Reid December Newsletter

December 11, 2018

As It Relates to You

Reminder: Use New Provider Forms

Please remember to use our new forms to update provider information or add a provider to your practice. You’ll find the forms in the Forms & Resources section of Your Health Alliance for providers.

If adding providers to a currently contracted practice, please use the Provider Addition Form, not the Prospective Provider Form. If you have any questions, contact your provider relations specialist.

Use Internet Explorer to Access EviCore

When using eviCore, please use Internet Explorer as your web browser for best results.

We’ve heard that several providers have received error messages when using eviCore in other web browsers, like Google Chrome. According to eviCore, their system is intended to be used in Internet Explorer only. Please keep this is mind when using eviCore.

Focus on High Blood Pressure

A message from Dr. Good, our chief medical officer:

To all providers: Treat high blood pressure. We continue to find that at least 30 percent of all people with a diagnosis of hypertension continue to have blood pressures over 140 systolic. We know that high blood pressure is the No. 1 treatable cause of coronary artery disease, kidney and heart failure, and stroke. Our non-treatment is adding to the CV statistics.

Prehypertension starts at 120 mm and usually many years before a diagnosis is made. Damage to the vascular system is already occurring at the prehypertension stage. Diet and lifestyle changes should start at this time

Hypertension is generally straightforward in treatment. Although white coat hypertension exists, it can be easily ruled out with verifiable home blood pressure readings. However, published studies suggest that people with white coat hypertension also have increased risk of vascular disease.

Thank you for your cooperation in addressing this serious health issue.

Updates to HEDIS Measures for 2019

Controlling High Blood Pressure. NCQA has revised this measure to reflect a new blood pressure target of < 140/90 mm Hg for all adults ages 18–85 with hypertension in accordance with updated clinical recommendations. NCQA has also updated the approach to allow for more administrative methods to collect the measure and added telehealth encounters to satisfy certain components of the measure.
Excluding Members With Advanced Illness. Quality measures that were designed and intended for a general adult population may not always be appropriate for those with limited life expectancy or advanced illness and frailty. As such, NCQA is implementing cross-cutting exclusions across selected HEDIS measures to help focus on the population that is most likely to benefit from the measured services.

For HEDIS 2019, the following nine measures exclude individuals 65+ who have an advanced illness and frailty or who live long-term in nursing home settings.*

Breast Cancer Screening
Colorectal Cancer Screening
Comprehensive Diabetes Care
Controlling High Blood Pressure
Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
Osteoporosis Management in Women Who Had a Fracture
Persistence of Beta-Blocker Treatment After a Heart Attack
Statin Therapy for Patients with Cardiovascular Disease
Statin Therapy for Patients with Diabetes

* Members with these conditions may not be excluded during HEDIS chart review.

HEDIS® Chart Reviews Coming Soon

Each spring, Health Alliance collects data to determine how we measure up against national averages for HEDIS® (the Healthcare Effectiveness Data and Information Set). This data collection and analysis indicates where we need to focus our quality efforts and is required for NCQA accreditation.

Successfully generating our HEDIS report depends largely on the cooperation we receive from provider office staff. Our representatives may visit your office in the spring and ask to review specific medical records or ask you to copy, fax, or mail records to us as part of the audit. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations.

Results of the HEDIS audit will be available on our website in the fall of 2019. If you have any questions about HEDIS, contact the Quality Management Department at 1-800-851-3379, ext. 28947.

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

Coding Reminders

Both the Medicare Advantage and commercial Marketplace condition category models are dependent on us receiving accurate diagnosis codes through claims submission. All claims submitted to us must have associated diagnosis codes. There are two areas of opportunity we need your assistance in addressing:

Code truncation, or systems limits on 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 leave gaps in accurate reflections of the overall risk of the population and may inadvertently omit members from being included in care management programs directed at assisting with health outcomes for their chronic conditions. 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 or have concerns that the above applies to your system, contact us at CodingCounts@healthalliance.org, and we’ll reach out to help with a solution.

For useful information on documentation and code reporting,subscribe to our coding e-newsletter.

Statins for Patients with Diabetes

Studies show that statin use in people with diabetes can reduce major cardiovascular events by 35 percent and strokes by 48 percent.

“Statin use in Patients With Diabetes” is a Star measure that follows the American Diabetes Association recommendation that people with diabetes ages 40–75 take a statin medication. This specific measure reflects the percentage of members who have filled at least two prescriptions for diabetes medication and have filled a prescription for a statin.

This Star measure is an administrative HEDIS measure, which means data is collected from claims submitted to Health Alliance. To get accurate results, claims information must be complete, reflecting accurate diagnosis and any conditions that may exclude a member from the denominator. Members with end-stage renal disease and members enrolled in hospice are excluded from the data.

Please discuss the importance of statin use with your patients who have diabetes.

Encourage Chlamydia Screening

Please discuss chlamydia screenings with patients and the parents of teen/young adult patients. 2017 marked the fourth year in a row in which the number of infections nationwide increased.

Eligible population for screening: Women 16–24 years as of December 31 of the measurement year.

One way to reduce the stigma associated with this screening is to encourage getting it as a preventive measure rather than framing it as a sexual-related issue.

Chlamydia is treatable with antibiotics, but it can have long-term consequences when undetected or untreated. Chlamydia can also cause infertility in women.

The national screening average is 50.2 percent. Our 2017 final screening rates are as follows.

Commercial HMO/POS: 34.4%
Marketplace HMO: 34.5%
Marketplace POS: 31.3%

Procedure codes for chlamydia screening:

87270
87320
87490–87492
87810

End-of-Year Screening Reminders

As we wrap up 2018, ensure patients are getting appropriate preventative services to identify any issues or gaps in care.

All Patients

Colorectal cancer screening
Controlled blood pressure reading
Medication review

Women

Breast cancer screening
Osteoporosis screening in women with a fracture

Patients with Diabetes

Controlled A1c readings
Nephropathy testing
Diabetic eye exams

Children/Adolescents

Document counseling for nutrition
Document counseling for physical activity

As a reminder, we have health coaching and care coordination services that can help our members better manage their conditions at no extra cost. These services can help improve their health outcomes between visits to your office.

Encourage Physical Activity in Winter

Physical activity is important for all ages and in all seasons. The American Heart Association recommends at least 150 minutes of moderate exercise or 75 minutes of vigorous exercise (or a combination of both) per week, and it doesn’t make exceptions for winter.

Staying active in the winter can be difficult for many. Talk to your patients about ways they can stay active in the winter, including:

Going to an exercise class
Working out at home with a DVD or free online tutorial
Walking around the local mall
Joining a gym

Pharmacy Updates

Medicare

Formulary Additions

Jynarque (tolvaptan)

Vasopressin antagonist indicated to slow the progression of autosomal dominant polycystic kidney disease (ADPKD)
Formulary placement recommendations:

Commercial—Tier 5 with preauthorization (PA)
Medicare—Tier 5 with PA

Luxturna (voretigene neparvovec)

One-time treatment approved for children and adults with retinal dystrophy due to a mutation of the retinal pigment epithelial 65 kDa protein (RPE65) gene, which causes severe visual impairment beginning in infancy
Formulary placement recommendations:

Commercial—Tier 6 with PA; change to criteria point #5 noted above
Medicare—Part B only

Mepsevii (vestronidase alfa-vjbk)

The first and only enzyme replacement therapy available to treat mucopolysaccharidosis VII (MPS VII, Sly syndrome)
Formulary placement recommendations:

Commercial—Tier 6 with PA
Medicare—Part B only

Palynziq (pegvaliase-pqpz)

Phenylalanine-metabolizing enzyme indicated to reduce blood phenylalanine concentrations in adult patients with phenylketonuria who have uncontrolled blood phenylalanine concentrations greater than 600 micromol/L on existing management
Formulary placement recommendations:

Commercial—Tier 6 with PA; update Continued Approval section as noted above
Medicare—Non-Formulary

Criteria Changes

Kuvan

Exclusion section states that we will not cover concurrent use of Kuvan and Palynziq

Spinraza

Updated baseline motor milestone scores criteria

Tier Changes

Desvenlafaxine ER (Pristiq)—moved from Tier 4 to Tier 2

This places it on the same copay tier as desvenlafaxine ER (Khedezla)

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