Informed

Sarah Bush Lincoln Leaves Network

April 11, 2018

Sarah Bush Lincoln Health Center gave notice that it will end its contract with us on June 30, 2018. This means as of July 1, 2018, Sarah Bush Lincoln will be considered out-of-network for our commercial group and individual members. While we are disappointed in the decision, we’d like to remind you of our continuity of care guidelines to help best serve our members.

Sarah Bush Lincoln will still be considered a network hospital for our Medicare members, and members on any of our plans can use it for emergency care at the in-network rate. We always cover emergency services as if they were in-network, regardless of whether the hospital is in- or out-of-network.

When a primary care provider or specialist leaves our network, any member who is in an ongoing course of treatment may be eligible to continue care with the termed provider (if certain criteria are met) during a 90-day transitional period. Any member in the 13th week or more of pregnancy may be eligible to continue care with the termed provider through post-partum care. You must request coverage for transitional care within 30 days of receiving notice.

Members with prescription coverage can also fill any remaining prescription refills after the prescribing provider leaves the network.

Our network remains strong and still gives members many options for local health care, including Carle Clinic in Mattoon. Our network also includes these hospitals:

  • Carle Foundation Hospital in Urbana
  • Carle Richland Memorial Hospital in Olney
  • Crawford Memorial Hospital in Robinson
  • Decatur Memorial Hospital
  • HSHS Good Shepherd Hospital in Shelbyville
  • HSHS St. Anthony’s Memorial Hospital in Effingham
  • HSHS St. Mary’s Hospital in Decatur
  • OSF Healthcare Heart of Mary Medical Center in Urbana
  • Pana Community Hospital
  • Paris Community Hospital

We are sending letters and a flier highlighting remaining in-network options to affected members and employers:

If you have any questions about this, contact your provider relations specialist or call us at 1-800-851-3379.

 

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Northwest April Newsletter

April 10, 2018

eviCore Online Enhancements to Improve Clinical Consultations

eviCore understands that the consultation process takes valuable time away from your patients. After reviewing feedback they’ve received, eviCore has developed educational materials to help you during the consultation scheduling process.

They’ve developed a Consultation Reference Guide for you to use when scheduling a consultation on eviCore.com. It provides a visual of what information needs to be included on each field of the consultation request form.

And don’t forget, if you feel the patient has a condition that’s a risk to their life, health, or ability to regain full function, or is experiencing severe pain, eviCore will allow you to get an urgent clinical consultation with a director or therapist reviewer within the first hour of the case initiation.

Note: Preauthorization requests that do not meet those criteria should schedule consultations with supporting clinical information before eviCore will make a final determination.

If you have any more questions, email ClientServices@evicore.com.

Continuity of Care When Providers Leave Network

When a primary care provider or specialist leaves our network, we take steps to make sure our affected members continue to have access to the care they need.

Any member who is in an ongoing course of treatment may be eligible to continue care with the termed provider (if certain criteria are met) during a 90-day transitional period. Any member in the 13th week or more of pregnancy may be eligible to continue care with the termed provider through post-partum care.

Members with prescription coverage can also fill any remaining prescription refills after the prescribing provider leaves the network.

If you have questions, contact your provider relations specialist.

Preauthorizations for Oncology Clinical Trials

Preauthorization requests for oncology clinical trials should be submitted through Health Alliance’s pharmacy form on the Request Preauthorization tab of Your Health Alliance for providers. These requests aren’t reviewed through eviCore, and providing this information to Health Alliance ensures timely review of your request.

When you’re submitting your request, make sure you note on the form that the member is on a clinical trial for oncology. Include the clinical trial number and a description of the medications provided by the trial. This will help us get your preauthorization reviewed correctly and minimize delays.

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

Opioids Pharmacy Criteria Change New Effective Date

The criteria change for opioids, long-acting and short-acting, we told you about in October will now be effective starting on May 1, 2018.

Learn more about Morphine Equivalent Dose (MED) and opioid prescribing in this article from our December newsletter.

Women’s Health Screenings

Part of our ongoing work is to increase appropriate preventive care for your Health Alliance patients. Recently, we’ve focused on women who receive breast and cervical cancer screenings, as reflected by HEDIS results.

HEDIS measure specifications for breast and cervical cancer screenings are based on U.S. Preventive Services Task Force recommendations. While our 2017 HEDIS results are above the national average for these screenings, we’re continuing to work toward our goal of the 90th percentile for our members.

We’ve entered member care gaps into our system so that we can automatically alert those who haven’t had breast cancer screenings for that year. We also sent out mailers to remind women to get breast and cervical cancer screenings and their preventive care in February. We appreciate your responsiveness in ordering and scheduling these screenings.

Check out the U.S. Preventive Services Task Force recommendations for the most recent guidelines for breast cancer screenings and cervical cancer screenings. We appreciate your partnership by encouraging and ordering these screenings for your patients.

If you have access to the Quality Dashboard on Tableau, you can also use this tool to investigate your member care gaps with interactive HEDIS data.

Ongoing Efforts to Improve Star Ratings

Star Ratings measure the quality of care given to our members and how satisfied members are with the medical care and services provided by our Medicare Advantage plans. We strive to be a 5-star plan and are working to continuously improve all measures and create a high quality, high member satisfaction plan through various reporting and communication tools. Our team will be working with provider partners and departments across Health Alliance to implement improvement strategies to improve the overall health of our members.

We’re committed to contracting with high-performing providers, and our quality ratings are directly tied to this population’s care. Please continue to strive for high quality results, and check our current Star Ratings and HEDIS results to stay informed about our current performance and progress as we advance towards a 5-star rating.

Helping Children Manage ADHD

Dr. Malcolm Hill, a Carle pediatrician in Urbana, IL, consistently has ADHD management HEDIS scores in the top quarter. His approach is all about bringing children great care.

“My goal is to provide the best care possible,” Dr. Hill said.

Oftentimes, making sure the patient and their family understands ADHD is a big part of a new diagnosis. “I explain the diagnosis to the patient and parents. I also explain that ADHD medication may have side effects and stress the importance of follow up visits,” he said.

Follow up visits are a key part how Dr. Hill handles an ADHD diagnosis. “To me, the follow up visit is part of the treatment,” he said. “Since meds like Concerta are not dosed by weight, but by response, I bring patients back in 2 weeks for a re-check.”

For CNS stimulants, “Usually, families know within a week how effective the medication is,” he said. Other ADHD medications may take longer to assess effectiveness, but Dr. Hill said, “By coming back in 2 weeks (versus a one month follow up visit), we avoid wasting time and delaying getting to the right prescription.”

Dr. Hill thinks getting children on the right medication and dosage as quickly as possible can help them get back on track. “That first month is crucial to get the meds set up right. Kids are struggling in school, and school moves faster than it used to,” he said.

He also recommends taking the time to find out the “why?” to help patients and their families with the diagnosis. “I always take time to find out the ‘why?’ As we would in any situation, we need to understand why parents are not bringing the kids in for follow up,” Dr. Hill said. “Transportation, cost of medications, lack of understanding of the need for follow up? Is it a perception that meds are harmful? The stigma of having an ADHD [diagnosis]?”

“Whatever the reason, I try to work through it with the families,” he said. Only then, can he help his patients work through their diagnosis to manage their ADHD.

Key Takeaways

  • Make sure patients and families understand the ADHD diagnosis and treatment.
  • Follow up visits are key to treatment and helping kids manage their ADHD as quickly as possible.
  • Find out the “why?” to help mitigate parents’ concerns, increase understanding, and better manage the ADHD diagnosis.

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

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, contact us at CodingCounts@healthalliance.org.

 

View as PDF

Midwest April Newsletter

April 10, 2018

eviCore Online Enhancements to Improve Clinical Consultations

eviCore understands that the consultation process takes valuable time away from your patients. After reviewing feedback they’ve received, eviCore has developed educational materials to help you during the consultation scheduling process.

They’ve developed a Consultation Reference Guide for you to use when scheduling a consultation on eviCore.com. It provides a visual of what information needs to be included on each field of the consultation request form.

And don’t forget, if you feel the patient has a condition that’s a risk to their life, health, or ability to regain full function, or is experiencing severe pain, eviCore will allow you to get an urgent clinical consultation with a director or therapist reviewer within the first hour of the case initiation.

Note: Preauthorization requests that do not meet those criteria should schedule consultations with supporting clinical information before eviCore will make a final determination.

If you have any more questions, email ClientServices@evicore.com.

Continuity of Care When Providers Leave Network

When a primary care provider or specialist leaves our network, we take steps to make sure our affected members continue to have access to the care they need.

Any member who is in an ongoing course of treatment may be eligible to continue care with the termed provider (if certain criteria are met) during a 90-day transitional period. Any member in the 13th week or more of pregnancy may be eligible to continue care with the termed provider through post-partum care.

Members with prescription coverage can also fill any remaining prescription refills after the prescribing provider leaves the network.

If you have questions, contact your provider relations specialist.

Preauthorizations for Oncology Clinical Trials

Preauthorization requests for oncology clinical trials should be submitted through Health Alliance’s pharmacy form on the Request Preauthorization tab of Your Health Alliance for providers. These requests aren’t reviewed through eviCore, and providing this information to Health Alliance ensures timely review of your request.

When you’re submitting your request, make sure you note on the form that the member is on a clinical trial for oncology. Include the clinical trial number and a description of the medications provided by the trial. This will help us get your preauthorization reviewed correctly and minimize delays.

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

Opioids Pharmacy Criteria Change New Effective Date

The criteria change for opioids, long-acting and short-acting, we told you about in October will now be effective starting on May 1, 2018.

Learn more about Morphine Equivalent Dose (MED) and opioid prescribing in this article from our December newsletter.

Welcoming Dr. Smith

We’re pleased to announce that Michael Smith, MD, FAEMS, has been named as an Associate Medical Director for Health Alliance.

Dr. Smith will focus on the inpatient utilization and serve as medical director for the Reid Health Medical Center in Richmond, Indiana.

Dr. Smith is an Emergency Physician at Carle and serves in leadership capacities including as the EMS Medical Director for Carle Regional EMS and Arrow Ambulance Service and the University of Illinois EMS and Fire Service Institute. He earned a MD from the University of Illinois College of Medicine in Peoria and completed an Emergency Medicine Residency at St. Vincent Medical Center in Toledo, Ohio. Mike is a Clinical Assistant Professor of Surgery at the University of Illinois College of Medicine.

Prior to coming to Carle, Dr. Smith served as a staff physician and EMS Medical Director at Reid Health. His experience with their health system will be invaluable as he works with them on behalf of us and Carle.

Please join us in congratulating Dr. Smith and supporting his expanded role as our Associate Medical Director.

Women’s Health Screenings

Part of our ongoing work is to increase appropriate preventive care for your Health Alliance patients. Recently, we’ve focused on women who receive breast and cervical cancer screenings, as reflected by HEDIS results.

HEDIS measure specifications for breast and cervical cancer screenings are based on U.S. Preventive Services Task Force recommendations. While our 2017 HEDIS results are above the national average for these screenings, we’re continuing to work toward our goal of the 90th percentile for our members.

We’ve entered member care gaps into our system so that we can automatically alert those who haven’t had breast cancer screenings for that year. We also sent out mailers to remind women to get breast and cervical cancer screenings and their preventive care in February. We appreciate your responsiveness in ordering and scheduling these screenings.

Check out the U.S. Preventive Services Task Force recommendations for the most recent guidelines for breast cancer screenings and cervical cancer screenings. We appreciate your partnership by encouraging and ordering these screenings for your patients.

If you have access to the Quality Dashboard on Tableau, you can also use this tool to investigate your member care gaps with interactive HEDIS data.

Ongoing Efforts to Improve Star Ratings

Star Ratings measure the quality of care given to our members and how satisfied members are with the medical care and services provided by our Medicare Advantage plans. We strive to be a 5-star plan and are working to continuously improve all measures and create a high quality, high member satisfaction plan through various reporting and communication tools. Our team will be working with provider partners and departments across Health Alliance to implement improvement strategies to improve the overall health of our members.

We’re committed to contracting with high-performing providers, and our quality ratings are directly tied to this population’s care. Please continue to strive for high quality results, and check our current Star Ratings and HEDIS results to stay informed about our current performance and progress as we advance towards a 5-star rating.

Helping Children Manage ADHD

Dr. Malcolm Hill, a Carle pediatrician in Urbana, IL, consistently has ADHD management HEDIS scores in the top quarter. His approach is all about bringing children great care.

“My goal is to provide the best care possible,” Dr. Hill said.

Oftentimes, making sure the patient and their family understands ADHD is a big part of a new diagnosis. “I explain the diagnosis to the patient and parents. I also explain that ADHD medication may have side effects and stress the importance of follow up visits,” he said.

Follow up visits are a key part how Dr. Hill handles an ADHD diagnosis. “To me, the follow up visit is part of the treatment,” he said. “Since meds like Concerta are not dosed by weight, but by response, I bring patients back in 2 weeks for a re-check.”

For CNS stimulants, “Usually, families know within a week how effective the medication is,” he said. Other ADHD medications may take longer to assess effectiveness, but Dr. Hill said, “By coming back in 2 weeks (versus a one month follow up visit), we avoid wasting time and delaying getting to the right prescription.”

Dr. Hill thinks getting children on the right medication and dosage as quickly as possible can help them get back on track. “That first month is crucial to get the meds set up right. Kids are struggling in school, and school moves faster than it used to,” he said.

He also recommends taking the time to find out the “why?” to help patients and their families with the diagnosis. “I always take time to find out the ‘why?’ As we would in any situation, we need to understand why parents are not bringing the kids in for follow up,” Dr. Hill said. “Transportation, cost of medications, lack of understanding of the need for follow up? Is it a perception that meds are harmful? The stigma of having an ADHD [diagnosis]?”

“Whatever the reason, I try to work through it with the families,” he said. Only then, can he help his patients work through their diagnosis to manage their ADHD.

Key Takeaways

  • Make sure patients and families understand the ADHD diagnosis and treatment.
  • Follow up visits are key to treatment and helping kids manage their ADHD as quickly as possible.
  • Find out the “why?” to help mitigate parents’ concerns, increase understanding, and better manage the ADHD diagnosis.

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

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, contact us at CodingCounts@healthalliance.org.

 

View as PDF

Reid April Newsletter

April 10, 2018

eviCore Online Enhancements to Improve Clinical Consultations

eviCore understands that the consultation process takes valuable time away from your patients. After reviewing feedback they’ve received, eviCore has developed educational materials to help you during the consultation scheduling process.

They’ve developed a Consultation Reference Guide for you to use when scheduling a consultation on eviCore.com. It provides a visual of what information needs to be included on each field of the consultation request form.

And don’t forget, if you feel the patient has a condition that’s a risk to their life, health, or ability to regain full function, or is experiencing severe pain, eviCore will allow you to get an urgent clinical consultation with a director or therapist reviewer within the first hour of the case initiation.

Note: Preauthorization requests that do not meet those criteria should schedule consultations with supporting clinical information before eviCore will make a final determination.

If you have any more questions, email ClientServices@evicore.com.

Continuity of Care When Providers Leave Network

When a primary care provider or specialist leaves our network, we take steps to make sure our affected members continue to have access to the care they need.

Any member who is in an ongoing course of treatment may be eligible to continue care with the termed provider (if certain criteria are met) during a 90-day transitional period. Any member in the 13th week or more of pregnancy may be eligible to continue care with the termed provider through post-partum care.

Members with prescription coverage can also fill any remaining prescription refills after the prescribing provider leaves the network.

If you have questions, contact your provider relations specialist.

Preauthorizations for Oncology Clinical Trials

Preauthorization requests for oncology clinical trials should be submitted through Health Alliance’s pharmacy form on the Request Preauthorization tab of Your Health Alliance for providers. These requests aren’t reviewed through eviCore, and providing this information to Health Alliance ensures timely review of your request.

When you’re submitting your request, make sure you note on the form that the member is on a clinical trial for oncology. Include the clinical trial number and a description of the medications provided by the trial. This will help us get your preauthorization reviewed correctly and minimize delays.

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

Opioids Pharmacy Criteria Change New Effective Date

The criteria change for opioids, long-acting and short-acting, we told you about in October will now be effective starting on May 1, 2018.

Learn more about Morphine Equivalent Dose (MED) and opioid prescribing in this article from our December newsletter.

Welcoming Dr. Smith

We’re pleased to announce that Michael Smith, MD, FAEMS, has been named as an Associate Medical Director for Health Alliance.

Dr. Smith will focus on the inpatient utilization and serve as medical director for the Reid Health Medical Center in Richmond, Indiana.

Dr. Smith is an Emergency Physician at Carle and serves in leadership capacities including as the EMS Medical Director for Carle Regional EMS and Arrow Ambulance Service and the University of Illinois EMS and Fire Service Institute. He earned a MD from the University of Illinois College of Medicine in Peoria and completed an Emergency Medicine Residency at St. Vincent Medical Center in Toledo, Ohio. Mike is a Clinical Assistant Professor of Surgery at the University of Illinois College of Medicine.

Prior to coming to Carle, Dr. Smith served as a staff physician and EMS Medical Director at Reid Health. His experience with their health system will be invaluable as he works with them on behalf of us and Carle.

Please join us in congratulating Dr. Smith and supporting his expanded role as our Associate Medical Director.

Women’s Health Screenings

Part of our ongoing work is to increase appropriate preventive care for your Health Alliance patients. Recently, we’ve focused on women who receive breast and cervical cancer screenings, as reflected by HEDIS results.

HEDIS measure specifications for breast and cervical cancer screenings are based on U.S. Preventive Services Task Force recommendations. While our 2017 HEDIS results are above the national average for these screenings, we’re continuing to work toward our goal of the 90th percentile for our members.

We’ve entered member care gaps into our system so that we can automatically alert those who haven’t had breast cancer screenings for that year. We also sent out mailers to remind women to get breast and cervical cancer screenings and their preventive care in February. We appreciate your responsiveness in ordering and scheduling these screenings.

Check out the U.S. Preventive Services Task Force recommendations for the most recent guidelines for breast cancer screenings and cervical cancer screenings. We appreciate your partnership by encouraging and ordering these screenings for your patients.

If you have access to the Quality Dashboard on Tableau, you can also use this tool to investigate your member care gaps with interactive HEDIS data.

Ongoing Efforts to Improve Star Ratings

Star Ratings measure the quality of care given to our members and how satisfied members are with the medical care and services provided by our Medicare Advantage plans. We strive to be a 5-star plan and are working to continuously improve all measures and create a high quality, high member satisfaction plan through various reporting and communication tools. Our team will be working with provider partners and departments across Health Alliance to implement improvement strategies to improve the overall health of our members.

We’re committed to contracting with high-performing providers, and our quality ratings are directly tied to this population’s care. Please continue to strive for high quality results, and check our current Star Ratings and HEDIS results to stay informed about our current performance and progress as we advance towards a 5-star rating.

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

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, contact us at CodingCounts@healthalliance.org.

 

View as PDF