Reid August Newsletter

As It Relates to You

Subscribe to Informed to Stay in the Loop

This e-newsletter is our way to relay important industry and plan-specific information to you and your staff. We maintain a spreadsheet of all active providers, but we’ve created a more reliable way to keep track of who should receive the newsletter.

Please go to Provider.HealthAlliance.org/Informed and subscribe to the appropriate version of Informed based on your location.

Contact your provider relations specialist with any questions.

Provider Directory Updates through Lexis Nexis

As you know, it is vital your patients have access to accurate, up-to-date information in the provider directory. To ensure this accuracy, the Illinois Department of Human Services, the Illinois Department of Insurance, and the Centers for Medicare & Medicaid Services all require that providers review and update their information quarterly or whenever there is a significant change.

To help you meet this requirement, we have partnered with the search firm LexisNexis Risk Solutions and American Medical Association Business Solutions. They will be reaching out on a quarterly basis by one or more of their three communication channels (phone, fax, and Verify Health Care Portal) to verify that your provider information is accurate.

As a reminder, here is the directory information that must be reviewed and updated:

• Ability to accept new patients
• Street address
• Phone number
• Office Hours
• Hospital privileges
• Any other information that affects availability to the patient

Members must be able to call the phone number listed in our provider directory and make an appointment with that specific provider at that location.

If you have any questions or have trouble with your updates, please contact your provider relations specialist or call our Provider Services team at 1-800-851-3379, option 3.

Thank you for your cooperation in this important initiative.

Colorectal Cancer Screening Updates

Colorectal cancer screening is an important part of preventive care for adults starting at age 50. In the June 2017 publication of the American Journal of Gastroenterology, the U.S. Multi-Society Task Force of Colorectal Cancer updated their recommendations for colorectal cancer screenings.

In an office-based practice setting, they recommend offering colorectal screenings in a tiered, sequential approach.

Tier 1 screening tests are a colonoscopy every 10 years or an annual fecal immunochemical test (FIT) for those who decline colonoscopies.

Tier 2 tests are a FIT-fecal DNA (Cologuard) every 3 years, a flexible sigmoidoscopy every 5 to 10 years, or a CT colonography every 5 years.

Diagnosis Code Reminders

Both the Medicare Advantage and commercial Marketplace adjustment models are dependent on us receiving diagnosis codes through claims submission. All claims submitted to us must have associated diagnosis codes. There are 2 areas of opportunity related to provider business processes that could improve:

• Code truncation, or limiting the number of diagnosis codes per claim submission
• Claims that are not submitted at all (e.g. claims for capitated, custodial care, etc.)

These scenarios lead to inaccurate reporting of the overall risk of our population. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you.

If you identify these issues in your provider system, contact us at CodingCounts@healthalliance.org, and we’ll reach out to help with a solution.

Access useful information on documentation and code reporting from Coding Counts, and sign up for our monthly emails.

5 Ways to Help Improve Patient Outcomes

Here are some key areas you can focus on to have a positive impact on your patients’ health.

1. Help patients control high blood pressure to <140/90. Only 54 percent of Americans with high blood pressure have it under control, according to the Centers for Disease Control and Prevention. Hypertension is a major cause of congestive heart failure, renal failure, MI, and stroke, so we need to be more aggressive with prevention measures.
2. Diagnose diabetes. People have a higher risk of diabetes as they age. More than 25 percent of Americans age 65 and older have diabetes, according to the American Diabetes Association. Many of those people have undiagnosed or uncontrolled diabetes.
3. Screen for colon cancer. Remind all age-appropriate patients to get screened, as the five-year survival rate is 90% when caught early. You can suggest less invasive options than a colonoscopy when appropriate.
4. Keep a patient’s problem list up to date and relevant to the active condition. Code to appropriate level for all active chronic conditions. Sign up at CodingCounts.com to receive the latest coding updates from Health Alliance.
5. Encourage patients to make the most of their healthcare coverage. We offer free care coordination, disease management programs and many other perks. Please remind patients to take advantage of these valuable services.

These steps can improve the quality of care provided to the Medicare Advantage patients, which affects our CMS Star Ratings. This system is a way to measure and improve care provided by hospitals, physicians and other providers in a high-performing network.

The outcomes are based on patient experience, access and processes for Medicare Advantage plans. Our goal is to have the top network of providers and to achieve the top decile of patient satisfaction and quality in the nation.

Pharmacy Updates

Medicare

Formulary Additions

• Fasenra (benralizumab)
• Non-formulary
• Symdeko (tezacaftor-ivacaftor)
• Tier 5 with PA
• Trelegy Ellipta (fluticasone furoate, umeclidinium, vilanterol)
• Tier 3
• Bevyxxa (betrixaban)
• Tier 4 with QL

Tier Changes

• Anoro Ellipta – Move from Tier 4 to Tier 3
• Stiolto Respimat – Move from Tier 4 to Tier 3
• Utibron Neohaler – Move from Non-Formulary to Tier 4

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