating for 2020 — now for six years in a row! Tufts Health Plan is one of only two plans in the country to achieve 5 Stars for six consecutive years.

We ask that you make it easy for your patients to get information they need by:

  • Displaying plan materials, including AEP materials and the virtual sales meeting flyer.
  • Informing staff about the Annual Election Period
  • Educating staff about the Medicare plans you accept

As a reminder, we also offer Tufts Medicare Preferred Supplement plans and, for participating providers, Tufts Health Plan Senior Care Options (SCO). Tufts Health Plan SCO (which also has a 5-Star rating) may be a great option for patients who are 65+ and on MassHealth Standard and continues to offer monthly enrollment.  If you have questions or need additional marketing materials for your practices, please contact Marcel Philippe, Manager of Business Development Senior Products Division, Tufts Health Plan Cell: 617-417-2587, Office: 617-972-9400 Ext: 48010.

 *Medicare evaluates plans based on a 5-Star rating system.  Star ratings are calculated each year and may change from one year to the next.  Visit for more information.


Please take a moment to look at our Provider Spotlight on the website by clicking here.
If you would like to be featured on the PHO website, please reach out to Alycia Messelaar to discuss next steps, 978-236-1784 or

Interested in being Featured?

The Northeast PHO Provider Relations Department is excited to have you as part of our network of physicians!
In an effort to spread the word about the services you currently or will be providing, we would like to obtain information to be used to host virtual introductions, virtual drop-in sessions, a video to be posted on the NEPHO website, along with a provider spotlight bio to share with the NEPHO Primary Care Providers.  Click here to be directed to our Virtual Networking page.

Please send requested marketing materials to Alycia Messselaar,, in order to begin the marketing process.

Thank you,
The NEPHO Provider Relations Department

Please provide the following to create a 1-3 minute video about yourself.  This can be done right from your smartphone!  Please see Tips for Shooting better video on your smartphone.

Short bio (In paragraph format that includes the following information – please do not send a copy of your CV)

  • Name
  • Practice
  • Specialty
  • Ages treated
  • Education/Training
  • Past professional experience
  • Special interests
  • Whether you offer telehealth services
  • Personal hobbies
  • Professional photograph
  • Best hours and days to set up brief virtual meetings with PCP practices that are interested in speaking with you directly
  • Best ways to reach out directly regarding patient specific care questions

Please reach out to Alycia Messelaar at 978-236-1784 or to keep NEPHO informed of changes in practice schedules due to COVID-19 (office closures, limited office hours, scope of appointment, telehealth use, phone line to reach staff, etc.) or if you have questions about other practice schedules.

Click here  to access a list of practices who are scheduling in office visits and/or TeleHealth visits at this time.

Please take a moment to review your practice information and reach out to Alycia Messelaar, with update requests.

The Northeast PHO is here to ensure you are not alone and that we are in this together. We are doing our best to keep your practice as updated as possible with all things COVID-19.  Please take a moment to visit the COVID-19 tab on the by clicking here.

Click here to find the most recent links to COVID-19 specific health plan materials and updates. Please note, we have included health plans that NEPHO does not contract with in an effort to help keep you well informed of current COVID-19 updates we have been made aware of.  If you have questions or concerns, please reach out to Alycia Messelaar,


Melissa Diggin, NP

NP Melissa Diggin at North Shore Neurology & EMG is the recipient of the 2020 American Parkinson’s Disease Association Shawn Thornton Award for Excellence!

Click here for the press release.

This award acknowledges individuals who go above and beyond in caring and advocating for patients and families with Parkinson’s disease. Melissa has worked hard and shown great dedication over the years in her work with the American Parkinson’s Disease Association. She has greatly impacted the Parkinson’s community. We are proud to have her on our team at North Shore Neurology & EMG! Attached is the press release the APDA will be disseminating. We will be sharing this with our patients and on our website as well.


Please visit the NEPHO website by clicking here to view the updated Northeast PHO Contract Participation and Referral Requirement Grid for distribution within your office. We are here to answer any questions or clarifications needed upon review of this document.

For questions specific to contract participation or provider enrollment please contact Alycia Messelaar at  978-236-1784 or .

For questions specific to referrals please contact Ann Cabral at 978-236-1758 or .


November is American Diabetes Awareness Month

According to the 2020 National Diabetes Statistics Report, a periodic publication of the Centers for Disease Control and Prevention (CDC), an estimated 34.2 million people (10.5% of the US Population) live with diabetes.   Of that 34.2 million, 26.9 million are diagnosed patients (including 26.8 million adults) and 7.3 million people (21.4%) are undiagnosed. The Prediabetes breakdown is as follows:

  • Total: 88 million people aged 18 years or older have prediabetes (34.5% of the adult US population)
  • 65 years or older: 24.2 million people aged 65 years or older have prediabetes

According to national statistics, likely one-third of your patients older than age 18 have prediabetes and are at risk for developing type 2 diabetes. More than eight in 10 of those individuals do not know their risk.  We have several local resources you can refer your patients to, whether to prevent Diabetes or to better manage the condition.

The Lifestyle Management Institute offers services encompassing prevention, detection, treatment and disease management for the care of individuals with, or at risk for, chronic health problems such as diabetes.

The ADA Certified Diabetes Care Center at Lahey Outpatient Center in Danvers and Addison Gilbert Hospital in Gloucester offers comprehensive programs for the management of Diabetes. The Certified Diabetes Care and Education Specialists (CDCES) follow National Standards for Diabetes Self-Management Education.

Some of the DCC services include, but are not limited to:

  • The Diabetes Care Clinic is staffed with Registered Nurses and Registered Dietitians who are Certified Diabetes Care and Education Specialists The specialists will identify key educational components to self-manage your diabetes.
  • Diabetes Group Classes include a 9 week program led by a Certified Diabetes Care and Education Specialist that covers the most recent technologies and therapeutics available including Continuous glucose monitoring (CGM’s), latest advances in insulin delivery and pump therapy.
  • Gestational Diabetes patients are managed from diagnosis to delivery and thereafter as needed. This multidisciplinary approach includes glucose monitoring, nutrition and diabetes counseling.

Lifestyle Management Institute /Diabetes Care Center

Lahey Outpatient Center, Danvers 
480 Maple Street
Danvers, MA 01923
TTY: 978-304-8016

Diabetes Care Center

Addison Gilbert Hospital
298 Washington Street
Gloucester, MA 01930
TTY: 978-491-6733

Diabetes Care Center

As the NEPHO Health Coach I am more than happy to help your patients navigate our system by facilitating appointments or helping with accountability when needed, as a complement to your care and the services the DCC offers.

Lucia Kmiec
NEPHO Health Coach


Blue Cross Blue Shield (BCBS) Update

  • As you may have heard, the BCBS Blood Pressure measures have been updated to allow for patient reported BP measurement with a digital device.
  • Please see the additional guidance we have received recently from BCBS for implementation of patient reported BP readings:
    • Support in telehealth BP collection: Telehealth encounters with MAs, nurses, or other support staff are acceptable to meet the necessary requirements for measure adherence.
      • These visits do not have to be billed, but the method of collection must be clearly documented in the EHR for acceptance.
    • In-home nurse visits: These are also acceptable to meet the requirements for measure adherence.
    • The following information must be included in documentation:
      • Who Captured the BP?
      • How was the BP taken?
      • When was the BP taken?
      • What device was used to take the BP

Please reach out with questions to Liz Isaac at


OPTUM Newsletter – October Focus – Breast Cancer 

Diagnosis Capture and Documentation Complete the Patient Visit

Patient Risk Adjustment Factor (RAF) is reset annually on January 1, 2021. Accurate diagnosis coding and documentation contribute to a complete picture of patient health status. Complete documentation supports the patient medical status and diagnosis captured. The following support best practice to follow for complete visit documentation:

Elements of good clinical documentation

When documenting, it is useful to keep in mind the potential audience – clinical staff, other providers, payers and administration. This will help achieve clarity and allow you to focus on the details that are most relevant to include.

  • The basics of documentation:
    • Date, time and signature.
      • Timing of events and review is crucial in putting together the information regarding a patient’s health.
    • Include your name and title, add the names and titles of others present at the encounter.
    • Document immediately or as soon as possible after care is provided.
    • Prompt documentation reduces the risk of forgetting key details, and ensures all other team members are aware of any changes to a patient’s condition or management of care.
    • If you are returning to the patient’s notes later, document clearly in the heading that it was documented in retrospect with current date and time.
    • Document legibly.
    • Be thorough, accurate and objective.
    • Only use approved abbreviations
      • It is better to use to no abbreviations at all to avoid confusion.
      • If an addendum is made, communicate the change in documentation to other team members and clinical staff. Sign off any addenda with the time, date and full details.
    • Documentation mistakes
      • If a mistake is made, correct it with a single strikethrough, clearly sign and date the correction.
  • Documentation Examples:
    • Documenting a face-to-face visit based off time:
      In the office, a physician selects the level of service based on face-to-face time, when more than 50 percent of that time is spent discussing with the patient and family the diagnosis, prognosis, risk and benefits, instructions for management, and education. You can count only face-to-face time.
      An example of documenting based off time: “I spent 30 minutes with the patient and 50% of time was spent counseling and reviewing plan of care.”
    • Documenting a Telehealth visit:
      The technology used to conduct the visit via video/audio, the location of the provider conducting the visit, the patient name and location, include others on the video visit such as parent, spouse or care manager, verbal patient consent to have the visit conducted via telehealth video/audio (HIPAA compliant platform). The rest of the documentation will follow a face-to-face encounter requirements.
    • Documenting a telephone visit:
      It is important to document phone conversations with other medical teams and relatives of patients or clinical staff involved in the care of your patient.  After the phone conversation, write a note clearly stating who was involved in the conversation including their role. Document the clear question that was posed, and summarize the main information and points that were gained from the conversation. It’s important to note the pager number/telephone number of the person who was contacted to facilitate further contact if they need to be contacted again.
    • Important Areas of Documentation:
      • Principal diagnosis – the condition which after investigation was found to be the cause for the admission.
      • Co-morbidities – any conditions present on admission and treated. These conditions resulted in a change to the patient’s treatment, care or length of stay.
      • Complications – conditions which arose during the admission and affected the patient’s treatment and length of stay.
      • Procedures – surgical, non-operative, diagnostic, therapeutic procedures which required anaesthesia, sedation or injected contrast.

Please contact Shawn Bromley at 978-236-1704 or if you would like more information related to diagnosis capture and/or documentation requirements.


Cape Ann Pediatrics – 298 Washington Street, Gloucester
Dr. Jeffrey Stockman has always been very professional.  Couldn’t ask for a better

Garden City Pediatrics – 83 Herrick Street, Beverly
Dr. John Dean is a dream! We all love him!
Dr. Eric Sleeper is always great – we love all the nurses and Dr. Sleeper!

Lahey Primary Care, Beverly – 900 Cummings Center
Dr. Andrew Lenhardt is probably one of the very best doctors I have ever meet. I’m so
fortunate to be his patient.
Dr. Daniel McCullough continues to provide excellent advice and recommendations to
improve my health care needs.

Lahey Primary Care, Beverly – 30 Tozer Road
Dr. Susan Deluca has been my primary care doctor for over twenty years. She
demonstrates professionalism and genuine interest in my care and well-being.
Dr. Gail Ellis is a dedicated thorough professional with a great sense of humor.
Translation she’s awesome!
Dr. Neeraj Mahajan was excellent. I want him as my doctor.

Lahey Primary Care, Danvers 5 Federal Street
Dr. Mauri Cohen is the best primary care doctor I’ve ever had! Friendly, thorough,
compassionate, follows through, he includes me in his thinking as he thinks continually.
He treats me like a partner!  Love him!
Dr. Steven Keenholtz is exceptional. The practice is very professional; caregivers,
fantastic staff who all work as a perfect team together to bolster patient’s confidence in

Lahey Health Primary Care, Gloucester – 298 Washington Street 4th Floor
I have referred people to Dr. Victor Carabba in the past and will again he really cares.

Lahey Health Primary Care, Gloucester – 298 Washington Street 1st Floor
I was very impressed with Dr. Amy Esdale. Her concern and professionalism were top

Lahey Primary Care, Hamilton – 15 Railroad Avenue
Dr. Laurence Gordon is by far the best primary care physician I’ve had. He is always so
thorough and very concerned about all my concerns with my health and well-being. He’s
the best!!
I have received excellent care resulting in improved health and quality of life from
Dr. William Medwid for over 15 years.

Lahey Primary Care, Manchester – 192 School Street
Dr. Nicholas Avgerinos is a pleasure to deal with such a refreshing change happening at
this practice!!
Dr. Jana Oettinger was wonderful to work with and I’m so glad she’s my primary care
ALWAYS exceptional care from Dr. Matthew Plosker.

Leonard Horowitz, MD 7 Federal Street, Danvers
Dr. Leonard Horowitz is an excellent doctor! He has always been there when I needed him.

North Shore Pediatrics – 480 Maple Street, Danvers
We are so lucky to have Dr. Lance Goodman as our kid’s pediatrician. He is so positive, so
amazing. We all love him!!
We are so thankful for Dr. David Danis as new parents he has been so helpful and


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:

Kelly Stapleton, Garden City Pediatrics was recognized by a patients’ comment which read:  We love Dr. Sklaver, Nurse Kelly and the whole GCPA office.

Amy Hutton, Cummings Center Medical Associates, BILH Primary Care, Beverly for being a strong team player who works with our staff to keep referrals within our NEPHO specialty network.

Susan Henry, North Shore GI, for collaborating with and supporting the Quality Team for BCBS AQC submission.  Sue insists on sharing this award with the staff as she states that everyone contributed to the work this year.  She wishes to share this award with: Caitlynne White, Lori Stephens, Sue Henry, Angie Calitri, Julie Garrisi, Harley Cornell,  Karen Kasper, Lynette Foss, Kim Benson, Margarita Manon, Moriah Pinto and Alexandria Rose.

The team  will be putting together an article for Quality to share in this newsletter about this team approach so stay tuned for that! 

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!