December Newsletter

Pharmacy

Diabetes

For Type 2 diabetes treatment space, Victoza and Tradjenta/Jentadueto are now Tier 2 for commercial members. Effective January 1, 2013, Tier 3 drugs used to treat diabetes will have new preauthorization criteria for members on a non-preferred agent.

Non-preferred DPP4 (Januvia/Janumet/Juvisync and Onglyza/Kombiglyze) and GLP1 drugs (Byetta/ Bydureon) require documentation that the member’s hemoglobin A1c is between 6.5% to 9% and a trial of the preferred agent (Tradjenta for DPP4 and Victoza for GLP1) in addition to the current step, through metformin or a sulfonlyurea.  Members who have met their A1c goal of less than 7% on a non-preferred agent are exempt from the step through the preferred agent.

Pain Management

Oxycontin will be moving to Tier 3 effective January 1, 2013, for commercial members. All non-preferred brand-name long-acting opioids (Avinza, Embeda, Exalgo, Kadian, Nucynta ER, and Oxycontin) will require trial of a preferred long-acting agent (morphine, fentanyl, or Opana ER) prior to coverage of the non-preferred drug. Existing members on a non-preferred agent for malignant pain are exempt from the step edit. Providers with a specialty in pain medicine are also exempt from this edit.
Tramadol extended-release will require a trial of Tramadol immediate-release. Nucynta will require a trial of a Tier 1 short acting agent.

Behavioral Health – Narcolepsy

Provigil and Nuvigil, drugs used in the treatment of narcolepsy, will require preauthorization starting January 1, 2013. Preauthorization criteria will provide coverage for the medically necessary FDA label indications only. Provigil will also require a trial of Nuvigil.

Behavioral Health – Opiod Dependence

Suboxone now has an electronic reverse step edit in place to prevent concurrent opioid prescriptions if a member is prescribed Suboxone.

Behavioral Health/Neurological Disease – Cymbalta

For new starts for all indications and members currently receiving Cymbalta for a pain indication (i.e., fibromyalgia, DPN, musculoskeletal pain), coverage will require trial and failure on more cost-effective generics. Members currently receiving Cymbalta for a psychiatric diagnosis (i.e., depression, GAD) will be grandfathered.

Cardiovascular – Statins

An electronic step edit will be in place January 1, 2013, on brand name statins (Advicor, Altoprev, Crestor, Caduet, Livalo, Lescol XL, and Simcor). The brand name will be covered if there is a documented 90-day trial with the maximally tolerated dose of atorvastatin. Members currently on Crestor 40 mg are exempt from this edit.

Tier Changes

The following drugs will move to Tier 3 effective January 1, 2013.

• Toviaz
• Premarin
• Premphase
• Prempro
• Pristiq
• Cymbalta
• Savella
• Oxycontin
• Lipofen
• Helidac

Health Alliance Partners with TC3

The Centers for Medicare and Medicaid (CMS) requires all Medicare Advantage plans to make a concerted effort to prevent, detect, and correct health care fraud, waste, and abuse. We’ve selected TC3 Health (an Emdeon company) to partner with in this ongoing effort.

Fraud analysis will be conducted on all our claims. Provider offices may see an increase in medical record requests from Health Alliance or TC3 starting in January. If you have questions regarding these requests, please contact Mark Halbach, manager of fraud, waste, and abuse, at 217-337-3488 or Mark.Halbach@healthalliance.org.

HEDIS^® Chart Reviews Are Coming

Each spring, we collect data to determine how we compare to national averages for the Healthcare Effectiveness Data and Information Set (HEDIS). This data collection and analysis indicates where we need to focus our quality efforts and is required to obtain NCQA accreditation. Successfully completing our HEDIS report depends largely on the cooperation we receive from provider office staff. In other words, we need your help.

Gathering data for the HEDIS audit requires access to medical records. Random samples are generated for each HEDIS measure. If your office is identified in one or more sample, you may receive a request by mail or fax to copy and send specific medical records to us, or a representative may visit your office to review and obtain copies of specific medical records relating to HEDIS.

The HEDIS audit is overseen by an external audit group to ensure rigorous compliance to standards and specifications. Our reviewers are professionals who understand the importance of protecting personal health information. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations.

More information about HEDIS is available in your provider manual, and HEDIS results are posted at HealthAlliance.org.

You can review the provider manual on the Forms and Resources page of  Your Health Alliance for providers and office personnel.

If you have any questions about HEDIS, contact the Quality Management department at 1-800-851-3379, extension 8112.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

Diabetes Care Standards Need Improvement

HEDIS scores indicate that our members are not receiving care that meets the national standard of quality set by the NCQA in 2 areas of Comprehensive Diabetes Care.

One is the recommendation of annual LDL-C screenings. Please ensure your patients have their LDL tested at least annually to meet that standard of care.

The second is for monitoring nephropathy. This measure can be met in a number of ways:

• A member has documented ESRD, chronic or acute renal failure, renal insufficiency, diabetic nephropathy, dialysis, or renal transplant.
• Urine test for gross protein that was positive in the measurement year. This can be a simple dipstick protein, but it only counts if the results are positive.
• Any spot urine microalbumin, microalbumin/creatinine ratio, 24-hour urine protein, or random urine for protein/creatinine ratio test in the measurement year.
• Evidence that an Ace inhibitor or ARB therapy was prescribed in the measurement year.

Note:  The GFR test does not meet the HEDIS quality standard for nephropathy monitoring for comprehensive diabetes care. NCQA recently released the following response to an FAQ about GFR use:“GFR testing is not currently acceptable for the Medical Attention for Nephropathy indicator. Clinical experts determined that certain characteristics, such as age, sex and race, may impact the effectiveness of such tests for monitoring nephropathy. If a member was determined to have impaired kidney function based on a GFR test, it is expected that there would be other documentation in the medical record that would make the member compliant for the nephropathy indicator.”

HEDIS measure for Rheumatoid Arthritis

The HEDIS measure for Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis is determined by the percentage of diagnosed adults with rheumatoid arthritis (RA) who are dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD). DMARDs may protect joints and minimize inflammation to slow the progression of the disease and reduce pain.

In 2012, 90% of our Medicare HMO members with RA and 86% of Medicare PPO members with RA received DMARDs.

We encourage you to keep striving to meet this important HEDIS and star rating measure to ensure patients with RA get the most appropriate treatment.

HEDIS/CAHPS Scores Available

Health Alliance’s HEDIS and CAHPS (Consumer Assessment of Healthcare Providers and Systems) scores have been released and are available on HealthAlliance.org.

NCQA accredits and certifies a wide range of health care organizations and manages the evolution of HEDIS, the performance measurement tool used by more than 90% of the nation’s health plans. HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the health care quality.

Here are some Health Alliance HEDIS highlights, or measures that meet or exceed the NCQA Quality Compass® 90th percentile:

Commercial HMO/POS

• Weight Assessment, Nutrition and Physical Activity – Discussing physical activity for children aged 12-17
• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
• Use of Appropriate Medication for People with Asthma – ages 5-11
• Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

Commercial PPO

• Adult BMI Assessment
• Weight Assessment, Nutrition and Physical Activity – BMI assessment in ages 3-11, 12-17 and Total
• Weight Assessment, Nutrition and Physical Activity – Discussing nutrition for children aged 12-17
• Weight Assessment, Nutrition and Physical Activity – Discussing physical activity for children aged 12-17
• Childhood Immunization Status Combinations 4, 7, 8 & 10
• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
• Pharmacotherapy Management of COPD Exacerbation – Systemic Corticosteroid rate (w/in 14 days)
• Use of Appropriate Medication for People with Asthma – ages 12-18
• Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
• Antidepressant Medication Management – Effective Acute Phase Treatment rate (remained on antidepressant for 12 weeks)
• Postpartum Care

Medicare HMO

• Colorectal Cancer Screening
• Pharmacotherapy Management of COPD Exacerbation – Bronchodilator
• Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
• Annual Monitoring for Patients on Persistent Medications – Anticonvulsants
• Initiation and Engagement of Alcohol Dependence Treatment – Initiation

Medicare PPO

• Comprehensive Diabetes – Blood Pressure <140/80
• Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
• Osteoporosis Management in Women Who Had a Fracture
• Antidepressant Medication Management – Effective Continuation Phase
• Initiation and Engagement of Alcohol Dependence Treatment – Initiation

New Provider Relations Specialists

We’re welcoming 2 new Provider Relations Specialists to our team. Jennifer Kagel started on November 19, and her service area is East Central Illinois. Sarah Sturgeon’s first day is December 17, and her service area will be Macomb, Quincy, South Central Illinois and Decatur.

Carrie Kuennen’s last day was October 26, and Anthony Allison’s last day is December 14.

New Providers

Central Iowa

Laura Moeller, MD – Family Practice, Ankeny
Tina Flores, MD – Family Practice, Carroll
Michael Sullivan, LMHC – Behavioral Health, Des Moines
Suzanne Kuhl, LISW – Behavioral Health, Des Moines
Heather Christiansen, PsyD – Pediatric Psychiatry, Des Moines
Alladdin Abosaida, MD – Pediatric Pulmonology, Des Moines
Jennifer Larusso, DO – Dermatology, West Des Moines
Matthew Rauen, MD – Ophthalmology, West Des Moines/ Marshalltown/Fort Dodge
Sarah Tofilon, MD – Oncology, Fort Dodge
Erica Gruen, LMHC – Counseling, Marshalltown

Decatur

Angela Oberreiter, OD – Optometry, Decatur

DeKalb

Heather Mucha, LCPC – Behavioral Health, DeKalb
Nathan Perron, LCPC – Behavioral Health, DeKalb
Rebecca Jaster, LCSW – Social Work, DeKalb
Awais Azmat, MD – Family Practice, Rockford
Qamar Saleheen, MD – Infectious Disease, Rockford
Ahmed Bolkhir, MD – Internal Medicine, Rockford
William Asihene, MD – General Surgery, Sandwich
Maureen Dela Cruz, MD – Family Practice, Sandwich
William Asihene, MD – General Surgery, Sandwich
Jeffrey Cook, MD – Cardiology, Sycamore
Fareha Malik, MD – Psychiatry, Rockford
Patricia Kroll, LCSW – Social Work, Rockford

East Central Illinois

Puja Sharma, MD – Family Practice, Clay City, IN
Tammy Zweeres, NP – Nurse Practitioner, Dwight
Laura Smith, MD – Family Practice, Hoopeston
Donna Cassella-Johnson, LCPC – Behavioral Health, Morris
Morteza Farasat, MD – Cardiology, Urbana
Michael Hennesy, MD – Obstetrics/Gynecology, Urbana
David Zeman, MD – Orthopaedics, Urbana
Harsha Behavioral Center – Behavioral Health Facility, Terre Haute, IN
Kelly Klein, OD – Optometry, Spring Valley
Beth Kunkel, OD – Optometry, Spring Valley

Eastern Iowa

Lauren Doughty-McDonald, MD – Dermatology, Cedar Rapids
Monica Minjeur, DO – Family Practice, Cedar Rapids
Scott Piper, MD – Family Practice, Cedar Rapids
Kahlil Andrews, MD – Plastic Reconstructive Surgery, Cedar Rapids
Housam Soukieh, MD – Pulmonary Medicine, Cedar Rapids
Warangkhana Wongba, MD – Pulmonary Medicine, Cedar Rapids
Penny Freeman LISW – Social Work, Cedar Rapids
Paula Krings, LISW – Social Work, Cedar Rapids
Joella Smith, LISW – Social Work, Cedar Rapids
Dhyana Kaufman, LMHC – Behavioral Health, Iowa City
Linda Cadaret, MD – Cardiology, Iowa City/Coralville
Anthony Johnson, MD – Cardiovascular Disease, Iowa City
Cristina Ogrin, MD – Endocrinology, Iowa City
Elizabeth Cramer, MD – Family Practice, Iowa City/Coralville
Rachael Dirksen, MD – Internal Medicine, Iowa City
Tara Hochwalt, MD – Internal Medicine, Iowa City
Divya Shah, MD – OBGYN, Reproductive Endocrinology, Iowa City
Melanie Frogozo, OD – Optometry, Iowa City
Apurva Shah, MD – Orthopaedics, Iowa City
Amanda Stumpf, DO – Psychiatry, Iowa City
Jeannie Hartel, LISW – Social Work, Iowa City/Dubuque
Monta Saxon, LISW – Social Work, Iowa City
Rodney Spencer, LMSW – Social Work, Iowa City
Rene Genadry, MD – Uro-Gynecology, Iowa City/Coralville
Lila Bjornsdottir, MD – Vascular Surgery, Iowa City
Daniel Leisinger, DO – Family Practice, Oelwein
Megan Sullivan, OD – Optometry, Waverly
Sareem Wani, MD – Internal Medicine, Waterloo
James Harley, DO – General Surgery, Waterloo
Arthur Schmidt, MD – Internal Medicine, Waterloo/Cedar Falls

Northern Illinois

Marcia Huston, MD – Infectious Disease, Aurora
Lizy Andrews, MD – Obstetrics/Gynecology, Bourbonnais
Duncan Hall, LCSW – Social Work, Crest Hill
Mouhannad Kantar, MD – Family Practice, Crest Hill
Megan Lukan, LCPC – Behavioral Health, Elgin
Elizabeth Shelus, OD – Optometry, Geneva
Mohanad Joudeh, MD – Adult/Internal Medicine, Joliet
Surendra Gulati, MD – Neurology, Joliet
Michael Osei, MD – Physical Medicine/Rehabilitation, Joliet
Bernard Charles, MD – Physical Medicine/Rehabilitation, Joliet
Ming Hung, MD – Physical Medicine/Rehabilitation, Joliet
Neelima Kabre, MD – Radiation Oncology, Joliet
Fabiola Espinoza, MD – Infectious Disease, Kankakee
Ashley Chappell, ARNP – Nurse Practitioner, Kankakee
Geetha Narasimhan, MD – Radiation Oncology, Kankakee
Mir Shah, MD – Radiation Oncology, Kankakee
Joseph Pigato, MD – Urology, Kankakee
Adam Cohen-Lewe, DO – Family Practice, New Lenox
Crystal Hines-Mays, MD – Family Practice, New Lenox
Heather Decker, MD – Pediatrics, New Lenox
Ashley Beaudry, LCPC – Behavioral Health, Plainfield
Deborah Vaughan, LCPC – Behavioral Health, Plainfield
Jennifer Waitkus, LCPC – Behavioral Health, Plainfield
Maureen Werrbach, LCPC – Behavioral Health, Plainfield
Stephanie Wiese, LCPC – Behavioral Health, Plainfield
Lisa Goldman, PsyD – Psychology, Plainfield
Jennifer Manfre, PsyD – Psychology, Plainfield
Kathleen Culen, LCSW – Social Work, Plainfield
Julie Franklin, LCSW – Social Work, Plainfield
Rebecca Gadomski, LCSW – Social Work, Plainfield
Abby Koch, LCSW-  Social Work, Plainfield
Miriam Neugebauer, LCSW – Social Work, Plainfield
Adam Russo, LCSW – Social Work, Plainfield

Macomb

Dan Ruiz, MD – Colorectal Surgery, Macomb

Peoria

JaCara Kelley-Muhammad, MD – Family Practice, Galesburg
Lorraine Garland, MD – OB/GYN, Galesburg
Nancy Anderson, LCPC – Counselor, Morton
Curtis Meiss, LCPC – Counselor, Peoria
Ravishankar Hasanadka, MD – General Surgery, Peoria
John Hsu, MD – General Surgery, Peoria
Allison Tanck, MD – General Surgery, Peoria
Anne Risk, MD – Internal Medicine & Pediatrics, Peoria
Hongmei Yang, MD – Internal Medicine, Peoria
Bonnie Keung, MD – Neurology, Peoria
Kumarpal Shrishrimai, MD – Nephrology, Peoria
Diedre Wagers, MD – OB/GYN, Peoria
Stacy Twenhafel, OD – Optometry, Peoria
Juan Carlos Meneses-Paz, MD – Pediatric Critical Care, Peoria
Deepak Taneja, MD – Pulmonary Disease, Peoria
Jianxun Zhou, MD – Physical Medicine & Rehabilitation, Peoria
Emily Aiman, LCSW – Social Work, Peoria
Karen Washington, LCSW – Social Work, Peoria
Melissa Huggins, MD – Uro/gynecology, Peoria
Vanessa Worsley, BCBA – Autism, Washington

Quad Cities

Thomas Staley, MD – Family Practice, Bettendorf, IA
Rick Martenson, LMHC – Counseling, Davenport, IA
Hassan Haji-Abdirahman, MD – Family Practice, Davenport, IA
Mukesh Kumar, MD – Family Practice, Davenport, IA
Janice Willis, LCPC – Behavioral Health, Moline, IL
Waqas Hussain, MD – Orthopaedics, Moline, IL
Aimee Staskal-Brecht, OD – Optometry, Muscatine, IA
Manprett Chhabra, MD – Ophthalmology, Rock Island, IL

Quincy

Rachel Yankey, MD – Family Practice, Quincy
Richardo Garcia-Rivera, MD – Neurology, Quincy
Kamaldeen Saldin, MD – Neurology, Quincy
Eric Sklar, MD – Neurology, Quincy
Anthony Vitto, MD – Neurology, Quincy
Marc Stam, MD – Thoracic Surgery, Quincy
Louis Suarez, MD – Thoracic Surgery, Quincy

South Central Illinois

Andrei Croitoru, MD – Adult/Internal Medicine, Evansville, IN
Yousef Altowaireb, MD – Endocrinology, Evansville, IN
Johnathan Weyer, MD – Ophthalmology, Evansville, IN
Sridhar Bhaskara, MD – Pain Medicine, Evansville, IN
Rebecca Carey, MD – Pediatric Gastroenterology, Evansville, IN
Catherine Gayle, MD – Psychiatry, Evansville, IN
Muhammed Habib, MD – Pulmonology, Evansville, IN
Anna Gilley, MD – Pediatrics, Jasper, IN
David Gilley, MD – Urology, Jasper, IN
Kristopher Gunn, MD – Urology, Jasper, IN
John Girardi, MD – Adult/Internal Medicine, Mt. Carmel
Karsten Slater, MD – Orthopaedics/Sports Medicine, Mt. Carmel, IN
Karenrose Contreras, MD – Obstetrics/Gynecology, Newburgh, IN
Rhonda Trippel, MD – Obstetrics/Gynecology, Newburgh, IN
Wambui Waruingi, MD – Pediatrics/Neonatology, Newburgh, IN
Bradley Houston, MD – General Practice, Olney, IL
Lindy Brentlinger, OD – Optometry, Princeton, IN
James Braunlin, MD – Adult/Internal Medicine, Tell City, IN
Austin Muranaka, DPM – Podiatry, Vincennes, IN
Kiran Burla, MD – Adult/Internal Medicine, Washington, IN

Southern Illinois

Tamer Aiti, MD – General Practice, Anna
Brett Dempsey, MD – General Surgery, Carbondale
Mark Fleming, MD – Neurosurgery, Carbondale
Hetal Amin, MD – Psychiatry, DuQuoin
Matthew Eubanks, MD – Internal Medicine/Pediatrics, Harrisburg
Krystina Eubanks, OD – Optometry, Harrisburg
Shelley Hill, LCSW – Social Worker, Herrin
Alex Garrido-Zambrano, MD – Family Practice, Murphysboro
Pavan Gupta, MD – Cardiology, Sparta
Verletta Saxon, LCPC – Counseling, West Frankfort
Katie Harvey, LSW – Social Work, West Frankfort

Springfield

Karen Brauer, LCPC – Behavioral Health, Havana
Bethany Bitner, MD-  Family Medicine, Havana
Wendy Harmon, LCSW – Behavioral Health, Hillsboro
Ekta Basnet, MD – Pediatrics, Jacksonville
Cynthia Fedor, LCSW – Behavioral Health, Lincoln
Catherine Teodoro, MD – Family Medicine, Pana
Swapna Devanna, MD – Adult Medicine, Springfield
Joanna Ream, MD – Adult Medicine, Springfield
Richard Chiola, LCPC – Behavioral Health, Springfield
Patricia Fehr, LCPC – Behavioral Health, Springfield
Paul Pacheco, MD – Colon-Rectal Surgery, Springfield
Jamie McGinnis, MD – Dermatology, Springfield
Chaitanya Mamillapalli, MD – Endocrinology, Springfield
Mesaya Higuchi, MD – Family Medicine, Springfield
Phyllis Eze, MD – Ophthalmology, Springfield
Senthil Krishasamy, MD – Ophthalmology, Springfield
Steven Lee, MD – Ophthalmology, Springfield
Jianjun Ma, MD – Orthopaedics, Springfield
Shubhangi Peche, MD – Pediatric Neurology, Springfield
Obiora Onwuameze, PSYMD – Psychiatry, Springfield
Daniel Butnariu, MD – Pulmonology, Springfield
Muhammad Siddique, MD – Pulmonology, Springfield
Dragicia Milicevic, MD – Family Medicine, Taylorville

Sterling/Rock Falls

Kari Ernst, ARNP – Nurse Practitioner, Clinton
Hina Khan, MD – Family Practice, Dixon
Thomas Hernandez, MD – Orthopaedics, Dixon
John Plescia, MD – Family Practice, Mt. Morris
Jeanne Worcester, NP – Nurse Practitioner, Sterling
Ajay Kumar Buddaraju, MD – Rheumatology, Sterling