August 2016
General News
Dr. Alan Spiro joins Medica as new chief medical officer
Alan Spiro, MD, MBA, has joined Medica as chief medical officer (CMO) and senior vice president. As CMO, Dr. Spiro has overall responsibility for the Medica Health Management division. This includes working with Medica's provider partners to develop new models of collaboration aimed at improving quality, patient experience and value. It also includes working with the health management staff and Medica segment leaders to build on the work currently underway to improve the quality and cost of health care.
In his new role, Dr. Spiro reports to David Tilford, Medica president and chief executive officer. Reporting to Dr. Spiro are Jana Johnson, senior vice president of health and provider services, and Jim Hartert, MD, vice president and senior medical director.
Dr. Spiro has provided leadership for well-established companies such as Anthem Health. He has also built new businesses from the ground up. Most recently he founded Accolade Inc., which works with employers and health plans to transform the member experience and control medical costs. Throughout his career, Dr. Spiro has been dedicated to improving quality and satisfaction for health care consumers, while improving the efficiency of the health care system. As principal and national clinical practice leader at Towers Perrin, he worked with a number of Fortune 100 companies to develop corporate health strategies and implement health advocate and care management programs ___ some of the first in the industry. In addition, Dr. Spiro has been a visiting professor at the Harvard School of Public Health and a frequent speaker at national health care conferences.
Dr. Spiro holds a Doctor of Medicine degree from the Columbia University College of Physicians and Surgeons as well as a Masters of Business Administration degree from the Northwestern University Kellogg School of Management. In clinical practice, he was a gastroenterologist in Chicago, Ill.
Effective September 1, 2016:
Restricted Recipient criteria to expand for commercial, IFB
Medica will soon expand its Restricted Recipient Program criteria for both commercial and individual and family business (IFB) members, effective with September 1, 2016, dates of service. Members who meet criteria for the program will be required to have designated providers to provide all services — these include a primary care provider and clinic, a hospital (including emergency room), and a pharmacy. The designated primary care provider will also coordinate any referrals to non-designated providers, as needed.
Medica will inform providers if they are a designated provider and provide them with an overview of the program and requirements. Beginning with September 1, 2016, dates of service, Medica will only pay claims for services provided by program members’ designated providers unless there are referrals from designated primary care providers. Currently, Restricted Recipient Program claim denials for commercial members are only for controlled substances.
Note: Although Medica uses claims data to identify potential health care abusers who may be eligible for the Restricted Recipient Program, providers can also give Medica tips about suspected fraud or abuse of services by calling the Medica Fraud Hotline at 1-866-821-1331.
To learn more about this program, see the Provider Administrative Manual.
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Clinical News
Effective October 1, 2016:
Medica to implement new coverage policy
The following benefit determination will be effective beginning with October 1, 2016, dates of service. This new policy will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Sphenopalatine ganglion back
Medica has reviewed sphenopalatine ganglion block used in the treatment of headache and has determined that this procedure is investigative and therefore will not be covered.
The sphenopalatine (SPG) ganglion, also known as the pterygopalatine ganglion, nasal ganglion, Meckel’s ganglion, and Sluter’s ganglion, lies within the pterygopalatine fossa, which is located behind the nose, above the jaw, and below the maxillary nerve. The direct role that the SPG plays in initiating headaches is not fully understood.
Intranasal SPG nerve block for headache involves the threading of a catheter through one of the patient’s nostrils to the back of the nose. An anesthetic, such as lidocaine or bupivacaine, is injected while the patient inhales. The procedure is typically repeated in the other nostril.
The complete text of the policy that applies to the determination above will be available online or on hard copy:
-
See Medica’s coverage policies as of October 1, 2016
- Call the Medica Provider Literature Request Line for printed copies of documents, toll-free at 1-800-458-5512, option 1, then option 5, ext. 2-2355.
Effective October 1, 2016:
Prior authorization to be required for wheelchairs, scooters
Beginning with October 1, 2016, dates of service, Medica will require prior authorization for wheelchairs (both manual and powered), scooters and accessories. Specifically, the following services will require prior authorization:
- purchase of manual and powered wheelchairs, including replacement
- purchase of scooters, including replacement
- accessories, repair and/or modifications that are $500 or more per item
As of October 1, Medica will implement a new utilization management (UM) policy using MCG Care Guidelines® criteria to address the purchase of wheelchairs (both manual and powered), scooters and accessories. This new UM policy will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare, or Medicaid) requires different coverage. By instituting prior authorization, Medica aims to support members and providers in making evidence-based decisions about appropriate, medically necessary care.
On October 1, the Medica Prior Authorization List will also be updated to reflect this change. As a reminder, Medica requires that providers obtain prior authorization before rendering services. If any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability.
The complete text of the policies that apply to the determination above will be available online or on hard copy:
- See Medica’s UM policies as of October 1, 2016; or
- Call the Medica Provider Literature Request Line for printed copies of documents.
Effective October 1, 2016:
Prior authorization to be required for pre-transplant evaluation
Beginning with October 1, 2016, dates of service, Medica will require prior authorization for pre-transplant evaluations. Medica’s utilization management (UM) transplant policies will be modified to include criteria for the pre-transplant evaluation. These policies include:
- Bone Marrow or Stem Cell (Peripheral or Umbilical Cord Blood)
- Heart-Lung Transplantation
- Heart Transplantation (Adult and Pediatric)
- Intestinal Transplantation
- Kidney Transplantation
- Liver Transplantation
- Lung Transplantation (Single or Double)
- Pancreas-Kidney (SPK, PAK) Transplantation
- Pancreas Transplantation (Pancreas Alone)
Pre-transplant evaluations generally include an evaluation of the patient’s medical, social, and psychological conditions. The pre-transplant evaluation can include patient education and discussion of selection criteria, testing, psychosocial factors, nutritional considerations, and medical suitability for transplant.
By instituting prior authorization, Medica aims to support members in making evidence-based decisions about appropriate, medically necessary care. The changes above will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage. For example, these changes will not apply to Medica Medicare products, which will continue to follow National Coverage Determinations (NCD) guidelines.
In all cases, timely requests for prior authorizations, as well as timely notifications and responses to Medica’s requests for medical records, help ensure timely review and communication of determinations back to the facility. Medica may review health services prospectively, concurrently or retrospectively to determine if medical necessity criteria were met. In any case, after Medica reviews services, claims may be denied as provider liability if facilities have not met medical criteria.
On October 1, the Medica Prior Authorization List will also be updated to reflect this change. As a reminder, Medica requires that providers obtain prior authorization before rendering services. If any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability.
The complete text of the policies that apply to the determination above will be available online or on hard copy:
- See Medica’s UM policies as of October 1, 2016; or
- Call the Medica Provider Literature Request Line for printed copies of documents.
Effective October 1, 2016:
Medical policies and clinical guidelines to be updated
Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective October 1, 2016, unless otherwise noted.
UM policies — New
| Name |
Policy number |
| Wheelchairs, Scooters and Accessories (see details above) |
III-DEV.25 |
UM policies — Revised
These versions replace all previous versions.
| Name |
Policy number |
| Bone Marrow or Stem Cell (Peripheral or Umbilical Cord Blood) Transplantation (see details above) |
III-TRA.01 |
| Breast Implant Removal, Revision, or Reimplantation |
III-SUR.11 |
| Female Breast Reduction Surgery - Reduction Mammoplasty |
III-SUR.27 |
| Heart-Lung Transplantation (see details above) |
III-TRA.08 |
| Heart Transplantation (Adult and Pediatric) (see details above) |
III-TRA.12 |
| Intestinal Transplantation (see details above) |
III-TRA.13 |
| Kidney Transplantation (see details above) |
III-TRA.03 |
| Knee Arthroplasty/Replacement (administrative update only) |
III-SUR.41 |
| Liver Transplantation (see details above) |
III-TRA.02 |
| Lung Transplantation (Single or Double) (see details above) |
III-TRA.11 |
| Male Gynecomastia Surgery |
III-SUR.31 |
| Otoplasty |
III-SUR.33 |
| Pancreas Transplantation (Pancreas Alone) (see details above) |
III-TRA.04 |
| Pancreas-Kidney (SPK, PAK) Transplantation (see details above) |
III-TRA.05 |
| Rhinoplasty Procedure With or Without Septoplasty |
III-SUR.04 |
| Sacral Nerve Stimulation (SNS) (administrative update only) |
III-DEV.22 |
| Spinal Cord Stimulation of the Dorsal Column for Treatment of Pain (administrative update only) |
III-DEV.23 |
| Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/Hypopnea Syndrome (III-SUR.08) (revised to reflect use of Medica policy vs. MCG Care Guidelines) |
III-SUR.08 |
Coverage policies — New
| Name |
| Sphenopalatine Ganglion Block for Treatment of Headache |
Coverage policies — Revised
These versions replace all previous versions.
| Name |
| Epidural Lysis of Adhesions |
| Laser Surgery for Neovascularization Associated with Macular Degeneration |
| Prolotherapy |
| Single Nucleotide Polymorphism (SNP) Genetic Testing for Assessment of Cancer Risk |
These documents will be available online or on hard copy:
CAHPS and HOS patient surveys, and the data they collect
Medica regularly collects data about Medica members’ perceptions of their health plan, their medical care and their personal health status. Two important survey tools are the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and the Health Outcomes Survey (HOS).
What is CAHPS?
CAHPS is a survey administered annually by paper and phone to commercial, Marketplace, Medicaid and Medicare enrollees. Questions are grouped into the following categories:
- Getting Care Quickly
- Getting Needed Care
- Coordination of Care
- Rating of Personal Doctor
- Rating of Specialist Seen Most Often
|
-
Rating of All Health Care
- Rating of Health Plan
- Customer Service (health plan)
- Claims Processing (health plan)
|
While some CAHPS questions focus on health plan experience and services, others specifically address patients’ experience with primary and specialty care:
- Appointments as soon as needed
- Specialist appointments when needed
- Getting care right away when needed
- Personal doctor informed about care from other doctors
- Ease of getting care, tests, treatment
|
- Personal doctor listened carefully
- Personal doctor's explanations understandable
- Personal doctor showed respect
- Personal doctor spent enough time with patient
|
CAHPS scores are a key component of health plan accreditation by the National Committee for Quality Assurance (NCQA). These scores are also used to calculate annual health plan rankings published by NCQA and Consumer Reports. Selected CAHPS results are also part of the Medicare Stars ratings assigned to Medicare cost and dual-eligible plans.
What is HOS?
HOS is a survey administered by the Centers for Medicare and Medicaid Services (CMS) to Medicare cost and dual-eligible enrollees. Respondents are surveyed twice in a two-year period to assess changes over time. HOS consists of questions about respondents’ physical and mental health status and behaviors, activities of daily living, history of medical tests and treatment, and rating of physical and mental health. Several HOS measures are used to calculate Medicare Stars ratings:
- Improving or Maintaining Physical Health
- Improving or Maintaining Mental Health
- Monitoring Physical Activity
- Reducing the Risk of Falling
HOS information is also used for case-mix and risk adjustment and as a data source for clinical outcomes measures as part of the Healthcare Effectiveness Data and Information Set (HEDIS®).
How Medica uses CAHPS and HOS data
Medica analyzes CAHPS and HOS results annually to identify trends and opportunities for improvement. Some activities underway in 2016 to improve key rates include targeted member outreach, newsletter articles, staff training, and collaboration with external partners such as the American Cancer Society.
Annual notice:
Medica monitors Quality Improvement program goals for 2016
Medica prepares an annual Quality Improvement Work Plan to outline key quality improvement (QI) activities for the year. The work plan encompasses clinical quality, service quality, provider quality and patient safety, as well as community collaborations and ongoing quality monitoring activities. As of second quarter, the 2016 QI Work Plan features 28 individual quality improvement activities, 18 ongoing quality monitors and six community collaborations. More QI activities can potentially be added throughout the year.
Some Work Plan initiatives that may interest medical groups include activities to:
- improve depression management and antidepressant medication adherence
- improve well-child visit rates for select populations
- implement interventions to address opioid overprescribing
- implement process improvements to improve the member experience
The Medica QI program supports the Medica mission to meet its customers' needs for health plan products and services. The QI program's purpose is to identify and implement activities that will improve:
- member care, service, access and/or safety;
- service to providers, employers, brokers and other customers and partners; and
- Medica internal operations.
This program encompasses a wide range of clinical and service quality initiatives affecting Medica members, providers, employers and brokers, as well as internal stakeholders throughout Medica.
Medica evaluates its QI program annually, reviewing the year's QI activities and assessing progress toward goals. Medica also looks at its QI committee structure, program resources, and key challenges and barriers encountered during the year. Each year's program evaluation forms the basis of the next year's work plan.
The Medica Quality Improvement Subcommittee (QIS) of the Medical Committee of the Medica Board of Directors directs and oversees QI program implementation. QIS serves as a peer-review body, receiving and reviewing aggregate data on all aspects of clinical and service quality. QIS approves program activities, recommends policy changes and follows up on improvement opportunities.
For more details about the Medica QI program:
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Pharmacy News
Effective October 1, 2016:
Medica to make coverage change to viscosupplement drug class
In a continuing effort to make medications more affordable to its members, Medica will soon make a coverage change in the viscosupplement category of medical pharmacy drugs. These drugs are also known as hyaluronic acid (HA) derivatives. Effective with October 1, 2016, dates of service, Medica will no longer cover Synvisc® or Synvisc-One®. The preferred single-dose regimen in this drug class will be Gel One®, while Medica will continue to provide coverage for Euflexxa®, too. All other products in the viscosupplement/hyaluronic acid derivative category remain not covered.
This change will apply to all Medica members except Medica Medicare members.
Products in the viscosupplement/hyaluronic acid derivative category do not require prior authorization. However, they are managed according to conditions of their respective claims edit or coverage policies. Refer to Medica coverage criteria for reimbursement of products for:
Reminder:
Requesting drug prior authorizations online from Magellan Rx
For quicker response times when requesting prior authorization for medical benefit drugs for Medica members, providers can use an online tool from Magellan Rx, which manages this program. Last year, Medica implemented prior authorization for select specialty drugs administered by providers and billed under the medical benefit (i.e., medical benefit drugs). Use the Magellan Rx tool.
Using the online portal takes less time, even allowing approvals in real time. Going online provides a streamlined process that offers convenient access to a secure self-service website, allowing providers to submit prior authorization requests, track requests currently in progress, and view existing authorizations. New users can select the link "New User Request Access."
More details on prior authorization for medical benefit drugs are available at the Medica website, which includes a link to drug policies on the Magellan Rx website. See more on medica.com (under “Medical Benefit Applies”).
Providers who have questions or would like to inquire about a Magellan Rx training can send an e-mail to the Medica Provider College or call the Medica Provider Service Center at 1-800-458-5512.
Effective October 1, 2016
Upcoming changes to Medica Part D drug formularies
Medica posts changes to its Part D drug formularies on medica.com 60 days prior to the effective date of change. The latest lists will notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective October 1, 2016. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. As of August 1, 2016, view the latest Medicare Part D drug formulary changes.
Medica periodically makes changes to its Medicare Part D formularies: the Medica Prime Solution® Part D closed formulary (4-tier + specialty tier) and the Medica DUAL Solution® Part D closed formulary. The Medica Medicare Part D drug formularies are available online or on paper:
Medication request forms
A medication request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:
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Network News
Effective October 1, 2016:
Medica to update Medicare physician fee schedule
Beginning with October 1, 2016, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. This fee schedule change will reflect the October 2016 Centers for Medicare and Medicaid Services (CMS) update applicable to reimbursement for injectable drugs and immunizations. The reimbursement impact of this quarterly update will vary based on specialty and mix of services provided. Updates for durable medical equipment (DME) and orthotics and prosthetics (O&P) will not be implemented at this time.
Details on Medicare changes to drug fees are available online from CMS. Providers who have further questions may contact their Medica contract manager.
'Lag,' quarterly PCR checks to be mailed in July, August
Medica plans to mail final 2015 physician contingency reserve (PCR) distribution checks, or "lag" checks, to providers in late July 2016. Medica returned 100 percent of the PCR withhold for the Medica Prime Solution® Medicare product for 2015, including the lag return. The final 2015 distribution will include PCR withheld from claims with dates of service that fell outside the 90-day submission window for each quarter of last year. The July 2016 distribution will include PCR for claims payments processed through June 30, 2016, plus interest.
In addition, the PCR payment for the first quarter of 2016 for the Medica Prime Solution product is expected to be mailed by the end of August 2016. This represents a 100-percent return of the first-quarter 2016 PCR withhold, plus interest. Checks will cover PCR withheld for claims with dates of service of January 1, 2016, through March 31, 2016, and dates paid of January 1, 2016, through June 30, 2016.
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Administrative News
Reminder:
Provider College administrative training topic for August
The Medica Provider College offers educational sessions on various administrative topics. As published last month, the following class is available by webinar for all Medica network providers, at no charge.
Training class topic
"Advanced Claim Edits, Post-Payments and Pre-Payment Edits" (class code: APPE). This class translates the claim submission process into three components: advanced claim edits or “ACE” edits, which take place at the clearinghouse level; post-payments, which are audits constructed after a claim has been processed and paid; and pre-paid edits, which occur during a coding review prior to claim processing and output. Participants will learn how Medica has enhanced its overpayment detection and recovery program through the implementation of a pre- and post-pay claims editing solution. This class will help providers identify if a claim was denied due to one of these edits, what the denial means, and the appropriate process to appeal those denials. It will also go over the new ACE edit policy that Medica launched on January 1, 2016, which flags missing or potentially inaccurate claim information prior to submitting a claim. This ACE policy allows providers to correct their claim in “real time” to help them avoid receiving pre-pay and post-pay adjustments and denials.
Class schedule
| Class code |
Topic |
Date |
Time |
Notes |
| APPE-WA |
ACE, Post-Pay, Pre-Pay |
Aug. 17 |
1-3 pm |
Class code with “WA” means offered via webinar in August |
For webinar trainings, login information and class materials are e-mailed close to the class date. To ensure that training materials are received prior to a class, providers should sign up as soon as possible.
The time reflected above allows for questions and group discussion. Session times may vary based on the number of participants and depth of group involvement.
Registration
The registration deadline is one week prior to the class date. To register for the session listed, providers may do either of the following:
Effective October 1, 2016:
DME payment to be based on rental rate, not purchase rate
Medica will soon change the way it pays for durable medical equipment (DME) items. Effective with October 1, 2016, dates of service, when providers submit claims for a DME item without using a modifier, payment will be based on the DME item’s rental rate. Currently, when providers submit DME claims without a modifier, the default payment is based on the DME item’s purchase price.
Effective July 1, 2016:
Medica revises reimbursement policies
Medica recently updated the reimbursement policies indicated below, effective with July 1, 2016, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Add-On Code (updated code list) |
Ambulance Policy (updated code list)
|
Bilateral Procedures (updated code list)
|
| Contrast and Radiopharmaceuticals (updated code list) |
| From-To Date (updated code list) |
| Global Days (updated code list) |
| Injection and Infusion Services (updated code list) |
| Laboratory Services (updated code list) |
| Multiple Procedure Reduction (updated code list) |
| Professional and Technical Components (updated code list) |
| Same Day Same Service (updated code list) |
| Services and Modifiers Not Reimbursable to Health Care Professionals (updated code list) |
| Time Span (updated code list) |
These revised policies are available online or on hard copy:
Effective October 2, 2016:
Medica to revise reimbursement policy
Medica will update the reimbursement policy indicated below, effective with October 2, 2016, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Nonphysician Health Care Codes (updated code list) |
This revised policy will be available online or on hard copy:
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SelectCare/LaborCare News
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (June 2016). Highlights that may be of interest to LaborCare® network providers include:
- Reminder to inform patients when referring them to non-network laboratory, pathology providers
- Change to prior authorization for chemotherapy medications — now effective
- New Evaluation and Management Reimbursement Policy — scheduled for September 2016
- Billing change for NDC number, drug quantity — scheduled for January 2017
View the June 2016 UHC provider bulletin.