August 2017
General News
Lori Nelson joins Medica to lead provider strategy, network
Lori Nelson has joined Medica as senior vice president of provider strategy and network development. She reports directly to John Naylor, Medica president and chief executive officer.
Nelson has more than 23 years of health care experience that encompasses all aspects of provider contracting, finance and operations. Most recently, Nelson was chief operating officer at Buckeye Health Plan in Columbus, Ohio. In that role, she oversaw provider contracting, medical management, quality, pharmacy and operations. Prior to joining Buckeye Health Plan, Nelson was vice president of provider relations at Blue Cross Blue Shield of Minnesota. And, before that, she worked on the provider side as director of managed care contracts at Fairview. Nelson began her career in provider network-related operations at Medica as a manager, then director, of provider contracting.
"Throughout her career, Lori has been successful at implementing a number of innovative affordability strategies," said Naylor. "Lori is committed to creating relationships with providers and other stakeholders that focus on delivering value and quality for all constituents."
Reminder:
Premium designation reconsideration requests due by Aug. 7
This month, physicians included in the Premium Designation program received a mailing announcing their new designation for 2017. This year's Premium designations will be displayed online in the fall, tentatively scheduled for September 2017. However, physicians who want their designation reconsidered prior to the fall update of the Medica provider directory should request a reconsideration on or before August 7, 2017.
Submitting a reconsideration request by this date means the request can be completed before the online update. Physicians can request reconsiderations after August 7, although any change to a designation would not be displayed until the reconsideration is complete, which may be after the September update. To learn more and submit a reconsideration request, visit UnitedHealthcareOnline.com.
Also as a reminder, UnitedHealthcare now handles Premium program administration on Medica's behalf.
Reminder:
Telemedicine: coverage, eligible services and proper billing
Medica is committed to supporting its members by providing the best possible service and appropriate access to care. In some instances, remote telephonic care, or telemedicine, may be the difference between service and extraordinary service. When a member is unable to receive in-person care, telemedicine services offer an alternative solution.
Telemedicine is the delivery of health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site. It may be provided by means of real-time two-way, interactive audio and visual communications, including the application of secure video conferencing or store-and-forward technology to provide or support health care delivery, which facilitate the assessment, diagnosis, consultation, treatment, education and care management of a patient's health care. These medical services do not involve direct, in-person contact.
A communication between licensed health care providers that consists solely of a telephone conversation, e-mail or facsimile transmission does not constitute telemedicine consultations or services. A communication between a licensed health care provider and a patient that consists solely of an e-mail or facsimile transmission also does not constitute telemedicine consultations or services.
Medica's coverage does vary between Minnesota Health Care Programs (MHCP) and other non-Medicaid health plans. In general, though, telemedicine is covered, up to three services per week. Refer to the following Medica policies to see a complete list of health services included or excluded for telemedicine services; to learn which health care providers and practices are eligible to bill for them; and to see coverage limitations for them:
Proper documentation lacking for telemedicine services
In January 2017, Medica conducted an audit of medical records related to billing for telemedicine services. Records came from eight random and unique health care providers that billed for telemedicine services from January to May 2016. Patient medical records and visit notes were reviewed to ensure that the documentation included all required regulatory elements as described in Medica's policies for telemedicine services.
The audit revealed that issues exist with documentation submitted by providers. Improvements are needed in the following areas for more efficient payment for billed services:
- Document the need for telemedicine
- Document the mode of submission
- Document the start and end time of the service
- Document the location and/or distance of the patient
- Provide correct codes (CPT, HCPCS and modifiers)
Providers are encouraged to keep these factors in mind when billing for telemedicine services. Doing so helps speed the processing of related claims, helping to avoid delays or denials.
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Clinical News
Effective September 18, 2017:
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. These policies will be effective September 18, 2017, unless otherwise noted.
Monthly updates to Medica's policies are available on an ongoing basis. Updates are posted on medica.com prior to their effective date. The medical policy changes effective September 18, 2017, are already posted, and upcoming changes effective October 16, 2017, will be posted in August 2017. Policy changes are expected to be effective as of these dates unless otherwise noted.
The medical policies themselves will be available online or on hard copy:
Helping families prepare for a healthy return to school
Summer vacation is in full swing for families with children. While children are busy filling their summer days with natural antidotes of fresh air, Vitamin D and possibly extra sleep, it is time for parents, caregivers and health care providers to think about back-to-school preparedness.
Back-to-school immunizations
When students are packed into classrooms during the school year, germ-sharing can easily lead to the spread of illness. Medica encourages all of its members to follow recommended immunization schedules, particularly for children. Immunizations have been proven to be one of the most effective public health strategies in disease prevention and control.
Occasionally, parents may express concerns regarding vaccinations and recommended vaccination schedules, or may even decline vaccinations entirely for their children. These concerns may stem from personal beliefs based on religion, medical practices, socioeconomic factors or philosophical beliefs. It is important for providers to keep an open dialogue with parents and adult patients regarding the importance of immunizations, while directly addressing concerns surrounding vaccination. Efforts to improve immunization compliance may include patient counseling, improving access to vaccinations, offering combination vaccines, sending patient reminders and activating electronic medical record features to alert providers about vaccinations due at the time of office visits.
Here are common concerns that may arise during discussions with parents about childhood immunizations:
- Do vaccines or their ingredients cause autism?
Numerous scientific studies have shown that there is no link between vaccines and autism.
- Are vaccines more dangerous to infants than contracting the disease they are designed to prevent?
A person is less likely to be seriously injured by a vaccine than by a vaccine-preventable disease. Diseases like polio and measles, which are preventable with vaccination, could lead to paralysis, encephalitis or death if contracted by a non-immunized person.
- Will giving too many vaccines overwhelm the immune system?
The purpose for giving more than one vaccination at a given time is to reduce the number of shots a child gets, as with combination vaccinations, while also protecting the child from vaccination preventable diseases during the vulnerable early months of their lives. Scientific studies have shown the recommended vaccination schedule to be safe.
- Do vaccinations contain harmful ingredients, such as the preservative thimerosal?
The preservative thimerosal, which was never present in the measles, mumps, and rubella (MMR) shot, but was used in several vaccines in the 1990s, has been removed from all routinely used childhood vaccines with the exception of influenza multi-dose vials. The purpose of the preservative in multi-dose vials is to safeguard against contamination. Most single-dose vials and pre-filled syringes are not intended for multiple use and do not contain a preservative.
The following resources address immunization concerns, patient education and scientific studies showing vaccination safety:
It is important during discussions about vaccination efficacy and safety to acknowledge parental concerns for a child's well-being while expressing that the child’s health is also a top priority for health care providers. The childhood immunization schedules have been designed to provide disease prevention at the earliest possible time to prevent diseases which may affect infants and children in the early stages of life. Vaccination delay and decline leaves infants and children vulnerable to disease and can lead to outbreaks of disease and serious health complications. It is important to identify potential barriers when speaking to parents and caregivers about vaccinations. Education and conversations about these topics are essential to disease prevention.
ADHD follow-up care
In addition to immunization planning, parents or caregivers of children with attention-deficit/hyperactivity disorder (ADHD) may be needing guidance and support for successfully managing their child’s condition and medications. It is important to conduct appropriate follow-up care after prescribing a patient with ADHD medications. Recommendations by the National Committee for Quality Assurance (NCQA) for follow-up care for children prescribed ADHD medication are as follows:
- Initiation Phase: Re-evaluation by a prescribing practitioner within 30 days of ADHD medication initiation.
- Continuation and Maintenance Phase: A minimum of two follow-up visits with a prescribing practitioner in the 9 months following the initiation phase of a medication.
In addition, children are often taken off their ADHD medication during the summer months, but it should be restarted in time for the beginning of the school year. Parents may need a reminder about this: If they did take a child off an ADHD medication, then they will need to consider restarting it.
Evaluation of treatment efficacy at follow-up visits should consider growth (height and weight), medication side effects, school performance, social interactions and parental evaluation of behavior. The prescribing practitioner should tailor the treatment plan to meet the needs of the individual and his or her family.
Annual Notice:
Medica monitors Quality Improvement program goals for 2017
Medica prepares an annual Quality Improvement Work Plan to outline key quality improvement (QI) activities for the year. The work plan encompasses projects addressing clinical quality, service quality, provider quality and patient safety, as well as ongoing quality monitoring activities. As of second quarter, the 2017 QI Work Plan features 15 individual quality improvement activities and 18 ongoing quality monitors. 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
- implement interventions to address opioid overprescribing
- encourage case management participants to select a primary care physician
- 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, 2017:
Medica plans to update member formularies
Medica is reviewing several medications and will potentially be making changes in coverage status to drug formularies (or drug lists) effective October 1, 2017. For certain Medica members, as noted below, these changes would be effective October 1, 2017, for new prescriptions, but not effective until November 1, 2017, for existing prescriptions.
These upcoming changes may apply to one or more of the following drug formularies:
- 2017 Medica Commercial Large Group Drug List - effective 10/1 for new prescriptions, 11/1 for existing prescriptions (except for specialty drug quantity limit changes to be effective 10/1 for both new and existing users)
- 2017 Medica Commercial Small Group Drug List
- 2017 Medica Preferred Drug List for individual and family business (IFB)
- 2017 Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP) - effective 10/1 for new prescriptions, 11/1 for existing prescriptions
The Medica MHCP formulary applies to the following products: Medica Choice CareSM (for Minnesota Senior Care Plus program, or MSC+), Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs. More about upcoming changes that will apply to Medica Medicare Part D formularies is included below.
Medica will post changes to its drug formularies on medica.com prior to their effective date. To see the latest Medica drug list changes as well as full drug formularies for each member type, refer to medica.com
Medication request forms
A formulary exception 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 submit an exception form or call CVS Caremark.
Effective October 1, 2017:
Upcoming changes to Medica Part D drug formularies
Medica posts changes to its Part D drug formularies on medica.com prior to the effective date of change. The latest lists 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, 2017. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. These latest changes will be posted soon. 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 submit an exception form or call CVS Caremark.
Effective October 1, 2017:
Medica to update drug coverage policies
Medica will soon update the following drug coverage policies, effective with October 1, 2017, dates of service.
Drug coverage policies —Revised
These versions will replace all previous versions.
| Name |
| Ketamine for Mental Health Indications |
| Sublingual Immunotherapy |
These updated drug coverage policies will be available online or on hard copy
Effective October 1, 2017:
Medica to add new UM policies for medical pharmacy drugs
Medica will soon implement the following new medical pharmacy drug utilization management (UM) policies, effective with October 1, 2017 dates of service. Prior authorization will be required for the corresponding medical pharmacy drugs.
Medical pharmacy drug UM (prior authorization) policies — New
Prior authorization will be required.
| Drug code |
Drug brand name |
Drug generic name |
| J1447 |
Granix |
tbo-filgrastim |
| J1442 |
Neupogen |
filgrastim |
These policies will apply to Medica commercial, Minnesota Health Care Programs (MHCP) and individual and family business (IFB) members, but not to Medica Medicare members. All of these policies will be subject to pre-payment claims edits as well.
Note: Filgrastim-sndz (Zarxio) will be the preferred product in this drug category. Prior authorization for Zarxio is not required.
The new medical pharmacy drug UM policies above will be available online or on hard copy:
Effective October 1, 2017:
Medica to add new medical pharmacy claims-edit drug policies
Medica will soon implement the following new claims-edit policies for medical pharmacy drugs, effective with October 1, 2017, dates of service.
Medical pharmacy claims-edit policies —New
| Drug code |
Drug brand name |
Drug generic name |
| Q5101 |
Zarxio |
filgrastim-sndz |
This policy will apply to Medica commercial and Minnesota Health Care Programs (MHCP) members, but not to individual and family business (IFB) or Medica Medicare members.
The new medical pharmacy claims-edit drug policy above will be available online or on hard copy:
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Network News
Effective October 1, 2017:
Medica to update Medicare physician fee schedule
Beginning with October 1, 2017, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. The reimbursement impact of this quarterly update will vary based on specialty and mix of services provided.
Details on Medicare changes to drug fees are available online from CMS. Providers who have further questions may contact their Medica contract manager.
Reminder:
Medica to revise fee schedule for MHCP products
As published last month, Medica will soon implement a revised fee schedule for its enrollees in Minnesota Health Care Programs (MHCP), effective with October 1, 2017, dates of service. The revised Medica MHCP fee schedule will be based on the fee schedule used by the Minnesota Department of Human Services (DHS) to pay providers for services provided to its fee-for-service enrollees. The effect on reimbursement overall for specific clinics will vary by specialty and the mix of services provided. Providers who have questions may contact their Medica contract manager.
'Lag,' quarterly PCR checks to be mailed in July, August
Medica plans to mail final 2016 physician contingency reserve (PCR) distribution checks, or "lag" checks, to providers in late July 2017. Medica returned 100 percent of the PCR withhold for the Medica Prime Solution® Medicare product for 2016, including the lag return. The final 2016 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 2017 distribution will include PCR for claims payments processed through June 30, 2017, plus interest.
In addition, the PCR payment for the first quarter of 2017 for the Medica Prime Solution product is expected to be mailed by the end of August 2017. This represents a 100-percent return of the first-quarter 2017 PCR withhold, plus interest. Checks will cover PCR withheld for claims with dates of service of January 1, 2017, through March 31, 2017, and dates paid of January 1, 2017, through June 30, 2017.
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Administrative News
Effective January 1, 2017:
Medica revises reimbursement policies
As of July 1, 2017, Medica has updated the reimbursement policies indicated below, effective on or after January 1, 2017, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies —Revised
These versions replaced all previous versions.
| Name |
| Co-Surgeon/Team Surgeon (updated code list) |
| Multiple Procedure Reduction (updated code list) |
These revised policies are available online or on hard copy:
Effective October 1, 2017:
Medica to revise reimbursement policy
Medica will soon update the reimbursement policy indicated below, effective on or after October 1, 2017, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Physical medicine and rehabilitation
Effective October 1, 2017, Medica will revise its reimbursement policy titled "Physical Medicine & Rehabilitation: PT, OT and Evaluation & Management" with the following changes:
- The GP modifier ("Services delivered under an outpatient physical therapy plan of care") will be required when billing with Current Procedural Terminology (CPT®) codes 97161-97164 on a CMS-1500 claim form or its electronic equivalent for physical therapy services that have been rendered. Claims that do not include this modifier will be denied.
- The GO modifier ("Services delivered under an outpatient occupational therapy plan of care") will be required when billing with CPT codes 97165-97168 on a CMS-1500 claim form or its electronic equivalent for occupational therapy services that have been rendered. Claims that do not include this modifier will be denied.
These changes will apply to all Medica commercial, Medicare, individual and family business (IFB) and Minnesota Health Care Programs (MHCP) products.
This revised policy will be available online or on hard copy:
Effective October 1, 2017:
Medica to revise reimbursement policy
Medica will soon update the reimbursement policy indicated below, effective on or after October 1, 2017, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies —Revised
These versions will replace all previous versions.
| Name |
| New Patient (administrative update) |
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 (July 2017). Highlights that may be of interest to LaborCare® network providers include:
- New prior authorization requirement for Renflexis (infliximab-abda) medication — scheduled for August 2017
- New prior authorization dosage requirement for chemotherapy drug Yervoy (ipilimumab) — scheduled for August 2017
- Revision to telemedicine reimbursement policy — scheduled for October 2017
- New prior authorization requirement for Solaris (eculizumab) medication — scheduled for October 2017
- New prior authorization requirement for Radicava (edaravone) medication — scheduled for October 2017
View the July 2017 UHC provider bulletin.
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