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Reid February Newsletter 2019

As It Relates to You

New Preauthorization Form

Please use the new pharmacy preauthorization form when requesting coverage for all drugs covered under either the pharmacy or medical benefit.

We strongly encourage you to submit the form and all chart documentation through Your Health Alliance for providers. This helps ensure more reliable communication and expedited notification of determinations.

Provider Directory Updates

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.

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.

f 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.

ACE Inhibitor Reminders

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

There are a few medications in our regimens that can be successfully used for a variety of indications. The Angiotension Converting Enzyme (ACE) inhibitors are one group of medications that fall into that category. While initially promoted to lower blood pressure, research has demonstrated that the use of these medications can result in significant improvements in end organ function (heart, kidney, cerebral, peripheral vascular) by a variety of mechanisms.

However, these drugs are contraindicated in people with idiopathic or heritable angioedema (especially in those previously sensitive to ACE). People also taking allopurinol may have an increased risk of angioedema.

ACE inhibitors may cause potassium retention and should be used with extreme caution in people with high potassium (associated with potassium sparing diuretics, spironolactone, ARB, etc.), bilateral renal artery stenosis, use of NSAIDS, hypotension, and anemia with CKD. Electrolytes and kidney function should be monitored on an initial and then regular basis when ACE inhibitors are prescribed.

The most common side effect is cough–usually described as a hacking, non-productive cough that may be associated with dyspnea or exercise-induced bronchospasm. The cough is not dose related. Stopping the ACE will result in a slow resolution of the cough, taking up to 30 days to totally clear.

The cough and bronchospasms associated with ACE may take years to develop or may develop upon initiation of the medication. It is important to consider this side effect when patients present with cough, shortness of breath, decreased exercise tolerance, rashes or malaise.

Female patients and those of African descent are more likely to develop ACE inhibitor-induced angioedema compared to other patients.

The use of Angiotension Receptor Blockers (ARB) can be substituted for ACE when a cough develops. However, people can also develop cough and similar symptoms with ARB medications, though the frequency is less.

Members Have Access to Medication Disposal Program

Our individual, fully insured and self-funded members with OptumRx pharmacy coverage through their Health Alliance plans now have access to Deterra®, a safe and convenient way to dispose of unused medication. This program helps reduce the amount of drugs that enter our water system from flushing unwanted meds.

Any member with an OptumRx mail drug benefit can request up to two drug disposal kits per year. They must call OptumRx at 1-800-562-6223 and register a home delivery account.

An OptumRx customer service representative will answer the call, and the member or authorized representative should ask for a Deterra kit. The customer service rep will ask a few questions about why the kit is needed. All the member needs to say is that they need it for disposal of unneeded medication.

The kit should arrive in about 7–10 business days.

During the call, the customer service rep will also talk to the member about the benefits of home delivery and ask if they would like to use it. If the member is not interested, they can say no.

It is important to know that members are not required to change the way they receive their medications to home delivery to take advantage of this program, especially if they already enjoy cost savings at one of our preferred cost-sharing pharmacies, like Walgreens.

If the member or authorized representative wants to ask specific questions about Deterra kits and how to use them, an OptumRx pharmacist may speak to the member. Any other questions about the program can be directed to our Pharmacy Department at 1-800-851-3379, option 4.

Upcoming Surveys Affect Star Ratings

Two surveys that largely influence our Medicare Advantage Star Ratings are the Health Outcomes Survey and the Consumer Assessment of Healthcare Providers and Systems survey.

Medicare Health Outcomes Survey (HOS)

HOS assesses a health plan’s ability to maintain and improve its members’ health in five categories. It reaches homes in April to July.

  • Improving or maintaining physical health
  • Improving or maintaining mental health
  • Monitoring physical activity
  • Reducing fall risks
  • Improving bladder control

Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS)

CAHPS assesses a member’s satisfaction with the health plan in nine categories. It reaches homes in March to June.

  • Annual flu vaccine
  • Getting needed care
  • Getting appointments and care quickly
  • Customer service
  • Rating on healthcare quality
  • Rating of health plan
  • Care coordination
  • Rating of drug plan
  • Getting needed prescription drugs

How You Can Positively Impact Our Surveys

  • Ensure your patients on our Medicare Advantage plans get an annual wellness visit each year.
  • Discuss each HOS survey measure with your patients, such as improving or maintaining physical health.
  • Manage-up our Medicare Advantage plan by discussing resources the health plan offers members to help them work on their health goals outside of the provider’s office. The health plan can guide the patient through difficult understandings and help motivate better health outcomes.

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.

Importance of Statin Therapy

Patients with Diabetes

The American Diabetes Association recommends that people with diabetes who are 40–75 years old be prescribed a statin to reduce the risk of atherosclerotic cardiovascular disease (ASCVD).

This measure addresses patients ages 40–75 with diabetes who do not have ASCVD and who received statin therapy (dispensed at least one statin medication of any intensity) and achieved statin adherence of 80 percent (remained on statin medication for at least 80 percent of treatment period).

If a patient is unable to take a statin, this must be documented and coded annually to exclude them from this specific measure.

Exclusions include:

  • Patients with cardiovascular disease identified by diagnosis or event of MI, CABG, PCI, or other revascularization
  • Pregnancy
  • Receiving IVF
  • Current prescription for clomiphene
  • ESRD
  • Cirrhosis
  • Myalgia, myositis, myopathy, or rhabdomyolysis

Patients with Cardiovascular Disease

The American College of Cardiology and the American Heart Association treatment guideline for cholesterol recommends people with a history of ASCVD take a statin medication to reduce risk for future heart attack or stroke.

This measure addresses males ages 21–75 and females ages 40–75 with a diagnosis of clinical ASCVD who received statin therapy (dispensed at least one high-intensity or moderate-intensity statin medication) and achieved statin adherence (remained on statin medication for at least 80 percent of treatment period).

If a patient is unable to take a statin, this must be documented and coded annually to exclude them from this specific measure.

Exclusions include:

  • Pregnancy
  • Receiving IVF
  • Current prescription for clomiphene
  • ESRD
  • Cirrhosis
  • Myalgia, myositis, myopathy, or rhabdomyolysis

Healthcare Effectiveness Data and Information Set (HEDIS) Results

HEDIS 2018 (measured in 2017) and HEDIS 2017 (measured in 2016)

Statin Therapy for Patients with Diabetes

Commercial HMO/POS HEDIS 2018 HEDIS 2078
Received Statin Therapy 62.94% 61.18%
Statin Adherence 80% 73.80% 74.62%
Medicare HMO/POS HEDIS 2018 HEDIS 2017
Received Statin Therapy 71.46% 69.15%
Statin Adherence 80% 80.87% 82.85%
Northwest Medicare HMO HEDIS 2018 HEDIS 2017
Received Statin Therapy 73.95% 74.16%
Statin Adherence 80% 76.94% 72.95%
Midwest Medicare HMO HEDIS 2018 HEDIS 2017
Received Statin Therapy 77.22% 76.06%
Statin Adherence 80% 80.33% 81.48%

Statin Therapy for Patients with Cardiovascular Disease

Commercial HMO/POS HEDIS 2018 HEDIS 2078
Received Statin Therapy-Total 81.75% 79.49%
Statin Adherence 80% 78.81% 70.97%
Medicare HMO/POS HEDIS 2018 HEDIS 2017
Received Statin Therapy-Total 79.53% 73.60%
Statin Adherence 80% 84.19% 77.90%
Northwest Medicare HMO HEDIS 2018 HEDIS 2017
Received Statin Therapy-Total 86.39% 84.52%
Statin Adherence 80% 83.03% 79.39%
Midwest Medicare HMO HEDIS 2018 HEDIS 2017
Received Statin Therapy 67.50% 78.95%
Statin Adherence 80% NA (population too small) 86.67%

Please discuss the benefits of statin use with your patients, and if you have patients who cannot tolerate one of the statins, make sure to code the reason.

A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have or to provide member-specific examples from your panel of members. If interested, please contact them at CodingCounts@healthalliance.org.

If you have questions, please contact the Quality Management Department at 1-800-851-3379, ext. 28947, option 2.

Categories Removed from 2019 Preauthorization List

As a reminder, more than 5,000 codes no longer require preauthorization in 2019, of which more than 4,500 (90%) required preauthorization only when completed as planned elective inpatient procedures.*

Removed Categories:

  • Cochlear implants and associated DME
  • Endovenous laser ablation/radiofrequency ablation for varicose veins
  • Home health services
  • Intermediate and complex proton beam therapy for specific conditions
  • Skin lesion removals
  • More than 4,500 planned inpatient elective procedures
  • Type 4 portable home sleep tests
  • Vacuum-assisted wound closure/negative pressure wound therapy devices
  • Select codes from the following categories:
    • Ankle, spine, and wrist orthoses
    • Custom fabricated shoes for patients with diabetes
    • Enteral formulas
    • Joint revisions
    • Patient lifts
    • Prosthetic sockets
    • Shoulder surgeries
    • Wheelchair cushions

Please log in to YourHealthAlliance.org for providers to see the full list of CPT and HCPC codes that require preauthorization.

*Please note: Plans that follow preauthorization lists other than the standard list may still require preauthorization for the categories listed above.

Pharmacy Updates

All Plans

Formulary Additions

  • Crysvita (burosumab-twza)
    • Anti-FGF23 monoclonal antibody indicated in the treatment of X-linked hypophosphatemia (XLH) in children ≥ 1 year of age and adults
    • Formulary placement recommendations:
      • Commercial—Tier 6 with preauthorization (PA)
      • Medicare—Tier 5 with PA
  • Galafold (migalastat)
    • Indicated in the treatment of adults with a confirmed diagnosis of Fabry disease and an amendable galactosidase alpha gene (GLA) variant based on in vitro assay data
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA
      • Medicare—Tier 5 with PA
  • Lucemyra (lofexidine)
    • Indicated for the treatment of opioid withdrawal syndrome (OWS): mitigation of opioid withdrawal symptoms to facilitate abrupt opioid discontinuation in adults
    • Formulary placement recommendations:
      • Commercial—Preferred Brand
      • Medicare—Non-Formulary
  • Onpattro (patisiran)
    • Indicated for the treatment of the polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA
      • Medicare—Part B with PA

Criteria Changes

  • Medicare D Morphine Equivalent Dose DUR Exceptions
    • Prescriptions for opioid naïve patients are limited to a 7-day supply per CMS requirement
  • Refill logic
    • Long-term care and retail locations—refillable after 90% used
    • Mail order— refillable after 80% used
  • Lowered MED threshold from 120 to 90mg

Tier Changes

  • Buprenorphine/naloxone sublingual tablets: Moved from Tier 3 to Tier 2
  • Buprenorphine/naloxone sublingual films: Moved from Non-Formulary to Tier 2

 

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