provider - Care1st Health Plan

SPRING ‘10
www.care1st.com
PROVIDER
Newsletter
Adapting to the New
HIPAA Requirements
Are you ready for the coming changes to the HIPAA
regulations for Electronic Data Transfer? On January 16,
2009, the U.S. Department of Health and Human Services
(HHS) published two final rules supporting the continued
transformation of the U.S. healthcare system toward a
comprehensive electronic data exchange environment.
All of the recently proposed health reform bills in the U.S.
House and the Senate included provisions to mandate increased use of electronic standards-based administrative
& financial transactions. At this time, only about 30% of
Hospitals and Providers surveyed have reported beginning assessments for this change and fewer than half of
those surveyed have begun preparations to convert their
current transactions and systems to comply with the requirement. The rule changes apply to all covered entities
under HIPAA.
What is changing?
One rule addresses adoption of the Accredited Standards
Committee (ASC) X12 005010 for healthcare transactions
and the National Council for Prescription Drug Programs
(NCPDP) Version D.0 for pharmacy transactions (ASC X12
5010/D.0.). Some of the important dates in the required
implementation of these standards are:
Effective Date of the regulation: March 17, 2009
Level I Compliance by: December 31, 2010
Level II Compliance by: December 31, 2011
All covered entities have to be fully compliant on: January 1, 2012
Level I compliance means “that a covered entity can demonstrably create and receive compliant transactions,
resulting from the compliance of all design/build activities
and internal testing.”
Level II compliance means “that a covered entity has
completed end-to-end testing with each of its trading
partners, and is able to operate in production mode with
in this
issue
Adapting to New HIPAA Requirements... cover
by Michael Rowan, Chief Information Officer
The False Claims Act (FCA)......................... p.3
by Janet Eisenberg, Compliance Audit Manager
Utilization Department................................. p.4
by Alice Diaz, IPA Compliance Nurse
Care1st Health Plan Formulary Changes 1st Quarter 2010........................................... p.6
by Nora Tomassian , Clinical Pharmacy
Program Manager
First-Time Generics Currently Available
on the Market............................................... p.6
by Nora Tomassian , Clinical Pharmacy
Program Manager
Preventive Health Guidelines....................... p.9
by Rosa Hernandez, Health Education Manager
Quality Outreach Efforts Making Strides in
Taking “HEDIS to the Next Level”.............. p.10
by Rebecca Romo, QI Project Manager
Meteorite & Spearphishing........................ p.10
by Alan Bloom , Vice President - Legal &
Regulatory Services
Cultural & Linguistics Corner..................... p.11
by Therese Horth, Cultural &
Linguistics Specialist
ADAPTING TO THE NEW HIPAA REQUIREMENTS (cont’d)
the new versions of the standards.”
The second rule addresses the adoption of
the International Classification of Diseases,
Tenth Revision, Clinical Modification (ICD10-CM) for diagnosis coding and the International Classification of Diseases, Tenth
Revision, Procedure Coding System (ICD10-PCS) for inpatient hospital procedure
coding. This replaces the current ICD-9
versions which were developed nearly 30
years ago. The ICD-10-CM and ICD-10PCS (ICD-10) compliance date is October
1, 2013. The improved and expanded code
set as well as the 5010 changes are intended to promote greater accuracy and
efficiency in electronic data exchange and incorporate changes requested by
CMS and industry groups.
5010 Transactions and ICD-10 Code Set
The new 5010 standard addresses many issues and limitations with the current
standard including the ability to transmit detailed information such as coordination of benefits, eligibility, present on admission (POA) data and expanded
support for NPI. One of the more important changes provides support for ICD-10
codes. The 5010 data exchange version has more than 850 complex changes
compared with existing HIPAA 4010 transaction sets. The implementation guide
for the health care claim transaction alone is over 700 pages long. The ICD-10
Code Standard includes a five-fold increase (from approximately 16,000 to over
70,000) in available codes. For example, a sprained or strained ankle is represented by 4 ICD-9 codes and over 70 for ICD-10.
How are we affected?
The impact of these changes to our business practices and the industry as a
whole are significant. Changes to systems, software and coding practices as
well as the significant training, testing and development with business partners
such as clearinghouses, billing services, software vendors and others mean that
the time to begin evaluating the impact to you and your business is now. While
the target implementation dates seem far away, the complexity of implementing
these changes has most experts predicting that we will need all of the time allotted to implement and take advantage of the opportunities the 5010 Standard
and ICD-10 changes present.
Next Steps
Finding out about your business partners and systems & software providers
plans and progress in preparing for the rule changes as well as understanding
the impact of the changes to your business are important first steps in preparing to meet the timelines set out in the rules. There are a number of sources
available to find out more about the upcoming rules including CMS’s web site at
http://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp
THE FALSE CLAIMS ACT (FCA)
tor who submits records that he knows (or should know) are
false and that indicate compliance with certain contractual
or regulatory requirements. The third area of liability includes
those instances in which someone may obtain money from
the federal government to which he may not be entitled, and
then uses false statements or records in order to retain the
money. An example of this so-called “reverse false claim”
may include a hospital that obtains interim payments from
Medicare throughout the year, and then knowingly files a false
cost report at the end of the year in order to avoid making a
refund to the Medicare program. In addition to its substantive
provisions, the FCA provides that private parties may bring
an action on behalf of the United States. 31 U.S.C. 3730(b).
These private parties know as “qui tam relators,” may share
in a percentage of the proceeds from an FCA action or settlement. Section 3730(d)(1) of the FCA provides, with some exceptions, that a qui tam relator, when the Government has
intervened in the lawsuit, shall receive at least 15 percent but
not more than 25 percent of the proceeds of the FCA action
depending upon the extent to which the relator substantially
contributed to the prosecution of the action. When the government does not intervene, section 3730(d) (2) provides that
relator shall receive and amount the court decides is reasonable and shall not be less than 25 percent and not more than
30 percent.
Care1st continues to comply with the Centers for Medicare and
Medicaid Services (CMS) memorandum (dated 8/21/2009)
regarding training or materials to be provided to our first-tier
and downstream contracted entities related to Fraud, Waste
and Abuse. In this issue of the Provider Newsletter, the False
Claims Act (“FCA”) is being addressed.
The False Claims Act provides, in pertinent part, that:
(a) Any person who (1) knowingly presents, or causes to
be presented, to an officer or employee of the United
States Government or a member of the Armed Forces
of the United States a false or fraudulent claim for payment or approval; (2) knowingly makes, uses, or causes
to be made or used, a false record or statement to get
a false or fraudulent claim paid or approved by the Government; (3) conspires to defraud the Government by
getting a false or fraudulent claim paid or approved
by the government;… (7) knowingly makes, uses, or
causes to be made or used, a false record or statement
to conceal, avoid, or decrease an obligation to pay or
transmit money or property to the Government, is liable
to the United States Government for a civil penalty of
not less than $5,000 and not more than $10,000 plus 3
times the amount of damages which the Government
sustains because of the act of that person…
The FCA provides protection to qui tam relators who are
discharged, demoted, suspended, threatened, harassed, or
in any other manner discriminated against in the terms and
conditions of their employment as a result of their furtherance
of an action under the FCA (31 U.S.C.3730(h). Remedies include reinstatement with comparable seniority as the qui tam
relator would have had but for the discrimination, two times
the amount of any back pay, interest on any back pay, and
compensation for any special damages sustained as a result
of the discrimination, including litigation costs and reasonable
attorneys’ fees.
(b) For the purposes of this section, the terms “knowing”
and “knowingly” mean that a person, with respect to
information (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard
of the truth or falsity of the information, and no proof of
specific intent to defraud is required.
31 United States Code (U.S.C) § 3729: While the FCA imposes liability only when the claimant acts “knowingly,” it does
not require that the person submitting the claim have actual
knowledge that the claim is false. A person, who acts as in
reckless disregard or in deliberate ignorance of the truth or
falsity of the information, also can be found liable under the
Act. 31 U.S.C. 3729(b). In summary, the FCA imposes liability
on any person who submits a claim to the federal government
that he or she knows (or should know) is false. An example
may be a physician who submits a bill to Medicare for medical services she knows she has not provided. The FCA also
imposes liability on an individual who may knowingly submit
a false record in order to obtain payment from the government. An example of this may include a government contrac-
In the next edition of
the Provider Newsletter, the Fraud Enforcement Recovery Act
(FERA) will be discussed. FERA includes
significant modifications to the federal
civil False Claims Act
at 42 §U.S.C. 37293722.
UTILIZATION MANAGEMENT DEPARTMENT
Care1st Health Plan’s Utilization Management (UM) Department is committed to delivering quality care that will result in improved and better health for our members. Continuity of care is accomplished through appropriate coordination with contracted
groups and/or primary care physicians in the provision of ambulatory care and inpatient health services.
Clinical Criteria for UM Decisions
Availability of Physician Reviewer
Care1st Health Plan’s UM Department uses nationally-recognized criteria or guidelines to make decisions based on medical
necessity. Potential sources include, but are not limited to:
• Milliman Care Guidelines
• Apollo Medical Review Criteria
• Care1st Health Plan approved Clinical Practice Guidelines
• Nelson’s Textbook on Pediatrics
Only a licensed physician can make a denial decision. The
physician reviewer is available to discuss denial decisions
with the requesting practitioner. The contact number is indicated on each denial notification letter.
Access to UM Department
• UM Department staff is available at least 8 hours a day
during normal business hours for inbound calls regarding a UM issue. A UM staff member can also send outbound communication after normal business hours to
discuss the authorization of care.
• Business hours at Care1st Health Plan are 8:00 A.M.–
6:00 P.M. Monday to Friday, excluding holidays.
• If you would like to contact the UM Department, call
1-800-468-9935.
• A licensed professional is available 24 hours a day to
answer any healthcare questions.
Availability of Criteria
Criteria used for UM decision-making are available to practitioners, members, and the public upon request with the following disclosure: “The material provided to you are guidelines used by this plan to authorize, modify, or deny care for
the person with similar illnesses or conditions. Specific care
and treatment may vary depending on individual need and the
benefits covered under your contract.” To obtain a copy of the
criteria, please contact the UM Department at 1-800- 4689935.
Behavioral Health: Behavioral health is a covered
benefit.
Appropriate Professionals
For Medi-Cal members:
Mental health services are provided through the County
Department of Mental Health:
• LA County:
1-800-854-7771
• San Diego County: 1-800-479-3339
Licensed physicians oversee all UM decision-making processes. Appropriate licensed health professionals conduct the
supervision of all review decisions and processes; all denials
or modifications are reviewed only by a qualified physician(s).
Non-licensed staff members may collect data for pre-authorization and concurrent review under the supervision of licensed
personnel.
For Medicare members:
• Los Angeles and San Diego Counties: members may
call CompCare at 1-877-224-7506
Financial Incentives
For Commercial members:
• LA County: Call Care1st at 1-800-468-9935
UM decisions are based only on appropriateness of care and
service and existence of coverage. Care1st Health Plan does
not specifically reward practitioners or other individuals for
issuing denials of coverage or care. Financial incentives for
UM decision makers do not encourage decisions that result
in underutilization.
For Healthy Families members:
• The requesting physician must submit an authorization
request form to CompCare for behavioral health services. Please call the UM Department at1-800-468-9935
to get a copy of the request form.
Nurse Advice Line
• Extension (if justified) – additional 14 calendar days
• Termination of Services – no later than 2 calendar
days or 2 visits before the coverage ends.
Care1st Health Plan members can access the Nurse Advice
Line to receive fast and free medical advice over the phone.
Registered nurses are available 24 hours a day, 7 days a
week, including weekends and holidays. Members can call
1-800-544-0888 or 1-800-605-2556 for medical advice.
C. Commercial
• Urgent – decision not to exceed 72 hours after receipt
of request; member and provider notification within
72 hours of receipt of request
• Urgent Concurrent – decision within 24 hours of receipt of request; member and provider notification
within 24 hours of receipt of request
• Non-urgent – decision within 5 business days; initial
notification to practitioner within 24 hours of the decision, written notification to member and practitioner
within 2 business days of making the decision
• Extension needed – decision must be made within
45 calendar days (for non-urgent cases) or within
the 48-hour timeframe allotted to submit additional
information (for urgent cases); member and provider
notification within 48 hours of receipt of information.
• Standing – decision within 3 business days of receipt
of request; notification timeframe depends on the service category
Advance Directive
If you have Medicare members under your care, ensure that
your staffs are provided educational training on advance directives annually.
UM Timeliness Standards
Timeliness standards for decision-making and notification
of decisions for all lines of business:
A. Medi-Cal / Healthy Families
• Emergency post-stabilization services – within 30
minutes of verbal request
• Urgent (expedited) requests –within 72 hours; member and provider notification within 72 hours from initial receipt of the request, including weekends and
holidays.
• Pre-Service routine (non-urgent) requests –within 5
working days; initial notification to practitioner within
24 hours, written notification to member and practitioner within 2 business days.
• Retrospective Review – within 30 days
• Hospice inpatient care – 24-hour response
• Expedited Review – within 72 hours
Note: Decisions for delay or deferred pre-service non-urgent
request will not exceed 14 calendar days from the date of
receipt of initial request. This timeframe includes initial notification to practitioner (within 24 hours of decision) and written
notification (within 2 working days of the decision) to members and practitioners.
B. Medicare
• Standard – decision within 14 calendar days; member and provider notification of decision within 14 calendar days after receipt of request
• Expedited – decision within 72 hours; member and
provider notification within 72 hours after receipt of
request
F O R M U L A R Y
U P D A T E
Care1st Health Plan Formulary Changes - 1st Quarter 2010
Drug Name
Label Name
Drug Strength
Formulation
Antiarthritics
Golumimab
Simponi
50 mg/0.5 ml
Injectable
Anticonvulsants
Levetiracetam
Keppra
250 mg, 500 mg, 750 mg,
1000 mg, 100 mg/ml
Tabs, Solution
Topiramate
15 mg, 25 mg, 50 mg,
100 mg, 200 mg
Tabs, Caps
Antineoplastics
Ofatumumab
Arzerra
100 mg/5 ml
Vial
Pazopanib
Votrient
200 mg, 400 mg
Tabs
Antiparkinson Drugs
Ropinirole
Requip
0.25 mg, 0.5 mg, 1 mg,
2 mg, 3 mg, 4 mg, 5 mg
Tabs
Antipsychotics
Iloperidone
Fanapt
1 mg, 2 mg, 4 mg, 6 mg
8 mg, 10 mg, 12 mg
Tabs
Potassium Channel Blocker
Dalfampridine
Ampyra
10 mg
Tabs
Topamax
FIRST-TIME GENERICS CURRENTLY AVAILABLE ON THE MARKET
Several drugs became available in generic in 2009. This
article lists selected drugs based on their utilization in Care1st
population.
Indication: Epilepsy (partial seizures, generalized tonicclonic seizures, mixed seizures) and trigeminal neuralgia.
• Divalproex Sodium extended release tablets (250mg
and 500mg) – AB rated generic for Depakote ER, delayed
release pellets (125mg) AB rated generic for Depakote,
sprinkle capsules
Indication - Divalproex sodium ER tabs: Mania, Epilepsy
(complex partial seizures, simple and complex absence
seizures, adjunct for multiple seizure types that include
absence seizures) and migraine prophylaxis.
Indication - Divalproex delayed release pellets: complex
partial seizures,simple and complex absence seizures,
adjunct for multiple seizure types that include absence
seizures.
1. Antineoplastics
• Bicalutamide tablets (50mg) – AB rated generic to
Casodex
Indication - for use in combination with a luteinizing hormone-releasing hormone (LHRH) analog for the treatment
of Stage D2 metastatic carcinoma of the prostate.
2. Central Nervous System Agents
• Carbamazepine extended release tablets (100, 200,
400mg) – AB rated generic to Tegretol XR
This report provides formulary changes approved by the Care1st Pharmacy and Therapeutics Committee.
For a complete listing and to obtain a prior authorization form please refer to the Care1st website at www.care1st.com. You
may also call the Care1st Pharmacy Department at (877) RX-CARE1 or (877) 792-2731.
Formulary Comments
Medicare
Formulary
Medi-Cal
Formulary
Healthy
Formulary
Commercial
Formulary
Add to Medicare formulary at tier 5
with a PA restriction
Yes
No
No
No
Add to Medi-Cal, Healthy Families and Commercial
formularies. Remove PA restriction from Medicare
formulary
Remove PA restriction from Medicare formulary
Yes
Yes
Yes
Yes
Yes
No
No
No
Add to Medicare formulary at tier 5
with a PA restriction
Yes
No
No
No
Add to Medicare formulary at tier 5
with a PA restriction
Yes
No
No
No
Add to Medi-Cal formulary. Remove PA restriction from
Commercial formulary
No
Yes
No
Yes
Add to Medicare formulary at tier 5
with a PA restriction
Yes
No
No
No
Add to Medicare formulary at tier 5
with a PA restriction
Yes
No
No
No
• Sumatriptan tablets (25, 50 and 100mg) – AB rated generic to Imitrex tablets
Indication - Acute treatment of migraine attacks in adults
3. Endocrine
• Nateglinide tablets (60, 120mg) – AB rated generic to
Starlix
Indication - adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
• Topiramate tablets (25, 50,100 and 200mg tablets) –AB
rated generic to Topamax tablets and topiramate capsules
(15, 25mg) –AB rated generic to Topamax Sprinkles.
Indication - Epilepsy: monotherapy for partial onset or
primary generalized tonic-clonic seizures; adjunctive
therapy for partial onset seizures, or primary generalized
tonic-clonic seizures, and in patients 2 years of age and
older with seizures associated with Lennox-Gastaut syndrome and migraine prophylaxis.
4. Gastrointestinal
• Lansoprazole delayed-release capsules (15, 30mg)
– AB rated generic to Prevacid
Indication - GERD, Short-Term Treatment of Erosive
Esophagitis, Maintenance of Healing of Erosive Esophagitis, Pathological Hypersecretory Conditions Including
Zollinger-Ellison Syndrome, Risk Reduction of NSAIDAssociated Gastric Ulcer, short-term treatment of ac
FIRST-TIME GENERICS CURRENTLY AVAILABLE ON THE MARKET (cont’d)
tive benign gastric ulcer, maintenance of healed duodenal ulcers.
6. Ophthalmic
• Ketorolac tromethamine ophth solution (0.4%, 0.5%)
– AT rated generic for Acular and Acular LS
Indication: temporary relief of ocular itching due to seasonal allergic conjunctivitis. Also indicated for the treatment of postoperative inflammation in patients who
have undergone cataract surgery.
5. Immunologic
• Mycophenolate capsules (250mg), tablets (500mg)
– AB rated generic to Cellcept
Indication - prophylaxis of organ rejection in patients receiving allogeneic renal, cardiac or hepatic transplants.
7. Respiratory
• Budesonide (0.25mg/2ml) inhalation suspension –AN
rated generic for Pulmicort Respules
Indication - Maintenance treatment of asthma in children 12 months to 8 years of age.
• Tacrolimus capsules (1, 2 and 5mg) –AB rated generic
to Prograf
Indication - prophylaxis of organ rejection in patients
receiving allogeneic liver, kidney, or heart transplants.
Generic Name
Brand Name
Bicalutamide
Carbamazepine ER
Divalproex Sodium ER
Sumatriptan
Topiramate
Nateglinide
Lansoprazole
Mycophenolate
Tacrolimus
Ketorolac opth sol
Budesonide (inh. susp.)
Casodex
Tegretol XR
Depakote ER
Imitrex
Topamax
Starlix
Prevacid
CellCept
Prograf
Acular
Pulmicort
PA:
F:
Formulary Status
Medi-Cal
Healthy Families
Commercial
Medicare
PA
NF
PA
F
F
F
F
F
F
F
F
F
F (Quantity Limit)
PA
F (Quantity Limit)
F (Quantity Limit)
F
F
F
F
NF
NF
PA
PA
NF
NF
F (Quantity Limit)
F (Step to omeprazole)
PA
NF
PA
B vs. D
PA
PA
NF
B vs. D
F
NF
F
F
F (Age)
F (Age)
NF
NF
Prior authorization required
On Formulary
NF:
Non Formulary
B vs. D: May be a part B benefit
PREVENTIVE HEALTH GUIDELINES (2010)
Please refer to the following sources for preventive health guidelines for your patients. You can access the websites
listed below by visiting our website at http://www.care1st.com.
Ages: 0-18 years*
Ages: 19-64 years
Recommendations
for Preventive
Pediatric Health
Care. American
Academy of Pediatrics, Committee on
Practice and Ambulatory Medicine and
Bright Futures Steering Committee, 2008
http://practice.aap.org/
content.aspx?aid=159
9&nodeID=4043
Guide to Clinical Preventive Services, 2009. AHRQ Publication No. 09-IP006, September 2009. Agency for Healthcare
Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/uspstfix.htm#Recommendations
Periodicity Schedule for Health Assessment Requirements by Age Groups, CA Department of Health Care Services, Systems of Care Division, Children’s Medical Services
Branch, September 2007
http://files.medi-cal.ca.gov/pubsdoco/chdp_appendix.asp
Recommended Adult Immunization Schedule, Centers for
Disease Control and Prevention. Recommended adult immunization schedule---United States, 2010. MMWR 2010;59(1).
http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm#print
Recommended Immunization Schedules for Persons
Aged 0 Through 6 Years, Centers for Disease Control and
Prevention. Recommended immunization schedules for persons aged 0 through 18 years---United States, 2010. MMWR
2010;58(51&52).
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable
Medicare Patients
Recommended Immunization Schedules for Persons
Aged 7 Through 18 Years, Centers for Disease Control and
Prevention. Recommended immunization schedules for persons aged 0 through 18 years---United States, 2010. MMWR
2010;58(51&52). http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable
Quick Reference
Information: Medicare
Preventive Services,
Centers for Medicare
& Medicaid Services,
Department of Health &
Human Services, USA,
Medicare Learning Network, January 2009
http://www.cms.hhs.
gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf
* Medi-Cal managed care
providers are required to
conduct all screenings required by CHDP, however,
patients need to be seen
according to the schedule
of the AAP Recommendations for Preventive Pediatric Health Care.
QUALITY OUTREACH EFFORTS MAKING STRIDES IN TAKING “HEDIS TO THE NEXT LEVEL”
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30.79%
1,614
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- The percentage
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%
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0 during the measureme
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r
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81.82
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110 for six
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84.80%
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re
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visit with a PCP
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78.18
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79.09
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diabetic members
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that had
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45.36
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66.94
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201
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during
vaccinations
100.0
194
ns (Combo
54.71%
43.20age
.
77.40% a Nephropathy test the measurement year.
2) - The
2
3) Completed
194
%
Completed Child Immunizati ons (Combo
%
performed during
of members
66.67% percentage
2
40.51
Child Immunizatio
by60.20
age 2 who received
the
conjugate vaccinations
%
ns134
2
(Combo 3)
4 DTaP;
Completed Child Immunizati nings
59.58
- The percentage
47.96%
Completed Chlamydia.201
76.90% 3 IPV; 1 MMR; 2 Hib; 3 hepatitis
of members by
143
201
Completed Chlamydia Screenings
age 2 who
B; and 1 VZV
66.02%
Screenings %
240
77.49%
Chlamydia during
46.80% received
The percentage
79.90
all antigens listed
the measureme 410
Completed CMC LDL Scree
in Combo 2 and
Completed 240
89.25%of female members
5.97% age 62.70%
%
nt year.
621
CMC
four pneumococc
16 - 24 who were 75.20
who also had621 LDL Screenings3,229
al
8.23%
Completed Lead Screenings
- The percentage
identified %
60.61%
an LDL-C screening
3,618
46.60%
of
85.20 as sexually active and had
members age %
s
20 the
Completed Lead
%
during
3,618Screenings
18-75
at
Completed Mammogram
%
measureme
least
72.95 nt year. 21.15
who were
%
one test for
discharged after
74.50
Completed Mammogra 243- The percentage
81.80
642
%
AMI, CABG or
243
%
of
members
Completed Pap Smears
ms 880
32.50
PTCA or who
- The percentage
79.79
prior (excludes
who have
69.80%
92.60%
had a lead screening
had a diagnosis
13
those
of female members
%
of IVD
Completed PCP Visits
Completed Pap880 who have
%by their second %
80.77%
40had mastectomies).
age
74.61
ngitis
40
78.40
69
Smears
that
birthday.
92.00
5
had a mammogram
Phary
- The percentage
%
the two years
40
Completed Testings for
86.96
performed
of female
prior (excludes 26
% during the
78.73%
3-6 yrs
85.60%
members
those who have
Completed
or More) PCP 26
20 had
measurement
% age 21-64 % received
QM: 60.58
Completed Well Child Visits 0-15 mos (6
Visits - The percentage
year or the year
a 75.36
23
total hysterectom 86.25who
oneall
year.
or more Pap
Over
y).
LBP
119
of members age %
tests performed
23
Completed Well Child Visits Studies for
89.8312 months-19
Completed Testing
483
during the measureme
ng
who had a visit
hitis
53
for Pharyngitis
nt year or
Bronc
with a primary
received a strep 483
Completed
lete Imagi
59 - The percentage
care practitioner
test for the episode
for Acute
Percentilentile
to Comp
(PCP) during
59
100%
within the specifiedof members age 2to- 18
Failure
the measureme
Antibiotics for URI Not prescribed an antibiotic
Perce
who
75%
were
time
ribed
nt
were not dispensed
for URI - The
top
and 75% diagnosed
otics
ntile with pharyngitis
in theperiod.
percentage
Not Presc
an antibiotic prescription.
and were dispensed
the 25% to 25% Perce
Completed Well
Rate is of members
ribed Antibi
=Reported
ations
3 months-18
an antibiotic that
between age0%
N
who were given
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more well-child Child Visits GREE
0
inverted
Rate isas an
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a diagnosis of
visits with ae:PCP - 15 months
-=The
percentage
is in theof members(higher rate is better).
OW
upper respiratory
rmanc
Completed Well
during
Prescribed
Rate
= 15
infection (URI)
who turned 15
Child Visits 3 YELL their first
on Perfo
months of life.
and
measureme
months old during
-RED
6 yrs - The percentage
d based nt year.
the measureme
CodeFailure
of members age
nt year and who
to Complete
are Color
3, 4, 5 or 6 who
Imaging Studies
had 6 or
Rates
within 28 days
received one
for LBP - The
or more well-child
of the diagnosis.
Provider
percentage of
Not Prescribed
visits with a PCP
members with
Antibiotics for
during the
a primary diagnosis
antibiotic prescription.
Acute Bronchitis
of low back pain
- The percentage
who did not have
Prescribed Asthma Reported as an inverted
of members age
rate
an imaging study
18-64 with a diagnosis
prescribed controller Medications - The percentage(higher rate is better).
of acute bronchitis
medication during
of members age
who were not
the measureme
5-56 who were
dispensed an
nt year.
identified as having
persistent asthma
and who were
appropriately
forn
of Cali
Care1st
Quality
Mana
geme
nt
le
r Profi
Provide
targets
rates are
expected
ed. All
All results are
based off administra
been includ
only and are
tive claims data
data has
not used for any
w no
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chart review data
other purpose.
no chart
has been included.
data only,
All expected rates
claims
are targets
nistrative
se.
d off admi other purpo
ts are base
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All resul are not used
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IMPORTANT!
PLEASE PLACE IN MEMBER CHART
Member Required Services Reminder
September 14, 2009
Member ID:
Name:
Address:
Telephone:
000000*01
Doe, John
DOB: 08/11/1955
1111 Care1st Plaza Drive, Los Angeles, CA 90005
(323) 889-5611
The above referenced Care1st member requires the following services within the
timeframes indicated.
•
•
•
•
•
•
Bilateral Mammogram before the end of this year
Referral to eye care specialist for Glaucoma screening before the end of
this year
HgbA1c Test before the end of this year (goal is <7%)
LDL Test before the end of this year (goal is <100)
Serum Potassium, Creatinine, and BUN before the end of this year
Documentation of a Body Mass Index (BMI) before the end of this year with
weight management counseling if indicated
You will soon be receiving a Physician Profile Report that includes your
2009 HEDIS rates. The report will provide your specific rates compared
to your peers, national benchmarks and health plan overall rates.
In addition, you will receive your Assigned Member Listing. This listing will detail all required preventive services that each member must
receive before December 31, 2010. Our primary goal is to provide you
with the necessary tools and on-going support to ensure that HEDIS
rates reflect an improvement.
Finally, the Quality Outreach Department is committed to assisting you
with outreach tools that will substantially impact improvement at the
“point of care” and increase provider and member satisfaction.
Care1st has conducted a query of all our Claims and Encounter Data as of August 2009
to determine if this member has obtained these services and we were not able to
determine that the member had these required services. We understand there is a
possibility that you have already provided these services and if you have we ask that you
submit encounter data to us so we do not request this information from you again in the
near future.
Please submit this encounter data to <Outreach Coordinator> at 601 Potrero Grande
Dr., Monterey Park, CA 91755. If you have questions, please contact us at (877) 4724332.
The Quality Outreach department is always available to assist you and
can be reached at (877) 472-4332.
METEORITES AND SPEARPHISHING
Recently, a meteorite crashed into a medical office in Lorton,
Virginia. There was nothing the doctors and staff could do except clean up the office and donate the rock to the Smithsonian
Institution. It is on display as Meteorite Lorton. There is nothing
anyone can tell you to help your office avoid a meteorite.
The experts tell us we can minimize exposure to phishing and
spearphishing by following these steps:
There is another potential threat to your office that can be
anticipated, and the experts can share information with you
to ward off damage. This threat is a unique form of phishing
called “spearphishing.” Everyone with a computer has experienced phishing where an e-mail sent to a large number
of people tells of an inheritance “waiting to be claimed” or
an official looking e-mail from a bank asking for usernames,
passwords, and PIN numbers. The American Medical News
has highlighted a form of phishing known as “spearphishing.”
Spearphising is not sent to a wide audience, but rather targets
a specific audience. For example, an official looking e-mail
from a hospital information staff member may be directed
only to physicians on the hospital staff, and will ask for the
individual’s login information for “upgrade” purposes. This request is from a scammer and the information can be used to
obtain personal and medical information on individual patients
to be used for identity theft purposes. Such official-looking,
but phony e-mails, may appear to be coming from employers, insurance companies, or vendors. There is another scam
where an e-mail may provide a link to what appears to be a
trust worthy web site. Clicking on the web site plants a virus
in the computer that allows a hacker access to the computer
and even an entire network.
2. If you are being requested to supply patient health or personal data, call the source to verify if the particular e-mail
being sent to you is from a legitimate party.
10
1. Never click on a link sent in an e-mail. Log in to the site of
the legitimate party you think sent the e-mail and transact business using the link you have personally entered.
3. Never send passwords by e-mail.
4. Never reply to an e-mail from a source you do not know.
5. Do not download files unless you can ascertain it came
from a legitimate source.
6. Tell patients that your office will never ask for personal
information by e-mail.
7. Don’t open files marked “.exe.” They may invade and infect you computer.
CULTURAL & LINGUISTICS CORNER
Care1st Cultural & Linguistic (C&L) Department is dedicated
to working with its contracted providers to effectively deliver quality health care services to its culturally and linguistically diverse membership. Please contact us if you need
help implementing your program.
Free Interpreting Services (Phone, Face-to-Face & Sign
Language)
Care1st Health Plan provides free interpreting services, 24-hours a
day & 7 days a week. These services are also available after standard business hours. Interpreting services include telephonic, faceto-face and American sign language (ASL).
Please contact us 5-7 days in advance to request a face-to-face or
sign language interpreter.
For a face-to-face, and sign language interpreter, use the following
Care1st Member Services Department phone numbers:
• Medi-Cal & Healthy Families members (800) 605-2556
• Medicare & Commercial members (800) 544-0088
For a phone interpreter during business hours, call our Member
Services Department or call our contracted vendor “Pacific Interpreters” at 1-800-259-4521. For a phone interpreter after business
hours, directly contact Pacific Interpreters. You will need to provide
Pacific Interpreters with an Access Code.
• For Los Angeles office during standard business hours:
Access Code – 840609
• For San Diego office during standard business hours:
Access Code – 838600
Access to Large Print on Care1st Website:
www.care1st.com
Care1st Health Plan added a new feature to its website which allows you and your patients to change the font size to a level that is
comfortable to read.
Language Preference
Record each non-English speaking patient’s language preference in
his or her medical record.
Request/Refusal of Interpreting Services
Do not use minors to interpret for adults unless there is an emergency. Also, discourage patients from using friends and family
members as interpreters. If your patient requests or refuses an
interpreter after being informed of the service, file a completed Request/Refusal form in the patient’s medical chart. Request/Refusal
forms are available in many languages other than English. You may
obtain free copies of the Request/Refusal form in all threshold languages by contacting the C&L Department at (323) 889-6638 ext.
6538 or download it from our Care1st website.
Bilingual Providers & Staff
If you want to communicate by phone with your hearing impaired,
deaf or speech impaired patients, call California Relay Service at 1888-877-5379 (English) or 1-888-877-5381 (Spanish). If your office
uses exchange services and/or on call providers, please educate
your staff on how to access interpreting services. If your office uses
an answering machine, please include a message on how patients
can access interpreting services after hours.
Maintain a language self-assessment form, certification of language
proficiency or interpreter training on file for you and office staff providing interpreting services. Bilingual staff providing medical interpreting services are encouraged to take a language proficiency test
by a qualified agency to determine if the candidate is qualified for
medical interpreting. Bilingual staff with limited bilingual capabilities
should not provide interpreting service to patients. The most updated
Industry Collaboration Effort (ICE) provider/staff language capabilities
self-assessment form is available. You may obtain free copies of the
self-assessment form by contacting the C&L Department at (323)
889-6638 ext. 6538 or download it from our Care1st website.
Interpreting Services Poster
Referrals to Community Programs and Services
• For after standard business hours (both offices):
Access Code – 828201
This sign must be posted in visible areas in your office (i.e. reception desk, waiting room, and exam room, etc.) This poster is
translated into LA County’s 10 threshold languages and will inform
patients that they can receive interpreting services at no cost. C&L
Department also developed an interpreting service poster for our
San Diego providers. You may obtain free copies of the poster by
contacting the C&L Department at (323) 889-6638 ext. 6538 or
downloading it from the Care1st website.
Care1st Health Plan encourages providers to refer their patients to
culturally and linguistically appropriate services that will meet their
patients’ health care needs. You may obtain free copies of the Community Resource Directory by contacting the C&L Department at
(323) 889-6638 ext. 6538 or download it from our Care1st website.
You can either submit your request to the C&L Department or directly refer your patients to a community resource by referring to
the C&L Community Resource Directory (CRD).
11
Health Care Fraud & Abuse
Common Managed Care Fraud Schemes
It is in your best interest and that of all citizens to report suspected fraud. Health care fraud, whether against Medicare, Medi-Cal and/or Private
Insurers, increases everyone’s health care costs. If we are to maintain and sustain our current health care system, we must work together to
reduce unnecessary costs.
I. Administrative/Financial
II. Services/Encounter
III. Member Issues
• Falsifying credentials.
• Billing fee-for-service [FFS] for capitated
services.
• Double-billing for health care services or
goods that were provided.
• Accepting kickbacks for referring sicker
patients to FFS specialists.
• Conducting improper dis-/enrollment practices.
• Attracting healthy patients or refusing sicker
patients.
• Persuading sicker patients to dis-enroll.
• Falsifying medical exemptions.
• Use of telemarketing/selling as marketing
tools.
• Falsifying encounter data.
• Misrepresenting services to meet quality
of care standards.
• Billing for “phantom patients” who did
not receive services.
• Billing for services/supplies not provided.
• Upcoding charges and unbundling
services.
• Excluding distinct groups of beneficiaries
[e.g. patients with chronic conditions].
• Engaging in under-utilization.
• Regularly denying treatment requests
and specialist referrals without regard
to proper medical evaluation.
• Concealing ownership in a related
company.
• Falsifying eligibility applications.
• Using another person’s health plan
identification card to obtain medical care.
• Doctor shopping to obtain multiple
prescriptions for controlled substances/
prescriptions drugs.
• Misrepresenting medical conditions.
• Failing to report third party liability.
Department Contact
Information
Provider Relations
P: (323) 889-6638 Ext. 6388
F: (323) 889-6212
Member Services
P: (800) 605-2556
F: (323) 889-6289
Authorizations
P: (800) 605-2556
F: (323) 889-6577
On-line: www.care1st.com
• Review Care1st Provider Manuals.
• Report potential fraud to the Department
of Health Services for Medi-Cal.
• Report potential fraud to the HHS Office
Inspector General for Medicare.
• Contact Care1st Health Plan’s Special
Investigations Unit and make aware of
potential fraud issue.
• Establish office policies and procedures to
address fraud and abuse issues.
• Share this important information with
your staff.
CONTACT INFORMATION BY COUNTY:
LOS ANGELES
ORANGE
SAN BERNARDINO
RIVERSIDE
SAN DIEGO
Care1st Health Plan
3131 Camino del Rio North
Suite 350
San Diego, CA 92108
Pharmacy
P: (877) 792-2731
P: (877) RX-CARE1
Care1st Health Plan
601 Potrero Grande Drive
Monterey Park, CA 91755
Phone
(619) 498-8228
F: (866) 712-2731
F: (866) R1-CARE1
Phone
(323) 889-6638
Main Fax
(619) 498-8237
Claims
P: (800) 605-2556 Ext. 6335
Ext. 6234
Main Fax
(323) 889-6255
0024-1310-PNO
WHAT CAN YOU DO?
Report potential fraud by calling:
Medicare Fraud Hotline of the HHS office
Inspector General
(800) 447-8477
Medi-Cal Fraud Hotline Department of
Health Services
(800) 822-6222
Care1st Health Plan Compliance Hotline
(877) 837-6057