Carle October Newsletter 2022

Falling Into Gratitude

It’s hard to believe we’re already a month into fall. As the weeks ahead take us into Halloween, Thanksgiving and the many other traditions we celebrate this time of year, we want to once again celebrate you. Without our provider partners, our members could never get the high-quality, compassionate healthcare they depend upon. Thank you for being there for our members. For being there for us. Like the autumn freshness, you bring health and hope to so many.

As It Relates to You

Key information for you and your staff.

Beyond Pink

October is Breast Cancer Awareness Month. You’ll probably see a lot of beautiful pink ribbons and artwork raising awareness. We’re always so heartened and encouraged by everyone doing all they can to bring attention to the disease. But what else can you – as healthcare providers – also be doing to further aid the cause?

Most importantly, remind your patients to get their regular mammograms. These screenings detect issues early, when they’re easiest to treat. In fact, according to the CDC, mammograms can even detect cancer up to three years before it would be physically felt.

Following guidance from the American Cancer Society^®, women age 45 to 54 should get mammograms every year, while those 55 and older can switch to every two years or continue yearly screenings. Women at higher risk of breast cancer should start getting mammograms before age 45. Many health plans cover these screenings at no cost to the patient. Please advise your patients to call the number on the back of their health plan ID cards for questions about coverage.

You should also remind your patients about the importance of breast self-exams. A monthly self-examination is easy to do and only takes a few minutes.

Also important – encourage your patients to make healthy lifestyle changes to help lower their risk of breast cancer. Promote physical activity, maintaining a healthy weight and limiting how much alcohol they drink.

Finally, share helpful information and resources with your patients. We have many at hally.com, including an insightful podcast with Dr. Maria Grosse Perdekamp of the Mills Breast Cancer Institute at Carle. All they have to do is visit hally.com and search “breast cancer.” We add more health and wellness resources every month.

The ABCDs of Medicare – Understanding the Different Types of Plans

It’s time once again for the Medicare Annual Enrollment Period, which takes place October 15 through December 7. As your patients look at their options and try to decide what’s best for them, they might come to you with questions. Here’s a quick review of some of the different types of Medicare coverage they can choose:

• Original Medicare is offered through the federal government and includes Part A (hospital coverage) and Part B (medical coverage). Like the other types of Medicare, it’s available for those who are 65 or older or have certain disabilities. Beneficiaries with Original Medicare can see any provider who accepts Medicare, but they won’t have extra perks or pharmacy coverage.
• Medicare Advantage (Part C) plans are private health plans that replace Original Medicare. They often include pharmacy coverage and extra perks, like dental, hearing and vision benefits. These plans typically have a provider network and can offer more care coordination than Original Medicare.
• Medicare Supplement (also known as Medigap) plans are sold through private insurance companies. They don’t replace Original Medicare but work as an add-on alongside it to help pay for what Original Medicare doesn’t. In general, they don’t cover additional services or offer extra benefits or perks – they simply pay (part of) the remainder of the bill since Original Medicare doesn’t pay the full 100% of many of the services it covers. Beneficiaries can generally see any provider who accepts Medicare.
• Finally, many people who have Original Medicare – whether they have a Medicare Supplement plan or not – also purchase standalone Part D plans to cover their prescription drugs. As mentioned above, many Medicare Advantage plans already have prescription coverage built in.

We invite you to visit the Understand Medicare page on our website for additional information, and as always, feel free to reach out to your provider relations specialist with any questions. And perhaps most helpful, we encourage you to visit our

Take Action This Flu Season

This year – like the last two – it’s of increased importance that people in our communities get their yearly flu shot. With the COVID-19 pandemic still among us, we need to be doing all we can to recommend both the flu and COVID-19 vaccines (and boosters, as appropriate). According to the CDC, recommendations – and even simple reminders – from their trusted providers are a critical factor in whether many adults get vaccines for themselves and their families.

With this in mind, the CDC is again leading a SHARE campaign to urge providers to do all they can to encourage their patients to get their yearly flu shot. Here are the basics, directly quoted from their campaign:

• S – Share the reasons why the influenza vaccine is right for the patient given his or her age, health status, lifestyle, occupation or other risk factors.
• H – Highlight positive experiences with influenza vaccines (personal or in your practice), as appropriate, to reinforce the benefits and strengthen confidence in influenza vaccination.
• A – Address patient questions and any concerns about the influenza vaccine, including side effects, safety and vaccine effectiveness in plain and understandable language.
• R – Remind patients that influenza vaccines protect them and their loved ones from serious influenza illness and influenza-related complications.
• E – Explain the potential costs of getting influenza, including serious health effects, time lost (such as missing work or family obligations) and financial costs.

Each patient is different, and you know them best. Consider the best approach that’ll let them know just how important the flu vaccine is and why they and their families should get it. With your help, our communities can stay safer – and breathe easier – this flu season. Thanks for your help in this vital endeavor.

It varies according to health plan, but flu shots are covered at no cost to our members in most cases. Your patients can call the number on the back of their health plan member ID card to learn more about costs and where they can go to get their shots.

Coming Soon – Provider Satisfaction Survey

We depend on you to take care of our members’ health, and we deeply value your opinion. Each year, we send provider satisfaction surveys to a random sample of our providers. We use the feedback from these surveys to make changes to our processes as part of our effort of constant improvement. If you receive a survey, please take the time to give us your honest feedback. It’s how we’re best able to adapt and meet your current and future needs.

We thank you in advance for your help with the survey and – as always – for the excellent care you give our members.

Credentialing Checklist for Provider Use

We’ve recently updated our Credentialing Checklist and made it available for our providers to use, making it easier for you to know what items are required.

Click here for the Provider Credentialing Checklist.

Click here for the Ancillary/Facility Credentialing Checklist. 

Effective immediately, all providers are required to complete and return the checklist, along with the necessary items, before the credentialing packet will be sent to our credentialing department. If the packet isn’t complete or the checklist isn’t included, the provider will not be sent to credentialing until all items are complete.

Also, please note: We do require the CAQH/Provider ADD form for all providers, regardless of CAQH status/enrollment.

Important Reminder – Complete Your Annual Attestation Form

We’re committed to making sure our contracted providers are compliant with the Centers for Medicare & Medicaid Services (CMS) guidelines – outlined in the Medicare Managed Care Manual and/or the Prescription Drug Benefit Manual – for the services provided on our behalf.

We require First Tier, Downstream and Related Entities (FDRs) under our Medicare Advantage plans, Part D plans and Qualified Health Plans to complete an attestation form annually to show you’ve met the CMS requirement. This form must be completed by your organization’s CEO, COO or compliance officer.

If you haven’t already, please complete your attestation form and send it to Provider.Relations@HealthAlliance.org. As always, feel free to contact your provider relations specialist with any questions. Thank you.

We Need Your Help – Please Keep Your Provider Information Up to Date

Federal and state governments require you to review and update your provider information in a timely manner or whenever there are significant changes.

Please send all provider updates to Provider.Updates@HealthAlliance.org. Note that this is a new email address. Your provider relations specialist will continue to be your contact for all other inquiries. Thanks for all that you do.

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Help Us Move the Needle

Together we can help people live their healthiest lives. Find reminders, tips and more in this section, to guide improvements in patient outcomes. Help us move the needle.

World COPD Day

Each year, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) hosts World COPD Day to raise awareness and share knowledge about the disease. Mark your calendars for Wednesday, November 16, as this year’s theme is “Your Lungs for Life.” According to GOLD:

“This year’s theme aims to highlight the importance of lifelong lung health. You are born with only one set of lungs. From development to adulthood, keeping lungs healthy is an integral part of future health and well-being. This campaign will focus on contributing factors to COPD from birth to adulthood and what we can do to promote lifelong lung health as well as protect vulnerable populations.”

Please continue to educate your patients and families on keeping their lungs healthy – by avoiding cigarettes, air pollution and occupational exposures. Make sure they stay active through regular physical activity or pulmonary rehab. And remind them that getting their recommended vaccines, keeping their medical appointments and taking their medications correctly can also help keep their lungs healthy.

Find helpful resources – to both use and share with others – here.

COPD and Shingles

Did you know that the risk of getting shingles increases with age – and that those with certain long-term health conditions like COPD are more likely to get the disease? Shingles isn’t life threatening, but it can be incredibly painful. The CDC recommends that most healthy adults 50 and older should receive the shingles vaccine. Talk to your patients about scheduling this important vaccine.

Closing Gaps in Care: End-of-Year Screening Reminders

It’s hard to believe, but late summer has given way to autumn, and 2023 will be here before we know it. As this year comes to a close, it’s important you make sure that your patients are getting the appropriate preventive services needed to identify any issues and close any gaps in their care. As appropriate, please remind your patients about the following end-of-year screenings:

All Patients:

• Colorectal cancer screening.
• Blood pressure reading.
• Medication review.

Women:

• Breast cancer screening.
• Osteoporosis screening for women who’ve had a fracture.

Patients with Diabetes:

• A1C test.
• Nephropathy screening.
• Diabetic retinal eye exams.

Patients with Rheumatoid Arthritis:

• Treatment with a disease-modifying antirheumatic drug (DMARD).

Also, please remember we have health coaching and care coordination services that can help our members manage their conditions at no extra cost to them. We know you worry about your patients’ health between visits, and these services can help improve their health outcomes throughout the entire year.

Care for Your Patients with Hypertension

Did you know hypertension’s the most common reason people visit a clinician? It affects almost one-third of American adults and is uncontrolled in nearly half of the cases. Hypertension is not only common, but dangerous too – it’s a major risk factor for heart disease, stroke and kidney disease. In fact, for individuals age 40 to 89, the risk of death from ischemic heart disease and stroke doubles for every 20 mm Hg. With hypertension both so common and so harmful, here are some important tips for you and your staff:

• Consider further clinical intervention for your patients with uncontrolled hypertension.
• Provide both initial and ongoing training to your staff to make sure they’re taking blood pressure readings correctly. This includes these practices:
  • Have patients sit in a chair with their feet on the floor and their arm supported so their elbow is at heart level. The inflatable part of the cuff should completely cover at least 80% of the upper arm. The cuff should be placed on bare skin, not over a shirt, and make sure to have the patient remove any tight-sleeved clothing.
  • Encourage staff to assess whether patients have used nicotine or caffeine, have exercised in the last 30 minutes, or have a full bladder, since these can affect the reading.
  • When blood pressure shows up as elevated, take a second reading after the patient has rested.
• Encourage your patients to monitor their blood pressure at home, and don’t forget to ask patients to bring their home blood pressure cuff into your office for calibration. Share this helpful video with them – it guides them through taking their blood pressure at home.
  Note: With the expanded use of telehealth, the National Committee for Quality Assurance (NCQA) has made changes allowing increased inclusion criteria for blood pressure monitoring, to now also include member-reported blood pressures taken on any remote digital device for the Controlling Blood Pressure HEDIS^® The patient-reported blood pressure must be recorded and dated in the patient’s chart. Patient-reported blood pressures taken with a manual cuff are not acceptable. See this CDC webpage for more information.
• Educate your patients on their blood pressure goals, as well as when to report their at-home readings.
• Encourage patients to lead a healthier lifestyle, including maintaining a healthy weight, reducing sodium intake and getting enough exercise.
• Stress the importance of medication adherence to your patients.
• Consider prescribing a statin medication as well.
• Consider non-pharmacological treatments in addition to medications.
• Encourage patients to sign up for health coaching or care coordination. Our members can call the number on the back of their health plan ID card to learn more.

Guidance for Breast Cancer Screening with Conventional Mammography

We know it can be difficult keeping track of the various recommendations and guidelines for the many different preventive screenings your patients need. Fortunately, the U.S. Preventive Services Task Force (USPSTF) creates short, easy-to-understand resources just for providers. October is Breast Cancer Awareness Month – a perfect time to re-familiarize yourself with the Task Force’s recommendations for mammograms.

To easily find – and read over – their clinical summary for Primary Screening for Breast Cancer with Conventional Mammography, visit the USPSTF Breast Cancer Screening webpage. Scroll down to “Clinician Summary,” and then click “View the Clinician Summary in PDF” to download the short document. In it you’ll find screening guidance by age; recommended screening intervals; assessments of other breast cancer screening methods (other than conventional mammography); and additional information and recommendations.

What to Know About Antidepressant Medication Management

Millions of Americans deal with major depression. It’s a common, but treatable, disease. Here’s some important information about pharmacologic avenues of treatment, which have been beneficial to many patients.

• Although most patients respond favorably to pharmacologic treatment, many do not have complete symptom relief.
• Since there’s relatively little variation in the effectiveness of different antidepressants, medication choices for each patient should be based on their individual characteristics and health history, anticipated side effects and safety.
• For those patients whom a medication isn’t effective – or only partially effective – you can consider changing drugs or augmenting with a second medication. This is sometimes helpful.
• It’s important to remember that all antidepressant medications are capable of producing harmful side effects. Some patients could even have an increase in suicidal thoughts due to the drugs. Additionally, some antidepressants are prone to dangerous drug-drug interactions. For all these reasons, close follow-up is required every time you start someone on a medication or adjust dosages – and, as best practice, you should always (not only at the start or when making changes) keep a close eye out for any issues.

Here are some key recommendations:

• As mentioned above, closely monitor your patients for side effects, suicidality and any other potentially harmful issues. Also important is to monitor the effectiveness of the drug.
• If you see no improvement in your patient after four to 12 weeks of taking the medication, consider a change in therapy.
  • The next option could be a different drug of the same class, one from a different class or augmentation with a second agent.

Finally, know that the risk factors for depression treatment failure include:

• Incorrect diagnosis.
• Inadequate medication dosage or treatment duration.
• Coexisting psychiatric or medical illness.
• Severity of depression.
• Addiction
• Cognitive impairment.
• History of physical or sexual abuse.

Great American Smokeout

Help your patients quit smoking. On Thursday, November 17, thousands across the country will take part in the annual Great American Smokeout^®, challenging themselves to go a full 24 hours without cigarettes. The hope is that they find strength and motivation in being able to go an entire day without smoking, and perhaps decide to quit for good. The day is an initiative of the American Cancer Society^® (ACS) and has brought health, hope and inspiration for nearly half a century. Between now and November 17, encourage your patients to take part, and point them to cancer.org/smokeout for more information about the day, along with tools and resources.

Also, for your patients who are members of our health plans, remind them that we offer access to Quit For Life^® at no additional cost. It’s a built-in part of their plan – just waiting for them to use – where they can get personalized help to quit smoking. They should visit hally.com/care for more information, and call the number on the back of their health plan ID card to see if their plan includes Quit For Life.

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Coding Counts:
The Importance of Accurate Claims Data
in Risk Adjustment Scores

Complete documentation and accurate coding are the key to making sure your patients receive the care they need. An additional factor to accurate documentation is ensuring that outgoing claims are comprehensive and include all diagnoses addressed during the encounter. Below are some common issues that may limit the transmission of claims information.

Claims Truncation

“Claim truncation” means that all of a claim’s data did not flow through to us at the health plan – that is, some of it was cut off or left out, leaving the data incomplete. Some billing clearinghouses limit the number of diagnoses that are transmitted to the health plan, effectively limiting the ICD-10-CM claims data and the HCCs that the plan receives. If your office identifies this issue, you can contact the clearinghouse (or us at the health plan) to make them aware of the issue. They can work with you to provide solutions.

Billing Practices

Best billing practices include submitting comprehensive claims information, every time. Use all of the spaces available on the claim form to encompass all diagnoses that were addressed during the encounter. Ensure ICD-10-CM codes are reflected to the highest-known specificity, both in documentation and on the claim.

Regularly reviewing the flow of claims data from your office not only ensures that the information is complete and accurate, but also results in improved and expedited care for your patients.

We thank you for your exceptional professionalism and attention to detail, and we’re here to help. To find more risk adjustment coding resources, visit our Coding Counts page. Thank you for your continued care and dedication to our members’ health.

Questions?

Please contact us at CodingCounts@HealthAlliance.org.

References Used for This Article

Brandon Solomon, Improve In-Year Performance by Addressing Encounter Data Quality Issues, Pareto Intelligence, 20 September 2019.

Monica M. Watson, Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories, Journal of AHIMA (vol. 89, no.6), June 2018.

Updates to High Cost Medical Drugs List

See the table below for changes to the High Cost Medical Drugs List with effective dates.

Note: Medications removed from the High Cost Medical Drugs List may still require prior authorization.

Note: This article/table does not apply to Medicare plans.

Pharmacy Updates

All Plans

Neurology

Formulary Additions

• Qulipta (atogepant)—Preventive treatment of episodic migraine in adults
  • Formulary placement recommendations for Qulipta
    • Commercial—Non-Preferred Brand with PA and QL #30/30 days
    • Medicare—Non-Formulary
• Vyvgart (efgartigimod alfa-fcab)—Treatment of generalized myasthenia gravis in adults who are antiacetylcholine receptor antibody positive
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Non-Formulary
• Ztalmy (ganaxolone)—Treatment of seizures associated with cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) in patients 2 years of age and older
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary

Psychiatry/Behavioral Health

Formulary Additions

• Quviviq (daridorexant)— Treatment of insomnia, characterized by difficulties with sleep onset and/or sleep maintenance, in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand
    • Medicare—Non-Formulary

Commercial

Neurology

Criteria Changes

• Botox (onabotulinumtoxin A)
  • Deleted Exclusion Criteria section
  • Further clarified Migraine Prophylaxis trial and failure criteria
  • Added nortriptyline and duloxetine to chronic migraine trial and failure criteria
  • Further clarified Migraine Prophylaxis trial and failure criteria
  • Added coverage criteria for pediatric detrusor overactivity associated with a neurologic condition
• Migranal (dihydroergotamine Mesylate) Nasal Spray
  • Added nortriptyline and duloxetine to trial and failure criteria
• Fintepla (fenfluramine)
  • Added Lennox-Gastaut Syndrome diagnosis to criteria
  • Added age requirement: 2+ years old
• P. Acthar Gel (corticotropin)
  • Changed policy name to Acthar Gel
  • Further clarified conditions that are not FDA-indicated
• Radicava (edaravone)
  • Added oral formulation to policy
  • Added medical director review requirement
• Xyrem and Xywav (sodium oxybate)
  • Added Xywav to formulary – Non-Preferred Specialty Pharmacy with PA
• Savella (milnacipran)
  • Added pregabalin as trial and failure prerequisite option
• Austedo (deutetrabenazine)
  • Updated MDL from 60 to 120 tablets
• Ingrezza (valbenazine)
  • Updated MDL from 60 to 30 tablets
• Brineura (cerliponase alfa)
  • Updated approval period to 6 months
• Dalfampridine
  • Updated approval period to 12 months
• Nuedexta (dextromethorphan hydrobromide/quinidine sulfate)
  • Updated approval period to 12 months
• Sabril (vigabatrin)
  • Updated approval period to 12 months

Psychiatry/Behavioral Health

Criteria Changes

• Behavioral Health
  • Removed Khedezla (discontinued), added Caplyta and Saphris
• Dyanavel XR (amphetamine ER) Suspension and Chewable Tablets
  • Added chewable tablets
• Dyanavel XR (amphetamine ER) Suspension and Chewable Tablets
  • Added chewable tablets
• Spravato (esketamine)
  • Updated approval period to 12 months

Pain

Criteria Changes

• Fentanyl Breakthrough Pain
  • Removed Abstral and Onsolis due to discontinuation

New Policies

• Continuous Glucose Monitoring
  • Requires that members be on insulin therapy to ensure CGM usage
• Medications Excluded due to Lack of Clinical Benefit
  • Ensures medications with lack of clinical benefit are not covered under the pharmacy benefit

Additional Criteria Changes

• Ankylosing Spondylitis Immunomodulator Therapies
  • Added Rinvoq

Tier Changes

Committee was presented the following formulary changes:

Positive Changes—Commercial

• Adbry: Move from non-preferred specialty pharmacy to preferred specialty pharmacy
• Nurtec: Move from Preferred Specialty Pharmacy to Preferred Brand
• Ubrelvy: Move from Preferred Specialty Pharmacy to Preferred Brand
• Reyvow: Move from Preferred Specialty Pharmacy to Non-Preferred Brand
• Aimovig: Move from Non-Preferred Brand to Preferred Brand
• Ajovy: Move from Non-Preferred Brand to Preferred Brand
• Xywav: Move from excluded to Non-Preferred Specialty Pharmacy

Negative Changes—Commercial

• Sunosi: Move from non-preferred brand to Non-preferred specialty pharmacy
• Nuvigil: Move from non-preferred brand to Excluded (generic remains on formulary)
• Provigil: Move from non-preferred brand to Excluded (generic remains on formulary)
• Vitafol: Move from non-preferred brand to excluded
• Vitafol-Nano: Move from non-preferred brand to excluded
• Vitafol-OB+DHA: Move from non-preferred brand to excluded
• Tristart DHA: Move from non-preferred brand to excluded
• Vitathely with ginger: Move from non-preferred brand to excluded
• Prenatrix: Move from non-preferred brand to excluded
• Prenatryl: Move from non-preferred brand to excluded
• Dermacinrx Therapy Pack: Move from non-preferred brand to excluded
• Enbrace HR: Move from non-preferred brand to excluded
• Westgel DHA: Move from non-preferred brand to excluded
• Jenliva: Move from non-preferred brand to excluded
• Prenatvite: Move from non-preferred brand to excluded
• Premesisrx: Move from non-preferred brand to excluded
• Fordagel Kit: Move from non-preferred brand to excluded
• Ovace Plus Shampoo: Move from non-preferred brand to excluded
• Ovace Plus Cream: Move from non-preferred brand to excluded
• Ovace Wash liquid: Move from non-preferred brand to excluded
• Condylox Gel: Add ST through Podofilox Solution; Move from preferred brand to non-preferred brand, brand penalty
• Nayzilam: Add QL of 4 per fill/month

Medicare

New Policies

• Medicare D Policy for Camzyos

Tier Changes

Committee was presented the following formulary changes:

Positive Change—Medicare

• Breztri: Move from non-formulary to preferred brand

Please Note: The P&T Committee meets bimonthly and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2022 and potential changes may be made:

• October: Ophthalmology, Specialty.