Updates to the Physician Recognition Program
Transcription
Updates to the Physician Recognition Program
A Quarterly Newsletter from Provider Relations and Education, BlueCross BlueShield of South Carolina Updates to the Physician Recognition Program E-Business……...…...……....2 Pharmacy Updates………….3 Policy Updates….............…….…….4 For Your Information……….5 Medicare Advantage.............................6 Did You Know?……………...7 Education Updates……........8 First Quarter 2011 BlueCross BlueShield of South Carolina and BlueChoice® HealthPlan of South Carolina are pleased to announce the continuation of the Physician Recognition Program (PRP). We launched the PRP in May 2005. Since then, we have recognized hundreds of physicians for their program achievements. Your participation in any of the Physician Recognition Programs is voluntary. You must be a member of BlueCross’ Preferred Blue® or BlueChoice HealthPlan’s provider networks. Network physicians who are recognized by the ADA/NCQA Diabetes Recognition Program, the AHA/ASA/NCQA Heart/Stroke Recognition Program or the American Society for Hypertension (ASH) Specialists Program may receive $2,000 from both BlueCross and BlueChoice HealthPlan! Become certified or re-certified for any two programs before September 30, 2011 and receive up to two $2,000 payments. Please review the Physician Recognition Program page for details and qualifications. If you have already met the qualifications, congratulations! To receive your award, complete the “Physician Recognition Program Payment Request Form.” Submit the form with the letter of recognition/certification and the W-9. We also introduced a new program. The Patient-Centered Medical Home Program began October 1, 2010 and offers incentives from BlueCross BlueShield of South Carolina and BlueChoice Health Plan up to $2000 for any physician practice that achieves A-C Mal status. This award is limited to one payment per practice. The National Committee for Quality Assurance (NCQA) defines a patientcentered medical home as a “health care setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by patient registries, information technology, health information exchange and other means to assure that patients get the indicated care when they need it and in a culturally and linguistically appropriate manner.” The NCQA-PCMH program reflects the input of the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP) and American Osteopathic Association (AOA). We encourage you to learn more about this program. It is rapidly gaining momentum and attention as an innovative approach to primary care. Visit http://www.ncqa.org/tabid/631/Default.aspx for more information. BlueCross and BlueChoice HealthPlan look forward to recognizing you for one of these programs. If you have any questions, please contact: BlueCross: [email protected] or 803-264-9082. BlueChoice HealthPlan: [email protected] or 803-382-5265. If you have any questions regarding the information in this newsletter, please email us at [email protected]. BlueCross BlueShield of South Carolina and BlueChoice HealthPlan are independent licensees of the Blue Cross and Blue Shield Association 1 HIPAA 5010: National Provider Identifier (NPI) Clarification The HIPAA 5010 mandate requires that the reporting of your NPI be consistent by January 1, 2012, which means that your NPI structure needs to be the same for all health plans. Doing so will simplify administrative efforts as well as eliminate any payment issues with crossover or secondary claims. This uniform NPI structure must be used for all HIPAA electronic transactions, including: 270/271 – Eligibility Request and Response 276/277 – Claim Status Request and Response 278 – Referrals and Prior Authorization 835 – Payment and Remittance Advice 837 – Claim Submission If you are not currently enumerated the same for all plans, you will need to make a business decision and develop a new enumeration strategy. Once you have made a decision on your new NPI structure, contact us and your clearinghouse/vendor as soon as possible to allow time for our systems to be updated to ensure a seamless transition. Please contact us via email at [email protected] if changes to your enumeration strategy are required so that we can work with you to update our files accordingly. The Voice Response Unit GPS! Electronic Funds Transfer: Let’s Go Green Together! Electronic Funds Transfer (EFT) is now our corporate delivery method for payment to providers. We are working to transition the remaining providers to this delivery method. If you have not transitioned, it is important that you do so immediately. Need help navigating through our Provider Services Voice Response Unit? We offer a Voice Response Unit Guide in our Bulletins section of www.SouthCarolinaBlues.com. Save it to your computer, bookmark it or print it out today! One of the benefits of being a Palmetto Paperless Provider is receiving payments three to four days faster. As a paperless provider you will access copies of remittance advices via My SM Insurance Manager or My Remit SM Manager . You can download the forms at http://www.southcarolinablues.com /providers/forms/financial.aspx. Fax completed forms to 803-8708065 to Attention: EFT Coordinator. If you have questions about this mandate, please call Provider Education at 803-264-4730. If you have any questions regarding the information in this newsletter, please email us at [email protected]. 2 Updates Pharmacy Management Changes On our behalf, a group of in-network doctors and pharmacists choose the medications for our drug lists based on their effectiveness, safety and value. Recently, these doctors and pharmacists recommended a few changes. The changes apply to prescriptions written on or after January 1, 2011. They are summarized here: Preferred Drug List Changes. See our website for details. Over-the-Counter (OTC) Drug Coverage. With a valid prescription, we will extend coverage for both OTC allergy (Alavert, Claritin, Zyrtec and any store brands) and OTC reflux (Prilosec OTC, Prevacid 24HR, Zegerid OTC and any store brands) medications for most members. Please consider OTC medications for your patients, when appropriate. Members will pay the lowest copayment under their plans for OTC medications. Step Therapy Program. See our website for the drugs included in the program. Prior Authorization Changes. We are adding several drugs to our prior authorization program. We will minimize impact to anyone currently using most of these drugs. See our website for details. Quantity Management Changes. We have added several drugs and changed some limits. See the changes and the complete listing on our website. Now there’s a one-stop shop for drug news, formulary lists, FDA recalls and prescription updates! Check out the Prescription Drug Information page in the Provider’s section of www.SouthCarolinaBlues.com. We believe you are best qualified to balance quality and costof-care in choosing prescription drug therapies for your patients. We are providing this information for your consideration only. We know that your prescribing decisions take into account a number of patient-specific variables that are not available to us. Although you can always find the most up-to-date drug list information on our website, it’s now easier than ever to stay on top of changes with an electronic prescribing tool. If you are not currently prescribing electronically, now is a great time to consider doing so. To learn more about ePrescribing, select the Electronic Prescribing link on the Provider’s Prescription Drug Information page on our website. You should know that generic drugs are always available at the lowest copayment under our plans. Whenever the FDA approves a new generic, most of the time its brand-name counterpart will become non-preferred. Please consider allowing generic substitution on the prescriptions you write when appropriate. If you have any questions regarding the information in this newsletter, please email us at [email protected]. 3 BlueCard® Reminder Member ID Numbers – Look Twice! Be sure to file the correct alpha prefix on your claims for BlueCard members. The alpha prefix is very important. We use this information to route your claims to the appropriate home plan. Approximately 1,500 claims each month are rejected due to having the incorrect alpha prefix filed on them. To prevent any delays in processing your claims, be sure to file the correct alpha prefix as it appears on the member’s ID card. A group with a recent alpha prefix change is WalMart (WMW). When reviewing your remits, be certain to pay particular attention to the member ID number section of the remittance: If there is a plus (+) next to the ID number on the remittance, that is an indication that the ID number you submitted was incorrect and that it has been corrected. On the same line of the remittance, next to the claim number, you will see the incorrect ID number that you submitted on the claim. Also, be sure to file your patients’ claims according to what’s printed on their ID cards. The name printed on the ID card is the name we have on our system. Filing claims under the patient’s nickname, for example, may prolong claim processing. Balance Billing We have had an increase in balance billing for total charges for services and procedures. This is a concern of our members. Our participating providers can collect appropriate copayments, deductibles and coinsurance from members at the point of service. It is important, however, to bill based on the appropriate allowables for the procedures, and not on total charges. Be sure to correct the ID number and/or patient name in your files so future claims you submit for that particular patient will come in with the correct data. Publix PPO Members Require Precertification of Outpatient Services Effective January 1, 2011, all outpatient services, with the exception of preventive services, labs, X-rays, emergency room and urgent care, will require precertification for Publix members with a BlueCross BlueShield PPO. This will also include all physical, occupational and speech therapy services rendered in an outpatient or office setting. New Codes Added Check the NIA section of our website for new procedure codes that require preauthorization through NIA. On behalf of BlueCross, NIA handles preauthorization for certain imaging services. NIA is an independent company. If you have any questions regarding the information in this newsletter, please email us at [email protected]. 4 CPAP Authorization Requirements Here is the information Health Care Services needs to review and approve CPAP machine authorizations: First Time CPAP Machine Renters: First time users of CPAP must be approved for a 10-month rental purchase period. Minimal Information Required for a Clinical Review: Complete scored reports of diagnostic sleep study CPAP Titration study or Auto Titration Study with download Most current diagnostic/baseline sleep study (must have been conducted within the previous two years or the review will be referred to the medical director) History and physical, to include sleep history CPAP Machine Changes or Replacements: We need a letter of medical necessity from the physician to upgrade or change the patient’s CPAP machine. The letter should include justification of medical necessity as well as the reason for the machine change. Fax letters to 803-264-0258. In some cases we approve replacement CPAPs as a direct purchase. Here is the review criteria for replacement machines: CITIA Program Free assistance in understanding Medicare and Medicaid incentive payment programs is available for most primary care providers with prescription privileges who practice in one of these specialties: adolescent medicine, family practice, general practice, geriatrics, gynecology, internal medicine, OB-GYN or pediatrics. To apply for up to one year of free assistance in EHR adoption and/or achieving meaningful use, go to www.citiasc.org and click on “Apply Online.” Nearly three fourths of the available 1000 slots have been committed in the first six months with more than 100 applications coming in each month. Interested eligible providers should sign up soon. Minimal Criteria Required for a Replacement Review: Clinical information to document history of obstructive sleep apnea diagnosis (old sleep studies are acceptable) Current machine age and specific malfunction problem Please note that the patient’s current CPAP machine should be at least two years old, out of warranty and have a malfunction in order to be considered for a replacement. You can also fax this information to 803-264-0258. Getting Online Precertifications My Insurance ManagerSM features an automated authorization, precertification and referral feature that allows you to request authorizations for many patient services online. Benefits of Web Precertification: This method provides a quick turnaround. Physicians get most authorizations within 24 hours of submission. Provide complete information to avoid delays. Our internal staff of precertification technicians and nurses works very closely together to review and authorize your patients’ procedures as quickly as possible. Fast Track allows you to submit precertification requests on procedures that you perform regularly. If you don’t see your procedure listed, the unlisted option allows you to provide detailed notes on the requested procedure. Submit thorough notes so our staff can make the most appropriate determination. Additionally, you can request specific procedures be listed as Fast Track items for future precertification requests. Your feedback allows us to continuously improve and effectively serve you. For complete instructions on getting an online precertification, visit: http://www.southcarolinablues.com/UserFiles/scblues/Documents/Providers/mim_precert.pdf If you have any questions regarding the information in this newsletter, please email us at [email protected]. 5 Medicare Advantage and Prescription Drug Plans The health care reform law enacted on March 23, 2010 makes some changes to Medicare, but it does not eliminate Medicare Advantage plans. People with Medicare can still choose between original Medicare and Medicare Advantage plans. New Medicare Benefits The new law adds a yearly wellness visit benefit and free preventive services to Medicare in 2011. BlueCross already offers the wellness benefit. We also offer many other preventive services such as colorectal cancer screening exams and mammograms at no or low cost sharing. In 2011, BlueCross will offer all Medicare-covered preventive services for free (no cost sharing to the member). We mailed our Annual Notice of Change (ANOC) to members in late October, which explained all of our 2011 benefits, including the free preventive benefits. Medicare Prescription Drug Plan Changes Rebate checks for the coverage gap: People with a Medicare prescription drug plan who don’t qualify for the low-income subsidy may have received a onetime, $250 rebate check in 2010. The check came in the mail, directly from Medicare approximately four to six months after the beneficiary hit the coverage gap. A word of caution: Once the member reaches the coverage gap, Medicare will automatically send him/her a rebate check. Members should never give out their Medicare, Social Security or bank account information to anyone to get their rebate checks. For more information about rebate checks, please call 1-800-MEDICARE. Discounts on brand-name drugs and changes to cost sharing for generic drugs: Starting in 2011 the “coverage gap” will get smaller each year until it completely closes by 2020. Once a beneficiary hits the coverage gap each year, he or she can save money through reduced cost sharing on generic drugs and manufacturer discounts on brand-name drugs. Medicare-Related Claims: Present on Admission Indicator On October 1, 2007, the Centers for Medicare & Medicaid Services (CMS) began requiring hospitals to use a Present on Admission (POA) indicator for every diagnosis for all patients they discharged on or after that date. It is one of the requirements of the Deficit Reduction Act of 2005 that the Secretary of Health and Human Services (HHS) identify a limited number of high-cost and/or high-volume conditions that are reasonably preventable through application of evidence-based guidelines, and pay at a lower rate when Medicare claims show these conditions as present only on discharge and not on admission. Starting October 1, 2008, claims began to receive a lower-paying Diagnosis Related Group (DRG) when one of the secondary diagnosis codes identified by CMS is present on discharge but not present on admission. What is the Present on Admission Indicator (POA)? Hospitals use the Present on Admission (POA) indicator to note a condition that is present at the time the order for inpatient admission occurs. The hospitals use one of these five values that identify whether secondary diagnoses are present when the patient is admitted to a facility: • Y = Yes • N = No • U = No information in the record • W = Clinically undetermined • 1 = Used on 4010A1 and 5010 versions of the 837 to represent a space or a blank and means the Diagnosis Code is exempt from reporting POA • Blank = Designates on the UB-04 Unreported/Not Used/Exempt from POA reporting If you have any questions regarding the information in this newsletter, please email us at [email protected]. 6 Why & How Allergies Can Make You Tired The ragweed is in bloom or you visited a friend with a cat, and now your allergies are leaving you so exhausted you're dragging around all day. Is it the allergies themselves that turn you into a lethargic ghost of your former self? Could it be your medication? Why and how can allergies make you tired? When you have an allergic reaction, your body releases proteins called pro-inflammatory cytokines, which are designed to neutralize invading particles. This includes allergens like pollen, pet dander and mold. Essentially, your body is creating a temporary state of inflammation to fight off the allergens. Researchers believe that cytokines act on the central nervous system and prompt leukocytes (white blood cells) and other cells to secrete IL-1 beta (also called interleukin-1-beta). IL-1 beta is a hormone-like substance that can make you feel lethargic and depress your mood. Perhaps fatigue from the inflammatory process is your body's way of telling you to rest so it can fight whatever is plaguing your system. Decreased Quality of Sleep Some research links daytime drowsiness and lethargy to poor nighttime sleep, a complaint from many who suffer from allergies. A stuffy nose, post-nasal drip and coughing can surely ruin a night's sleep. After several weeks of bad sleep during a typical allergy season you're in a state of chronic fatigue. This can lead to other health problems that worsen fatigue. One study reported that 35 percent of those suffering with allergic rhinitis (inflammation of the upper respiratory system due to an allergic reaction) struggle with insomnia. A good night's sleep is vital to feeling refreshed and helping the body heal. Allergies may lead to a vicious cycle of poor sleep and fatigue, as your body is less able to combat allergens. Also, your inflamed upper respiratory system could reduce the amount of oxygen your body gets during sleep. This can lead to a condition similar to sleep apnea and additional fatigue because of fragmented sleep. If you have allergy-related asthma, you are also getting less oxygen during sleep and may experience daytime fatigue. Medication Ironically, some allergy medications may also lead to poor sleep and the same vicious cycle of insomnia and daytime drowsiness. Many antihistamines can leave you groggy throughout the day. Or, if you take them at night, you may sleep for awhile but wake up when the medication wears off. Think switching to a decongestant will help? In one study, 15 to 25 percent of decongestant users reported insomnia. Some doctors switch their patients to prescription nasal corticosteroids, which are not as likely to cause fatigue. Can allergies make you tired? Yes. Can you do anything about it? Yes. Limit exposure to allergens, evaluate your medications and talk to your doctor about treatment options. Read more at http://www.brighthub.com/health/allergies-asthma/articles/85566.aspx. This links leads to a third party website. Bright Hub is solely responsible for the contents and privacy policy on its site. Curriculum Available Visit the Workshop section of our website for the complete Palmetto Provider University curriculum. We have scheduled webinars through September 2011. Topics include BlueCard®, Claims Filing, My Remit ManagerSM and My Insurance ManagerSM. You can register for any of the classes by visiting: http://www.southcarolinablues.com/providers/educationcenter /workshops/palmettoprovideruniversity.aspx If you have any questions regarding the information in this newsletter, please email us at [email protected]. 7 In the Field Our external provider advocates are currently visiting offices to educate providers on various topics. Here’s what they’re talking about in the field: 1. Remember to file the rendering physician’s NPI number on your claims. 2. All injections with J-codes must have an NDC number. 3. Avoid filing duplicate claims by checking claim status. 4. If you haven’t returned your EFT paperwork in order to become a Palmetto Paperless Provider, please do so immediately. 5. Make sure your practice has created a profile administrator for My Insurance Manager and make sure all office staff has been approved. We are here to help our providers and encourage proper claim filing. Our goal is to provide superior service and to enhance our relationships with you. Change is a Good Thing! We’ve experienced some recent management changes in Provider Services and Education. Brian Butler has been promoted to senior director! He has great knowledge and experience in the provider community. Tiffany Singleton has become senior manager over Provider Education and Relations. She has worked for several years in our area in many different capacities and brings very solid leadership to this role. Sandy Sullivan is returning to the area as a liaison for Hospital Relations. Brenda Bethel is the new director of Provider Services and also introduces a new management team. Marcelette Pearson, Brandon Saxon (former hospital manager) and Tammy Ross bring many years of experience in claims and service. These folks have worked with you for years and their proven leadership should take our levels of service to higher levels. We are excited to work with them in their new roles. Have a Question for Provider Education? Contact our Provider Education department by phone at 800-288-2227 extension 44730, or by email at [email protected] with any questions you may have. While our external provider advocates love hearing from you, they’re on the road three days a week visiting your offices and may not be able to respond to you immediately. Our internal provider advocates are equipped to handle your inquiries, and also notify the external advocates of your requests for education visits. If you have any questions regarding the information in this newsletter, please email us at [email protected]. 8