Informed

FLASH: Hurricane Florence and eviCore’s South Carolina Office

September 13, 2018

Our preauthorization vendor, eviCore, notified us that Hurricane Florence could cause its Bluffton, SC office to close unexpectedly. The office currently remains open, but please be aware that this could change at a moment’s notice. Call wait times could be longer if the Bluffton office closes and calls are routed to another eviCore call center.

Thank you for your patience and understanding as eviCore continues to monitor this situation.

 

View as PDF

Carle August Newsletter

August 14, 2018

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.

New Provider Relations Specialist

Provider Services would like to welcome a new provider relations specialist, Michele Carey. Michele joined the Health Alliance team in June and serves the Quad Cities/Sterling/Rock Falls network of providers. You can reach Michelle at 217-902-9186 or Michele.Carey@healthalliance.org.

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.

You’re Invited to the 2018 Coding Counts Workshop

Thursday, September 27

6 to 8 p.m.

Carle Forum

Join us to learn about the latest updates in neurology, lung cancer immunotherapy, and more. There will be free parking and refreshments, plus the first 50 people get a Health Alliance umbrella.

Providers, when you arrive at the event, ask for a raffle ticket for a chance to win a pizza lunch for your office, where a coding consultant will address your specific coding questions. You must be present to win, and lunch is for up to 20 people.

RSVP Now

Please RSVP by September 20.

Speakers and Topics

  • Dr. Robert Cranston: VNS adjustment, use of inpatient epilepsy monitoring units (IEMUs), updates in interventional neurology, and use of BOTOX injections in neurology
  • Dr. Vamsi Vasireddy: Lung cancer immunotherapy, indications, and side effects
  • Dr. Jens Yambert: Updates in hypertension management and gout

Carle Foundation Hospital is accredited by the Illinois State Medical Society to provide continuing medical education for physicians.

Carle Foundation Hospital designates this live activity for a maximum of 2.0 AMA PRA Category I Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The faculty and planning committee for this event disclose no relevant financial relationships related to the content of this activity.

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.

HPV Vaccination Rates High at Carle Pediatrics (Windsor branch)

As you may know, HPV vaccination rates are universally low. Therefore, we are encouraged that the main pediatrics clinic in our provider network, Carle Pediatrics (Windsor branch), has a vaccination rate of 68.5% for 13–17 year olds. Only 43% of teens nationwide and 48% of teens in Illinois are up to date on all the recommended doses of HPV vaccine, according to the CDC.

The CDC recommends that 11–12 year olds get two doses of HPV vaccine to prevent HPV cancers.

The CDC suggests you take action by:

  • Knowing your state HPV vaccine coverage rates to see how you’re doing with HPV vaccination in comparison
  • Sharing information about your state’s HPV vaccination rates with your office staff and colleagues
  • Identifying ways you can boost HPV vaccination rates in your practice and sharing what is working well in your practices with other immunization providers in your community

Please help protect your young patients by urging parents to vaccinate their children against HPV.

Learn About Our Care Coordination Program

Health Alliance offers members with chronic or complex health conditions access to a care coordinator who can answer questions and provide resources and support. The program doesn’t cost members anything extra. When applicable, please encourage our members to take advantage of this helpful service.

Learn more at HealthAlliance.org/Care-Coordination or in the provider manual, which is posted on Your Health Alliance for providers.

Pharmacy Updates

All Plans

Formulary Additions

  • Fasenra (benralizumab)
    • Commercial – Tier 5 with preauthorization (PA); Medicare – Non-formulary
  • Symdeko (tezacaftor-ivacaftor)
    • Commercial – Tier 5 with PA; Medicare – Tier 5 with PA
  • Trelegy Ellipta (fluticasone furoate, umeclidinium, vilanterol)
    • Commercial – Tier 3; Medicare – Tier 3
  • Bevyxxa (betrixaban)
    • Commercial – Tier 3 with quantity limit (QL); Medicare – Tier 4 with QL

Commercial

Criteria Changes

  • Statin Brand-Name
    • Removed Advicor and Simcor from policy (products discontinued)
    • Added Zypitamag (new pitavastatin product)
    • Added rosuvastatin as possible step pre-requisite drug
  • Azelaic Acid
    • Updated policy to specify that we only cover Azelex for acne vulgaris and Finacea for rosacea (previous policy allowed for coverage of any non-cosmetic condition)
  • Dapsone Gel
    • Updated policy to specify that we only cover for acne vulgaris (previous policy allowed for coverage of any non-cosmetic condition)
  • Isotretinoin Oral
    • Updated policy to state that the maximum covered cumulative treatment dose is 150 mg/kg
      • FDA label: 0.5 to 1 mg/kg/day in 2 divided doses for 15 to 20 weeks; may discontinue earlier if the total cyst count decreases by >70%. Adults with very severe disease/scarring or primarily involves the trunk may require dosage adjustment up to 2 mg/kg/day, as tolerated
      • Alternative dosing in LexiComp/UptoDate: 0.5 mg/kg/day in 2 divided doses for 1 month, then increase to 1 mg/kg/day in 2 divided doses as tolerated until a cumulative dose of 120–150 mg/kg is reached (AAD [Zaenglein 2016])
    • Also specified that there needs to be a 5-month wash-out period before a subsequent course of therapy is approved
  • Daliresp Step-Edit
    • Existing policy requires ST ICS
    • Recommending revising policy to require failure on triple therapy (this aligns with the 2018 Gold Guidelines)
    • Removed Aerobid (product discontinued)
  • Non-Preferred ICS Inhalers
    • Updated policy to add ArmonAir Resplick to policy
    • Removed Aerospan as ST agent (product discontinued)
  • Non-Preferred ICS/LABA Combination Inhalers
    • Combined Breo Ellipta and Advair policies into one

Retired Policies

  • Breo Ellipta – now addressed in Non-Preferred ICS/LABA Combination Inhalers policy
  • Flovent – PA removed, covered at Tier 3
  • Smoking Cessation – PA and QL removed (this aligns us with the DOI regulations)

Tier Changes

  • Estrace: Move from Tier 2 to Tier 3
  • ArmonAir RespiClick: Move from Excluded to Tier 3

Tier Change – Effective August 1, 2018

  • Santyl Ointment: Move from Tier 3 to Tier 5 (members have received 30-day notice)

Medicare

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

 

View as PDF

Reid August Newsletter

August 14, 2018

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

 

View as PDF

Northwest August Newsletter

August 14, 2018

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

All Plans

Formulary Additions

  • Fasenra (benralizumab)
    • WA Individual – Tier 5 with preauthorization (PA); Medicare – Non-formulary
  • Symdeko (tezacaftor-ivacaftor)
    • WA Individual – Tier 5 with PA; Medicare – Tier 5 with PA
  • Trelegy Ellipta (fluticasone furoate, umeclidinium, vilanterol)
    • WA Individual – Tier 3; Medicare – Tier 3
  • Bevyxxa (betrixaban)
    • WA Individual – Tier 3 with quantity limit (QL); Medicare – Tier 4 with QL

WA Individual

Criteria Changes

  • Statin Brand-Name
    • Removed Advicor and Simcor from policy (products discontinued)
    • Added Zypitamag (new pitavastatin product)
    • Added rosuvastatin as possible step pre-requisite drug
  • Azelaic Acid
    • Updated policy to specify that we only cover Azelex for acne vulgaris and Finacea for rosacea (previous policy allowed for coverage of any non-cosmetic condition)
  • Dapsone Gel
    • Updated policy to specify that we only cover for acne vulgaris (previous policy allowed for coverage of any non-cosmetic condition)
  • Isotretinoin Oral
    • Updated policy to state that the maximum covered cumulative treatment dose is 150 mg/kg
      • FDA label: 0.5 to 1 mg/kg/day in 2 divided doses for 15 to 20 weeks; may discontinue earlier if the total cyst count decreases by >70%. Adults with very severe disease/scarring or primarily involves the trunk may require dosage adjustment up to 2 mg/kg/day, as tolerated
      • Alternative dosing in LexiComp/UptoDate: 0.5 mg/kg/day in 2 divided doses for 1 month, then increase to 1 mg/kg/day in 2 divided doses as tolerated until a cumulative dose of 120–150 mg/kg is reached (AAD [Zaenglein 2016])
    • Also specified that there needs to be a 5-month wash-out period before a subsequent course of therapy is approved
  • Daliresp Step-Edit
    • Existing policy requires ST ICS
    • Recommending revising policy to require failure on triple therapy (this aligns with the 2018 Gold Guidelines)
    • Removed Aerobid (product discontinued)
  • Non-Preferred ICS Inhalers
    • Updated policy to add ArmonAir Resplick to policy
    • Removed Aerospan as ST agent (product discontinued)
  • Non-Preferred ICS/LABA Combination Inhalers
    • Combined Breo Ellipta and Advair policies into one

Retired Policies

  • Breo Ellipta – now addressed in Non-Preferred ICS/LABA Combination Inhalers policy
  • Flovent – PA removed, covered at Tier 3
  • Smoking Cessation – PA and QL removed (this aligns us with the DOI regulations)

Tier Changes

  • Estrace: Move from Tier 2 to Tier 3
  • ArmonAir RespiClick: Move from Excluded to Tier 3

Tier Change – Effective August 1, 2018

  • Santyl Ointment: Move from Tier 3 to Tier 5 (members have received 30-day notice)

Medicare

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

 

View as PDF

Midwest August Newsletter

August 14, 2018

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.

New Provider Relations Specialist

Provider Services would like to welcome a new provider relations specialist, Michele Carey. Michele joined the Health Alliance team in June and serves the Quad Cities/Sterling/Rock Falls network of providers. You can reach Michelle at 217-902-9186 or Michele.Carey@healthalliance.org.

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.

HPV Vaccination Rates High at Carle Pediatrics (Windsor branch)

As you may know, HPV vaccination rates are universally low. Therefore, we are encouraged that the main pediatrics clinic in our provider network, Carle Pediatrics (Windsor branch), has a vaccination rate of 68.5% for 13–17 year olds. Only 43% of teens nationwide and 48% of teens in Illinois are up to date on all the recommended doses of HPV vaccine, according to the CDC.

The CDC recommends that 11–12 year olds get two doses of HPV vaccine to prevent HPV cancers.

The CDC suggests you take action by:

  • Knowing your state HPV vaccine coverage rates to see how you’re doing with HPV vaccination in comparison
  • Sharing information about your state’s HPV vaccination rates with your office staff and colleagues
  • Identifying ways you can boost HPV vaccination rates in your practice and sharing what is working well in your practices with other immunization providers in your community

Please help protect your young patients by urging parents to vaccinate their children against HPV.

Learn About Our Care Coordination Program

Health Alliance offers members with chronic or complex health conditions access to a care coordinator who can answer questions and provide resources and support. The program doesn’t cost members anything extra. When applicable, please encourage our members to take advantage of this helpful service.

Learn more at HealthAlliance.org/Care-Coordination or in the provider manual, which is posted on Your Health Alliance for providers.

Pharmacy Updates

All Plans

Formulary Additions

  • Fasenra (benralizumab)
    • Commercial – Tier 5 with preauthorization (PA); Medicare – Non-formulary
  • Symdeko (tezacaftor-ivacaftor)
    • Commercial – Tier 5 with PA; Medicare – Tier 5 with PA
  • Trelegy Ellipta (fluticasone furoate, umeclidinium, vilanterol)
    • Commercial – Tier 3; Medicare – Tier 3
  • Bevyxxa (betrixaban)
    • Commercial – Tier 3 with quantity limit (QL); Medicare – Tier 4 with QL

Commercial

Criteria Changes

  • Statin Brand-Name
    • Removed Advicor and Simcor from policy (products discontinued)
    • Added Zypitamag (new pitavastatin product)
    • Added rosuvastatin as possible step pre-requisite drug
  • Azelaic Acid
    • Updated policy to specify that we only cover Azelex for acne vulgaris and Finacea for rosacea (previous policy allowed for coverage of any non-cosmetic condition)
  • Dapsone Gel
    • Updated policy to specify that we only cover for acne vulgaris (previous policy allowed for coverage of any non-cosmetic condition)
  • Isotretinoin Oral
    • Updated policy to state that the maximum covered cumulative treatment dose is 150 mg/kg
      • FDA label: 0.5 to 1 mg/kg/day in 2 divided doses for 15 to 20 weeks; may discontinue earlier if the total cyst count decreases by >70%. Adults with very severe disease/scarring or primarily involves the trunk may require dosage adjustment up to 2 mg/kg/day, as tolerated
      • Alternative dosing in LexiComp/UptoDate: 0.5 mg/kg/day in 2 divided doses for 1 month, then increase to 1 mg/kg/day in 2 divided doses as tolerated until a cumulative dose of 120–150 mg/kg is reached (AAD [Zaenglein 2016])
    • Also specified that there needs to be a 5-month wash-out period before a subsequent course of therapy is approved
  • Daliresp Step-Edit
    • Existing policy requires ST ICS
    • Recommending revising policy to require failure on triple therapy (this aligns with the 2018 Gold Guidelines)
    • Removed Aerobid (product discontinued)
  • Non-Preferred ICS Inhalers
    • Updated policy to add ArmonAir Resplick to policy
    • Removed Aerospan as ST agent (product discontinued)
  • Non-Preferred ICS/LABA Combination Inhalers
    • Combined Breo Ellipta and Advair policies into one

Retired Policies

  • Breo Ellipta – now addressed in Non-Preferred ICS/LABA Combination Inhalers policy
  • Flovent – PA removed, covered at Tier 3
  • Smoking Cessation – PA and QL removed (this aligns us with the DOI regulations)

Tier Changes

  • Estrace: Move from Tier 2 to Tier 3
  • ArmonAir RespiClick: Move from Excluded to Tier 3

Tier Change – Effective August 1, 2018

  • Santyl Ointment: Move from Tier 3 to Tier 5 (members have received 30-day notice)

Medicare

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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