Provider Update - Medical Practitioners - 11/09

HMSA’s
For Participating Medical Practitioners
NOVEMBER 2009
ALERT! EUTF PPO participants must actively choose
HMSA or their coverage will default to HMA
During the open enrollment period from November 2-30, 2009, EUTF participants in the EUTF PPO
administered by HMSA must take action and select HMSA or they will be automatically switched to HMA.
This may result in lower reimbursements from HMA to physicians as compared to what HMSA provides. A
new 80/20 PPO plan administered by HMSA has been added by the EUTF Board of Trustees for the remainder of the plan year through June 30, 2010. For this coverage, effective January 1, 2010, HMSA members
must complete their enrollment form and submit it to the EUTF to continue with HMSA. By doing nothing,
they will be automatically switched to HMA and may need to seek a new physician. If asked by your patients,
we welcome your recommendation to HMSA.
H1N1 Update: New codes for billing administration
Since the publication of the H1N1 billing instructions
in the October Provider Update, an additional code has
been issued that providers should use when billing for
administration of the H1N1 vaccine with HMSA’s
private business
plans.
HMSA is calling!
HMSA is targeting members
ages 50 to 65 with automated phone calls reminding them to get a flu shot.
These 3-minute calls provide
brief information on the
value of flu shots and about
the novel H1N1 flu virus. A
few yes or no questions will
be asked, and the system
will request an e-mail address so HMSA can provide
additional information in a
follow-up e-mail.
CPT code 90470,
swine flu administration, should
be used to bill for
H1N1 vaccine
administration. For
HMSA’s 65C Plus,
please use HCPCS
code G9141 when
billing for vaccine
administration. For
the ICD-9-CM diagnosis code please
use V04.81, pro-
phylactic vaccination and inoculation against certain
viral diseases, influenza. Blue Cross and Blue Shield
plans have agreed to provide administration coverage
for all insured members, with CPT code 90470 and
HCPCS code G9141.
• Bill HMSA for the vaccination administration.
H1N1 vaccine material, needles, syringes, alcohol
swabs and sharps containers are covered by the federal
government and are distributed without cost. As a
result, HMSA will not pay for vaccine material or any
supplies. Providers who submit claims for the vaccine
and/or supplies will not be paid for the vaccine material and/or supplies.
• If H1N1 is administered with any other immunization on the same day, the claim submitted should
bill one line for the H1N1 administration and on a
separate line bill the appropriate additional vaccine
administration code.
Questions about information in this publication can be
directed to HMSA Provider Services at 948-6330 on Oahu
or 1 (800) 790-4672 from the Neighbor Islands.
Hawaii Medical Service Association
Phone: (808) 948-5110
Internet address:
818 Keeaumoku St.
Branch offices
www.HMSA.com
P.O. Box 860
located on
Provider Resource Center:
Honolulu, HI 96808-0860
Hawaii, Kauai and Maui
hhin.hmsa.com
PS09-141
November 2009 Provider Update - Medical Practitioners • 2
HMSA PPP and HPH CAHPS 4.0H Member Survey Results
Results of the 2009 HMSA
CAHPS 4.0H member survey
indicate PPP members continue
to be highly satisfied with
their healthcare, with scores
in the 90th percentile for the
composite categories of Getting
Needed Care, Getting Care
Quickly and How Well Doctors
Communicate.
HPH survey results do not
indicate the same level of
satisfaction with declines to the
25th or less than 25th percentile
for the same composite
categories.
The differences in the CAHPS
survey results for PPP
and HPH continue to be
perplexing, given members are
served by many of the same
providers. For example, HPH
members continue to report
dissatisfaction with receiving
care and getting appointments
in a reasonable time as shown
by the less than 25th percentile
score for the Getting Care
Quickly composite. Yet, at
73.5 percent, more HPH
members report obtaining an
appointment for a chronic or
non-urgent illness in one week
or less compared to 67.2 percent
of PPP members.
The overall score from HPH
members for the How Well
Doctors Communicate
composite reflects a decline from
the 75th to the 25th percentile.
One question in the composite,
“How often did your personal
doctor spend enough time
with you” reflected a significant
decrease in members responding
usually or always with results
Continued on page 9
Improving the doctor-patient conversation
While the majority of patients are happy with the
care received from their physicians, problems with
communication can negatively affect their perception of the quality of care they receive.
Cultivating good communication skills:
•• Builds trust between physician and patient
•• Increases the chance patient will comply
with prescribed treatment regimens
•• Increases patient participation in their
healthcare decisions
•• Reassures patients and increases their
ability to cope with the healing process
Listen carefully and assess body language during
the history-taking phase of an office visit for a
better understanding of underlying concerns. Assess what the patient already knows by listening
and asking them pertinent questions to reveal how much they
understand – or misunderstand.
How much detail patients should
know is influenced by how much
detail they want to know and are able to understand. Physicians can start with basic information
and increase the level of detail while watching for
patients’ reaction.
Helpful tips:
•• Keep it simple.
•• Avoid highly technical language.
•• Give patients time to comprehend the
information and ask questions.
•• Keep to language that tells the truth. Use
caution when adding language to soften the
blow since this could cause confusion.
November 2009 Provider Update - Medical Practitioners • 3
HMSA’s Online Care
A free shot of Online Care
As part of our commitment to keeping the community healthy, during
this flu season HMSA is offering one Online Care visit per person at no
cost to all Hawaii residents. No-cost HOC visits are for online conversations only.
As a result of this promotion, HMSA expects an increase in traffic on
Online Care. Consumers can go to hmsa.com/flu for more information
on how to get the no-cost Online Care visit.
Free online
visit info
•
•
•
•
•
Coupon code = FLU
One free Online Care
visit per person for
HMSA members and
non-HMSA members
Valid through May
2010
Available only for
online conversations
Not for telephone
conversations
Go Green campaign prompts online 1099 filing
At the end of January 2010, HMSA will be mailing your 1099 form for the calendar year 2009. Included in the mailing will be instructions to access this form online. This new feature is aligned with
nationwide trends to “Go Green” and allows easy 24-hour access to HMSA 1099s going back five years
(on a rolling basis). More information will follow on the implementation of this feature as it becomes
available.
H1N1 mobile texting pilot
A free, three-month text messaging campaign pilot launched by the Centers for Disease Control sends important, timely health information directly to users. Feedback is sought during
this pilot.
To subscribe, text HEALTH to 87000. Once signed up, subscribers will be asked a few questions
and will begin receiving three short health tips from CDC per week. Standard text messaging
rates will apply. Opt out at any time by simply replying HEALTH QUIT.
November 2009 Ready, Set, Quit!
Help available for
HMSA members
Physicians often discuss quitting smoking with
their patients. Getting patients to make that
commitment can be difficult, especially without
support.
HMSA members can commit to quitting on
November 19, the day of the Great American
Smokeout, sponsored by the American Cancer
Society. HMSA’s Ready, Set, Quit! (RSQ!)
program is only a phone call away and can offer
additional support.
RSQ! helps to prepare members for their quit
day, whether it’s November 19 or anytime
throughout the year when they are ready.
Provider Update - Medical Practitioners • 4
Seasonal flu shot clinics
for HMSA members
HMSA’ s community flu clinics began in September and will continue through November. Clinic
attendees must have a driver’s license or other
photo ID, must be age 18 or older, and bring their
HMSA membership cards. There is no charge for
HMSA or Part B Medicare members, while other
recipients will be charged $40. No checks or credit
cards will be accepted.
2009 HMSA’s
Community Flu Clinics
Oahu
Tuesday, November 3
Consolidated Theatres
Pearlridge West 16
9 a.m. to
11 a.m.
Wednesday, November 4
Walgreens - Kailua
9:00 a.m. to
3:00 p.m.
Saturday, November 7
HMSA Center
Multi-Purpose Room, Lobby
9 a.m. to
11 a.m.
Wednesday, November 11
Walgreens - Kaneohe
9:00 a.m. to
3:00 p.m.
Friday, November 13
RSQ! supports members through services that
reinforce their commitment to quit:
The Ward Warehouse
Kakaako Room, second floor
9:00 a.m. to
3:00 p.m.
Maui
•• Telephone counseling for 18 months
•• Advice on how to deal with cravings
•• Education on nicotine replacement therapy
and stop-smoking aids
•• Referral to smoking cessation classes
•• Smoking cessation medication coverage for
most HMSA health plans
Thursday, November 12
Members can enroll by calling the RSQ!
program at 952-4400 on Oahu or 1 (888) 2254122 from the Neighbor Islands.
Friday, November 6
Consolidated Theatre
Kaauhumanu 6
8 a.m. to
11 a.m.
Hawaii
Thursday, November 5
Foodland - Kamuela
West Hawaii
PrimeTime Wellness Fair
Keauhou Sheraton Hotel
8:30 a.m. to
12:30 p.m.
8:30 a.m. to
12:30 p.m.
November 2009 Provider Update - Medical Practitioners • 5
Securing member records protects vital information
HMSA encourages participating physicians to
establish and maintain medical records for its
members in accordance with generally accepted
medical practices, plan documents and applicable
federal and state regulations.
Medical records should be maintained in a
manner that is current, detailed, organized and
inclusive of all aspects of care, orderly and legible,
so that someone other than the writer can access
the information and easily read its contents. All
HMSA practitioners should uphold policies and
procedures pertaining to confidentiality of specified patient information in medical records.
Policy News
Your policies and procedures should include:
• Storage in closed cabinets or in a room away
from public access areas
• Individual record for each patient
• Each page of each record has the patient’s
identification on it
• Requirement that written permission from
the patient prior to releasing his or her records outside the office be obtained
• A written policy or form stating that all the
information contained in the patient’s records
is confidential and will not be discussed or
disclosed outside the office without the patient’s permission
• An established system for organizing, filing
and tracking of information in the medical records (does not apply to independent practice
associations [IPAs]).
Annual review of medical policies
The following policies have undergone annual
review and have been updated:
•• Amniocentesis and Chorionic Villus
Sampling
•• Artificial Disc Replacement – Cervical –
Effective 02/01/10 with 90-day notice
•• Autologous Hematopoietic Stem-Cell
Transplantation for Malignant Astrocytomas
and Gliomas
•• Carotid Artery Stenting – Effective February
1, 2010 with 90-day notice
•• Clinical Trials
•• COX-2 Inhibitors
•• Heart/Lung Transplant
•• Home Apnea Monitor Infants
•• Home Pulse Oximeter for Children
•• Never Events and Hospital-Acquired
Conditions – Effective October 1, 2009
•• Panitumumab (Vectibix)
•• Screening Colonoscopy – Effective January
1, 2010
•• Spinal Cord Stimulators for Pain
Management
•• Lenalidomide (Revlimid)
Please refer to the Provider E-Library to view
the individual policies. Copies of the policies are
available upon request.
November 2009 Provider Update - Medical Practitioners • 6
Policy News
Additional Codes that Do Not Meet Payment
Determination Criteria
Effective January 1, 2010, the following codes will be added to the list of Codes that Do Not
Meet Payment Determination Criteria:
•• CPT Codes 0213T – 0218T: Injection(s) diagnostic or therapeutic agent, paravertebral facet (all
levels
•• CPT Codes 0219T – 0222T: Placement of a posterior intrafacet implant(s) (all sites)
New draft medical policy posted for comment - November
•• Preimplantation Genetic Diagnosis
This is a new draft policy posted for comment that can be viewed under Draft Policies in the Provider E-Library. A copy is available upon request. Comments are due by November 30, 2009, and can
be sent to [email protected] or faxed to 948-6340.
Artificial Disc Replacement - Cervical - effective 02/01/10
This new policy is effective February 1, 2010, and requires precertification. Cervical intervertebral disc
replacement or spinal arthroplasty is covered (subject to Limitations/Exclusions and Administrative
Guidelines) when performed at one level (22856, 22861, 22864) in individuals with cervical
degenerative disc disease (722.4) when certain criteria are met. The policy is available in the Provider
E-Library as Artificial Disc Replacement, Cervical – Effective 02/01/10.
Screening Colonoscopy - effective January 1, 2010
Effective January 1, 2010, colonoscopy for screening purposes is covered, subject to limitations and/
or exclusions, once every 10 years for HMSA members 50 years of age or older. Does not require
precertification. The policy is available in the Provider E-Library as Screening Colonoscopy –
Effective January 1, 2010.
November 2009 Provider Update - Medical Practitioners • 7
Billing and Coding
Blues benefit limits require careful verification
What is a limited benefit product?
Blue Cross and Blue Shield Health Plans that
have limited annual benefit payments of $50,000
or less.
How would I know if a patient is covered by
this type of health plan?
Patients who have Blue limited benefits coverage
carry ID cards that have:
•• either of two product names - InReach or MyBasic
•• tagline in a green stripe at the bottom of the card, and
•• a black cross and/or shield to help differ-
entiate it from other identification cards.
These ID cards may look like this:
system or you may call the 1(800) 676-BLUE
eligibility line for out-of-area members.
Both electronically and via phone, you will receive
patient’s accumulated benefits to help you understand the remaining benefits left for the member.
If the cost of services extends beyond the patient’s
benefit coverage limit, inform the patient of any
additional liability he or she might have.
What should I do if the patient’s benefits are
exhausted before the end of their treatment?
Annual benefit limits should be handled in the
same manner as any other limits on the medical coverage. Any services beyond the covered
amounts or the number of treatment might be
member’s liability. We recommend that you
inform the patient of any potential liability he or
she might have as soon as possible.
Who do I contact if I have additional questions about Limited Benefit Plans?
If you have any questions regarding this information on limited benefits products, contact
HMSA’s BlueCard department at 948-6280
or toll-free at 1 (800) 648-3190.
How would I know if
the patient has benefits available
under these plans?
Verify the patient’s benefits and eligibility
electronically by submitting HIPAA 270
eligibility inquiry through HMSA’s HHIN
November 2009 Provider Update - Medical Practitioners • 8
Billing and Coding
Coordination of benefits (COB) between BCBS, competitors
Coordination of benefits (COB) refers to how the Blue Cross Blue Shield system ensures that
members receive full benefits and prevent double payment for services when a member has coverage
from two or more sources. The members’ contract language explains the order for which entity has
primary responsibility for payment and which entity is secondary.
Please keep in mind the following when submitting claims for patients who may have other health insurance
coverage (i.e., Medicare, other Blues plan, or other health plans):
••
If a local plan or any other Blue Plan is the primary payer, submit other carrier’s name
and address with the claim to that plan. If you do not include the COB information with
the claim, the member’s Blue Plan will have to investigate the claim, which could delay
your payment or result in a post-payment adjustment, which will increase your volume of
bookkeeping.
••
If other non-Blue health plan is primary and a local plan or any other Blue Plan is
secondary, submit the claim to that local plan only after receiving payment from the
primary payer, including the explanation of payment from the primary carrier. If you
do not include the COB information with the claim, the member’s Blue Plan will have
to investigate the claim, which could delay your payment or result in a post-payment
adjustment, increasing your volume of bookkeeping.
••
Carefully review the payment information from all payers involved on the remittance advice
before balance billing the patient for any potential liability. The information listed on the
local plan’s remittance advice as “patient liability” might be different from the actual amount
the patient owes you, due to the combination of the primary insurer payment and your
negotiated amount with that local plan.
••
For more information regarding claims processing please contact HMSA’s BlueCard Department at
948-6280 on Oahu or toll-free at 1 (800) 648-3190.
Eligibility
for BlueCard
Members
Call the BlueCard Eligibility line at 1 (800) 676-BLUE
(2583), or use the Blue Eligibility function on the Hawaii
Healthcare Information Network (HHIN).
November 2009 Provider Update - Medical Practitioners • 9
CAHPS survey results
Continued from page 2
usually or always with results of 86.3 percent in 2009 to 91.4 percent in 2008. Effective
communication between the patient and physician continues to be an important component of care.
The score for Rating of Personal Doctor and Rating of Health Plan continues to reflect high
satisfaction with results at the 90th percentile for PPP and HPH.
While additional questions and further analysis did not identify a specific cause for the satisfaction
variation between PPP and HPH, there continues to be a perceived expectation difference on the part
of HPH members. With 17.2 percent of HPH survey responders in the 35-44 age group compared
to 12.5 percent PPP, the demographics for this group point to a younger member, one who is part of
a generation accustomed to instant results, with immediate access via cell phones and information on
the Internet readily available. This attitude and expectation has a direct influence on the satisfaction
perspective of the HPH member.
CAHPS Survey
Composite Category
PPP 2009
PPP 2008
NCQA Benchmarks &
Thresholds Percentile
HPH 2009
HPH 2008
NCQA Benchmarks &
Thresholds Percentile
Getting Needed Care
90th
90th
25th
50th
Getting Care Quickly
90th
90th
<25th
<25th
How Well Doctors
Communicate
90th
90th
25th
75th
Claims Processing
90th
90th
90th
75th
Rating of Personal Doctor
90th
90th
90th
90th
Rating of Health Plan
90th
90th
90th
90th
LRSP claims processing system retires January 1, 2010
It is important to file claims on a timely basis to
ensure payment. In accordance with HMSA
provider contracts, claims must be filed within
one year of the service date. This time frame also
applies when HMSA is a patient’s secondary
insurance carrier.
HMSA has completed conversion of its HMO
and PPO plans to the newer claims processing
system (QNXT). As a result, HMSA will begin
retiring its old claims processing system (LRSP).
Claims with dates of service on or before January
1, 2009, should be submitted to HMSA prior to
January 1, 2010, to ensure payment.
November 2009 Provider Update - Medical Practitioners • 10
Clearing up the confusion on copying military ID cards
On August 10, 2009, U.S. Army North published
a Force Protection Advisory (0050-09-FPA)
entitled Photocopying of Military Identification
Cards.
It states “Recent incidents regarding the photocopying of military identification cards and common access cards (CAC) by commercial establishments to verify military affiliation or provide
government rates for service have been reported.
“Commanders and Supervisors are reminded that
the photocopying of US Government Identification is a violation of Title 18, US Code Part I,
Chapter 33, Section 701, January 3, 2007, and
punishable by both fine and imprisonment. Many
military members, family member and DoD
employees are unaware of this law. Please pass to
the lowest level and include in training for force
protection, information security and OPSEC.”
The advisory was since rescinded by the Army
on August 13, 2009, but it has caused confusion
among Military personnel and providers alike in
the West Region about copying military ID cards.
Per Department of Defense (DoD)
instruction and reinforced in the TRICARE
Provider Handbook is both allowable and advisable for providers to copy a beneficiary’s ID card
to facilitate eligibility verification and for the
purpose of rendering needed services. The DoD
recommends that providers copy both sides of the
ID card and retain copies for future reference.
A valid uniformed Services ID card serves as
proof of eligibility for TRICARE coverage. Title
18, Section 701 of the U.S. Code and the Department of Defense Instruction 1000.13, paragraph
6.17, authorizes the photocopying of the front
and back of the ID card to establish the eligibility
of the patient to receive care.
For further information, please contact your
local representative at 1 (808) 948-5213, email
[email protected], or call 1 (888)
TRIWEST (874-9378). Refer to the TRICARE
Policy Manual at www.tricare.mil/
Separate payment for Fed Plan 87 services
HMSA is required by the U.S. Office of Personnel Management to separately disburse funds for the
Federal Employees Health Benefit Program by January 1, 2010. At that time, providers will receive a
separate claim payment and Report to Provider for Federal Plan 87 members.