Reid October Newsletter

As It Relates to You

New Provider Forms

We have new forms to update provider information or add a provider to your practice. Please discontinue using the old forms and use these new ones instead. If you have any questions, contact your provider relations specialist.

New Phone Numbers

With our recent move to Carle at The Fields, our phone numbers have changed. Please use the new phone numbers below.

*Note: The phone number for the Pharmacy Department for Medicare members remains the same: 1-800-851-3379, ext. 6010.

If you have any questions, contact your provider relations specialist.

Flu Season Is Coming

Please remind your patients about the importance of getting vaccinated each flu season. Explain that flu viruses change each year, so a yearly shot is necessary for the best protection. Our members can get their shot for free at in-network pharmacies, clinics or doctor’s offices but may have an office visit copay if they get their shot in a doctor’s office.

Medication Therapy

OptumRx Medication Therapy Management (MTM) is a service for members that reviews all of their medications to make sure they are receiving the best care. It’s free for members, and eligible members are automatically enrolled. However, many members do not use the service to its fullest.

Through the service, a pharmacist calls members to talk about their medications. This pharmacist makes sure members receive the safest medications, educates them on low-cost alternative medications (generics), and answers any questions they may have. After the phone call, members also receive a package of information about their personal medication therapy. OptumRx MTM may also communicate member interactions with prescribing doctors to ensure coordination of care.

This is a great service that tends to be underutilized because many members don’t engage in the calls. If our members ask you about this service, please encourage them to use OptumRx MTM to ensure the safest care.

Preauthorization Reminder

Please remember that if you’ve received preauthorization for a certain CPT code and during the procedure you have to perform something other than what was preauthorized, you need to call eviCore within 24 hours of the procedure to update the CPT code. This helps ensure the claim is paid correctly.

Coding 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:

1. Code truncation, or limiting the number of diagnosis codes per claim submission
2. 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.

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

Appropriate Use of GY Modifier

If you’re submitting a preauthorization request you know will be denied (for example, for patient non-compliance), please submit it as you would any other preauthorization request. Do not apply the GY modifier, which tells our claims system the service is not covered.

When we deny preauthorization requests that don’t have the GY modifier, it automatically sends a letter to the member telling them they’ll be responsible for the full cost of the service if they choose to get it. We want to make sure members receive this important notice, so please refrain from applying the GY modifier unless the service is actually not covered.

New eviCore Enhancements

EviCore has recently added the following features to its website.

1. Urgent Case on the Web-You can now process urgent cases online, without having to call.
2. Expanded Document Upload-You can now upload up to 5 documents online, in .doc, .docs, or .pdf formats.
3. Provider at a Glance-You’ll see a Certification Summary tab in your online account that shows details for recent cases you’ve created.

These changes were implemented based on provider feedback and with the support of various compliance, operations, and clinical departments.

When Insulin is Indicated in Type 2 Diabetes, Consider NPH

Last year, the American Diabetes Association developed a work group to review the marked increase in the cost of insulin, which tripled from 2002 to 2013. These high prices have interfered with patient compliance and the provider’s ability to improve diabetes control. The basal insulin analogs (Lantus and Levemir) and bolus forms (Novolog and Humalog) are extremely expensive. With coupons, Lantus is $278 per vial and Humalog is $178 per vial, according to GoodRx. Prices for pens and cartridges increase these costs to $540 and $550, respectively. The current patient charge for NPH and regular insulin is $24.

An article in the Journal of the American Medical Association (JAMA) from June 23, 2018, indicates that in people with Type 2 diabetes requiring insulin, there is no significant difference in outcomes between basal insulin analogs and NPH insulin. Current literature does support the use of basal/bolus insulin with analogs in persons with Type 1 diabetes, but that recommendation has not been supported by medical literature for Type 2 diabetes.

The JAMA study reviewed more than 25,489 people with diabetes (with an average age of 60) over a 10-year period. There was no difference in hypoglycemia, and diabetic control was actually a little better with NPH and regular insulins. Plus, for a person taking Lantus (60 U daily) and Humalog (20 U TID) at the lowest cost with coupons, the annual cost would be $10,944, compared to $1,152 for an NPH and regular insulin regimen.

In short, higher-priced analog insulins have not been demonstrated to have long-term clinical benefits over human insulin regimens in Type 2 diabetes. NPH insulin can lead to better patient compliance, as it requires fewer daily injections and costs 90 percent less than basal/bolus insulin. Please consider prescribing NPH insulin for people with Type 2 diabetes who require insulin therapy.

Pharmacy Updates

All Plans

Formulary Additions

• Aimovig (erenumab-aooe)
• Tier 4 with QL of 1 dose per 30 days
• Olumiant (baricitinib)
• New Janus-associated kinase inhibitor indicated for the treatment of moderate to severe active rheumatoid arthritis who have had an inadequate response to one or more tumor necrosis factor antagonist therapies
• Same category as Xeljanz
• Formulary placement recommendations
• Non-Formulary
• Xeljanz
• Added to Medicare formulary at Tier 5 with PA
• Siliq (brodalumab)
• Interleukin-17 inhibitor indicated for treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy and have failed to respond or have lost response to other systemic therapies
• Non-Formulary
• Symproic (naldemedine)
• Indicated for treatment of opioid-induced constipation in adults with chronic noncancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation
• Tier 4 with QL (#30/30 days)

Tier Changes

• Rytary—moved from Non-Formulary to Tier 4
• Proposed by Carle Neurology due to better tolerability, dosing flexibility, and reduced pill burden
• Movantik—moved from Non-Formulary to Tier 4 with QL (#30/30 days)
• Aligns with Commercial and Exchange formularies
• Xeljanz—moved from Non-Formulary to Tier 5
• Aligns with Commercial and Exchange formularies

Managed Drug Limitation (MDL) Changes

• Duloxetine—removed MDL
• Escitalopram-removed MDL

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