The Advantage A Newsletter for Providers - First … Advantage Winter 2015 | 1 The Advantage A...
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The Advantage A Newsletter for Providers Table of contents Star Ratings and medication adherence measures: How to manage patient adherence ...........1 Communication and education...3 Member rights and responsibilities ....................................4 Interpretive services..........................4 Community resources for your patient’s caregivers .................5 NaviNet Provider Portal ..................6 Important vaccines for our over-65 population............................7 Home- and community- based services ......................................7 High-risk drugs for the elderly .......................................8 Working together with primary care physicians in multidisciplinary team meetings. ................................................9 Member success story ..................10 Required annual Model of Care training.................................11 ADA survey .........................................11 Is your information current on the CAQH database? ..............12 Just for fun .........................................13 www.firstchoicevipcareplus.com Star Ratings and medication adherence measures: How to manage patient adherence 90-day supplies and the Star Ratings system First Choice VIP Care Plus is proud to announce that we are now allowing a 90-day supply of the most common diabetes, hypertension and cholesterol medications. As always, our goal is to improve our members’ health through proper medication adherence. Whenever possible, consider transitioning your patients to a 90-day supply. Managing patient adherence is a challenge. However, with a few extra steps, adherence can improve. The Star Ratings system In 2009, the Centers for Medicare & Medicaid Services (CMS) created the Five-Star Quality Rating System to rate the quality of care plans provide to their members. CMS scores plans using a variety of measures that evaluate adherence to medications, access to care and quality of care. Recently, CMS has given more focus to the measures that evaluate patients’ adherence to their medication. In fact, CMS made the medication adherence measures triple the value of other ratings in the system, because they recognize that one of the most important ways a member can stay healthy is by taking their medications. First Choice VIP Care Plus agrees with CMS, which is why we have decided to reinforce the importance of 90-day supplies. The three medication classes measured for adherence are oral diabetes medications, hypertension medications (RAS antagonists) and cholesterol medications (statins). All three of the adherence measures identify patients 18 years old and older with an 80 percent adherence rate or higher. Medication adherence calculation for diabetes, hypertension (RAS antagonists) and cholesterol medications (statins) The Pharmacy Quality Alliance (PQA) created and endorsed a calculation to measure patient adherence to diabetes, hypertension and cholesterol medications. The calculation takes the number of members 18 years old or older who had an adherence level of 80 percent or higher for a medication and divides it by the number of members 18 years old or older who had two or more fills of a medication in the same class. Members 18 years old or older who have a medication adherence rating of 80% for diabetes, hypertension or cholesterol medications. Members 18 years old or older who have at least two fills for a diabetes, hypertension or cholesterol medication. Adherence calculation Winter 2015 | 1 The Advantage Winter 2015
Transcript of The Advantage A Newsletter for Providers - First … Advantage Winter 2015 | 1 The Advantage A...
Winter 2015 | 1The Advantage
The Advantage A Newsletter for Providers
Table of contentsStar Ratings and medication adherence measures: How to manage patient adherence ...........1
Communication and education ...3
Member rights and responsibilities ....................................4
Interpretive services..........................4
Community resources for your patient’s caregivers .................5
NaviNet Provider Portal ..................6
Important vaccines for our over-65 population ............................7
Home- and community- based services ......................................7
High-risk drugs for the elderly .......................................8
Working together with primary care physicians in multidisciplinary team meetings. ................................................9
Member success story ..................10
Required annual Model of Care training .................................11
ADA survey .........................................11
Is your information current on the CAQH database? ..............12
Just for fun .........................................13
www.firstchoicevipcareplus.com
Star Ratings and medication adherence measures: How to manage patient adherence
90-day supplies and the Star Ratings systemFirst Choice VIP Care Plus is proud to announce that we are now allowing a 90-day supply of the most common diabetes, hypertension and cholesterol medications. As always, our goal is to improve our members’ health through proper medication adherence. Whenever possible, consider transitioning your patients to a 90-day supply. Managing patient adherence is a challenge. However, with a few extra steps, adherence can improve.
The Star Ratings systemIn 2009, the Centers for Medicare & Medicaid Services (CMS) created the Five-Star Quality Rating System to rate the quality of care plans provide to their members. CMS scores plans using a variety of measures that evaluate adherence to medications, access to care and quality of care.
Recently, CMS has given more focus to the measures that evaluate patients’ adherence to their medication. In fact, CMS made the medication adherence measures triple the value of other ratings in the system, because they recognize that one of the most important ways a member can stay healthy is by taking their medications. First Choice VIP Care Plus agrees with CMS, which is why we have decided to reinforce the importance of 90-day supplies.
The three medication classes measured for adherence are oral diabetes medications, hypertension medications (RAS antagonists) and cholesterol medications (statins). All three of the adherence measures identify patients 18 years old and older with an 80 percent adherence rate or higher.
Medication adherence calculation for diabetes, hypertension (RAS antagonists) and cholesterol medications (statins) The Pharmacy Quality Alliance (PQA) created and endorsed a calculation to measure patient adherence to diabetes, hypertension and cholesterol medications. The calculation takes the number of members 18 years old or older who had an adherence level of 80 percent or higher for a medication and divides it by the number of members 18 years old or older who had two or more fills of a medication in the same class.
Members 18 years old or older who have a medication adherence rating of 80% for diabetes, hypertension
or cholesterol medications.
Members 18 years old or older who have at least two fills for
a diabetes, hypertension or cholesterol medication.
Adherence calculation
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Star Ratings and medication adherence measures: How to manage patient adherence (continued)
Calculation exceptions and thresholdsThe adherence calculations exclude the following:
• Members who have one or more claims for insulin are not included in the diabetes measure.
CMS scores health plans using these adherence thresholds:
Plan type Star RatingAdherence for diabetes medication
Adherence for hypertension
Adherence for cholesterol (statins)
MA-PD 5 stars ≥ 83% ≥ 87% ≥ 85%
MA-PD 4 stars ≥ 80% to 83% ≥ 83% to < 87% ≥ 81% to < 85%
MA-PD 3 stars ≥ 75% to < 80% ≥ 76% to < 83% ≥ 71% to < 81%
MA-PD 2 stars ≥ 69% to < 75% ≥ 71% to < 76% ≥ 67% to < 71%
MA-PD 1 stars < 69% < 71% < 67%
PDP 5 stars 85% 84% 78%
PDP 4 stars 82% to < 85% 81% to < 84% 75% to < 78%
PDP 3 stars 79% to < 82% 76% to < 81% 69% to < 75%
PDP 2 stars 74% to < 79% 72% to < 76% 62% to < 69%
PDP 1 stars < 74% < 72% < 62%
Adherence class Drug classes Drugs
DiabetesBiguanide, sulfonylurea thiazolidinedione, DPP-IV inhibitor, incretin mimetic, meglitinide
Metformin, glyburide, glimepiride, glipizide, pioglitazone, rosiglitazone, sitagliptin, linagliptin, saxagliptin, exenatide, liraglutide, repaglinide, nateglinide
HypertensionAngiotensin converting enzyme inhibitor, angiotensin receptor blocker, direct renin inhibitor
Captopril, cilazapril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril, benazepril, azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan, aliskiren
Cholesterol HMG-CoA reductase inhibitors (statins)Atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin
Included drugs and drug classes
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Communication and educationCMS’s Star Ratings rules and measurement weights ensure health plans and physicians still have a profound effect on a patient’s medication adherence scores. Plans must communicate with the patient, educate them and gain their trust. In addition, they must allow the patient to have an active part in the decision-making process. Unfortunately, the biggest barrier to effective communication is time. The SIMPLE strategy, created by the American College of Preventive Medicine, improves adherence and communication while combatting time constraints.
Simplify the regimen. Match the regimen to the patient’s daily activities and avoid drugs that have special needs or requirements.
Impart knowledge. Focus on making a shared decision on the medication choice. Provide clear instructions — both written and verbal — by concentrating on three to four major points to make the patient understand and remember.
Modify the patient’s beliefs by emphasizing the risks of not taking the medications, even if those risks are not felt immediately.
Provide communication and trust. Studies have shown that most patients are routinely interrupted every 22 seconds when speaking with a doctor. Patients who are allowed to speak freely will typically speak for about two minutes and will have an increased level of trust with their doctor.
Leave bias. Recognize low health literacy and concentrate on different methods to better communicate with patients.
Evaluate the patient’s adherence. Always make sure the patient is complying with their medication regimen and remind patients how important it is to take their medications as directed.
The SIMPLE Strategy
Pharmacy questionsPlease contact Pharmacy Services at 1-855-327-0512 or visit our pharmacy website at www.performrx.com.
Sources
Centers for Medicare & Medicaid Services. Medicare 2015 Part C & D Star Rating Technical Notes. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html. Accessed August 18, 2015.
Medication Adherence: Improving Health Outcomes Time Tool: A Resource from the American College of Preventive Medicine. 2011. Retrieved from http://www.acpm.org/?MedAdhereTTProviders.
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Member rights and responsibilitiesFirst Choice VIP Care Plus informs its members of their rights and responsibilities, but members also have the right to request and receive from their health care provider a complete copy of these rights and responsibilities. As a First Choice VIP Care Plus provider, it is your responsibility to recognize these member rights and responsibilities. The complete list can be found in Section 1 of the provider manual, which is available at www.firstchoicevipcareplus.com.
Interpretive servicesSelect Health of South Carolina is dedicated to providing culturally competent health care services. To support this effort, we offer interpretation services at no cost for our First Choice VIP Care Plus members. LSA’s INTERPRETALK® program provides a fast and easy way to communicate with our Limited English Proficiency (LEP) members. They have interpreters in more than 200 languages available 24 hours a day, seven days a week.
Connecting with an interpreterCall Member Services at 1-888-978-0862 (8:00 a.m. – 8:00 p.m., seven days a week) to access this free service. After hours, contact the 24-hour Nurse Call Line at 1-855-843-1147 to connect to an interpreter.
Be prepared to:
• Provide the member’s name.
• Provide the member’s Medicare ID number.
• Tell them the member’s preferred language.
• Ask for a medical interpreter.
After you provide this information to our Member Services department or the Nurse Call Line, you will be connected to an interpreter. Explain the objective of the call to the interpreter and then proceed by speaking to the member in the first person.
In addition to language services, we also provide free TTY/TDD services for our hearing-impaired members. To connect to a TTY/TDD operator, members may call 1-866-428-7583.
Winter 2015 | 4The Advantage
Winter 2015 | 5The Advantage
Community resources for your patient’s caregiversUnlike the general population, according to authors Nancy L. Mace and Peter V. Rabins, a caregiver experiences a “36 hour day.” To a caregiver, this means there isn’t enough time in the day to complete all the necessary care for their loved one or patient and still have time for themselves. The health care system, as well as life, can be challenging to navigate, especially if it is on behalf of someone else. Below are some resources you may share with the caregivers of your patients.
1. Lieutenant Governor’s Office on Aging’s Family Caregiver Support Program:
Program eligibility:
• Unpaid adults caring for a frail or disabled adult 60 years old or older, or caring for someone with Alzheimer’s.
• Grandparents/relatives 55 years old or older caring for an adult with a disability.
• Grandparents/relatives 55 years old or older responsible for raising a child 18 years old or younger.
Services include:
• Answers to caregiving questions.
• Help locating community resources.
• Support groups to connect with other caregivers and share ideas.
• Training in care techniques, stress management, financial planning and nutrition.
• A short break from caregiving.
• Services such as counseling, caregiving supplies or medical equipment.
Call 1-803-734-9900 for more information.
2. Respite resources:
• ARCH National Respite Network and Resource Center www.archrespite.org Phone: 1-703-256-2084
• Aging Life Care Association www.caremanager.org Phone: 1-703-256-2084
• “Sitter List” from SC Access www.scaccesshelp.org (free)
• South Carolina Respite Coalition www.screspitecoalition.org Phone: 1-803-935-5027 Toll free: 1-866-345-6786
• Local Council on Aging www.aging.sc.gov/contact/pages/fcspcontacts.aspx Phone: 1-800-868-9095
3. 211 service: Informational line available 24 hours a day, seven days a week, in any language. Dial 211 to connect with a network of over 16,000 resources in South Carolina or call toll free at 1-866-892-9211.
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NaviNet Provider PortalFirst Choice VIP Care Plus offers participating network providers real-time information through our secure provider portal, NaviNet. This free service is America’s leading health care provider portal, connecting over 40 health plans and 60 percent of the nation’s physicians. NaviNet is not only used by First Choice VIP Care Plus, but also by payers like Cigna and Aetna. Through NaviNet, providers can:
• Access and respond to members’ individual care plans (ICPs).
• Check claim status.
• Check member eligibility.
• Enter referrals and authorization requests.
• Generate reports — PCP panel rosters, claims inquiries, care gaps, plus new options (see below).
Single condition care gap reportsMany providers have expressed interest in having access to a care gap report specific to a single condition or service, e.g., diabetic patients missing HbA1C or microalbumin screenings or patients missing their annual well-care visit. Therefore, effective immediately, your office can receive our new single service care gap report. The NaviNet report inquiry menu offers this service for a wide variety of conditions your office may find helpful to target specific patient populations, such as:
• Asthmatic patients missing refills for inhaled corticosteroids.
• Diabetic patients missing critical screenings.
• Hypertensive patients missing refills for their anti-hypertensive drug prescriptions.
• Women missing breast cancer or cervical cancer screenings.
• Many more.
To access the report within NaviNet, simply:
• Click the Report Inquiry link on the left-hand menu.
• Choose Clinical Reports.
• Select Single Service Care Gap Query from the drop-down menu.
• Choose Provider Group from the drop-down menu.
• In the Report Criteria section, choose the single service or condition report you want from the drop-down menu.
• Click Search.
Lab dataYour office can now access available lab data for your patients directly through the Member Clinical Summary in NaviNet. The new Lab Data section of the report displays up to two years of available lab data, including date and type of test, rendering lab, clinical result, and outcome (whether normal or abnormal).
With this enhancement, the Member Clinical Summary includes the following claims-based data for your patients:
• Demographic information (member and primary care provider information).
• Medications (filled within the past six months).
• Chronic conditions.
• Gaps in care (based on diagnosis compared to clinical recommendations).
• Emergency room visits (within the past six months).
• Inpatient admissions (within the past 12 months).
• New: Lab data.
The steps for accessing the Member Clinical Summary within NaviNet remain the same. To sign up for NaviNet, go to the link on our website or navinet.secure.force.com/.
Winter 2015 | 6The Advantage
Winter 2015 | 7The Advantage
Important vaccines for our over-65 population
Pneumococcal vaccineAdults 65 years old and older need two vaccines to better protect them from bacterial infection in the blood, meningitis and pneumonia, according to a revised vaccination schedule from the 2015 Advisory Committee on Immunization Practices (ACIP). CMS has aligned Medicare coverage to meet the ACIP recommendations:
• An initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare Part B.
• A different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered).
Since the updated ACIP recommendations are specific to vaccine type and sequence of vaccination, prior pneumococcal vaccination history should be taken into consideration. For example, if a beneficiary 65 years old or older received the 23-valent pneumococcal polysaccharide vaccine (PPSV23) a year or more ago, then the 13-valent pneumococcal conjugate vaccine (PCV13) should be administered next as the second in the series of the two recommended pneumococcal vaccinations1.
Influenza vaccineHuman immune defenses become weaker with age. Therefore, adults 65 years old and older are at greater risk of serious complications from the flu compared to young, healthy adults. While flu seasons can vary in severity, during most seasons, people 65 years old and older bear the greatest burden of severe flu disease. In recent years, for example, it’s estimated that between 80 percent and 90 percent of seasonal flu-related deaths have occurred in people 65 years old and older, and between 50 percent and 70 percent of seasonal flu-related hospitalizations have occurred among people in that age group2. So influenza is often quite serious for people 65 years old and older. People 65 years old and older have two flu shots available to choose from: a regular-dose flu vaccine and a newer flu vaccine designed specifically for people 65 years old and older with a higher dose. Medicare covers the costs of both the vaccine and its administration by recognized providers.
Both the pneumococcal and influenza vaccine are covered at 100 percent3 for Medicare beneficiaries.
Home- and community-based servicesBeginning in January 2016, benefits for home- and community-based services (HCBS), also known as long-term services and supports (LTSS), will become an integral part of the First Choice VIP Care Plus plan. These services and supports enable elderly individuals and/or individuals with disabilities to meet their daily needs for assistance and improve the quality of their lives. Examples of these types of benefits are:
• Assistance with bathing, dressing, laundering, shopping, transportation and other basic activities of daily living and self-care.
• Home-delivered meals.
• Pest control.
• Adult day care and companion care.
• Home modifications.
• Respite care.
These benefits have traditionally only been available to those enrolled in the state’s Community Choices, Mechanical Ventilator Dependent and HIV/AIDS Waiver programs, but they may now also be available to our members not enrolled in one of those programs. Eligibility for these benefits will be based on medical necessity as determined by our care coordinators after assessments are completed on the member and their home. If you have patients enrolled in First Choice VIP Care Plus who you feel would benefit from these types of services, please contact their care coordinators at 1-888-978-0862.
Sources
1 MLN Matters® Number: MM9051 cms.gov.
2 www.cdc.gov.
3 Of the Medicare Fee Schedule.
Winter 2015 | 7The Advantage
Winter 2015 | 8The Advantage
High-risk drugs for the elderlyAre you prescribing high-risk medications for your patients over age 65? High-risk medications are those identified by AGS Beers Criteria and by the PQA as tending to cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aging (see table below). Prescription drug use by the elderly can often result in adverse drug events that contribute to hospitalization, increased duration of illness, nursing home placement, falls and fractures. Potentially inappropriate medications continue to be prescribed for and taken by older adults despite the recognition of increased likelihood of adverse drug events and evidence of poor outcomes in elderly patients.1 First Choice VIP Care Plus would like to work with providers to find safer alternatives for our members over age 65. Please contact the member’s care coordinator at 1-888-978-0862, option 5, and we will be glad to assist you.
Description Prescription
Antianxiety (includes combination drugs)
Aspirin-meprobamate meprobamate
Antiemetics Scopolamine, trimethobenzamide
Analgesics (includes combination drugs)
Ketorolac
Antihistamines (includes combination drugs)
APAP/dextromethorphan/diphenhydramine, APAP/diphenhydramine/phenylephrine, APAP/diphenhydramine/pseudoephedrine, acetaminophen-diphenhydramine, carbetapentane/diphenhydramine/phenylephrine, codeine/phenylephrine/promethazine, codeine-promethazine, cyproheptadine, dexchlorpheniramine, dexchlorpheniramine/dextromethorphan/PSE, dexchlorpheniramine/guaifenesin/PSE, dexchlorpheniramine/hydrocodone/phenylephrine, dexchlorpheniramine/methscopolamine/PSE, dexchlorpheniramine-pseudoephedrine, dextromethorphan-promethazine, diphenhydramine, diphenhydramine/hydrocodone/phenylephrine, diphenhydramine-magnesium salicylate, diphenhydramine-phenylephrine, diphenhydramine-pseudoephedrine, hydroxyzine hydrochloride, hydroxyzine pamoate, phenylephrine-promethazine, promethazine
Antipsychotic, typical Thioridazine
AmphetaminesAmphetamine-dextroamphetamine, benzphetamine, dexmethylphenidate, dextroamphetamine, diethylpropion, methamphetamine, methylphenidate, phendimetrazine, phentermine
Barbiturates Butabarbital, mephobarbital, pentobarbital, phenobarbital, secobarbital
Long-acting benzodiazepines (includes combination drugs)
Amitriptyline-chlordiazepoxide, chlordiazepoxide, chlordiazepoxide-clidinium, diazepam, flurazepam
Calcium channel blockers
Nifedipine — short-acting only
Gastrointestinal anti-spasmodics
Dicyclomine, propantheline
Sources
1 American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Amer Geriatr Soc. 2012;60(4):616-631.
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Winter 2015 | 9The Advantage
Description Prescription
Belladonna alkaloids (includes combination drugs)
Atropine, atropine/CPM/hyoscyamine/PE/scopolamine, atropine/hyoscyamine/PB/scopolamine, atropine-difenoxin, atropine-diphenoxylate, atropine-edrophonium, belladonna, belladonna/ergotamine/phenobarbital, butabarbital/hyoscyamine/phenazopyridine, hyoscyamine, hyoscyamine/methenam/ m-blue/phenyl salicyl
Skeletal muscle relaxants (includes combination drugs)
ASA/caffeine/orphenadrine, ASA/carisoprodol/codeine, aspirin-carisoprodol, aspirin-methocarbamol, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine
Oral estrogens (includes combination drugs)
Conjugated estrogen, conjugated estrogen-medroxyprogesterone, esterified estrogen, esterified estrogen-methyltestosterone, estropipate
Oral hypoglycemics Chlorpropamide
Narcotics (includes combination drugs)
ASA/caffeine/propoxyphene, acetaminophen-pentazocine, acetaminophen-propoxyphene, belladonna-opium, meperidine, meperidine-promethazine, naloxone-pentazocine, pentazocine, propoxyphene hydrochloride, propoxyphene napsylate
Vasodilators Dipyridamole — short-acting only, ergot mesyloid, isoxsuprine
Others (including androgens and anabolic steroids, thyroid drugs, urinary anti-infectives)
Methyltestosterone, nitrofurantoin, nitrofurantoin macrocrystals, nitrofurantoin, macrocrystals-monohydrate, thyroid desiccated
High-risk drugs for the elderly (continued)
Working together with primary care physicians in multidisciplinary team meetingsWe have an integrated care approach for our members which involves conducting multidisciplinary team meetings. As the primary care physician, you will play an integral part on that team. This team will vary based on the member’s needs and may also be comprised of other health care providers the member sees, such as:
• Specialists.
• Behavioral health providers.
• Home health providers.
• Physical therapists.
• Pharmacists.
• Waiver case manager.
The member may also include other individuals on this team who play an important role in their care; this could be a:
• Family member.
• Friend.
• Pastor.
• Neighbor.
• Advocate.
Winter 2015 | 9The Advantage
Winter 2015 | 10The Advantage
First Choice VIP Care Plus members are assigned community health navigators and care coordinators who will be present during meetings to assist members as needed.
Each of our members also has a personal care connector who will call your office to schedule these team meetings. We will make these meetings as quick and convenient as possible for you while ensuring your patient gets the best care possible. We can meet in the member’s home, in your office or at another designated location. We can set up a conference call, video link or phone call. We will use technology to get as many of the team members involved as possible. Each meeting will be facilitated by a detailed agenda, which will be sent to you before the meeting for your review. During this meeting, an ICP, developed based on our assessment of the member, will be reviewed, focusing on two to three of the member’s greatest concerns. If you have any suggestions or updates to the ICP, the care coordinator will make the requested changes and fax an updated ICP back to your office.
We will continue to follow up with your office with any changes in the member’s care and ask that you place all communication you receive from us in their record.
Working together with primary care physicians in multidisciplinary team meetings (continued)
Member success storyWhen the First Choice VIP Care Plus community navigator first encountered one of our members, who suffers from a rare brain tumor, the member had several concerns. These included hunger, lack of transportation to and from her doctor’s appointments, the cleanliness of her home, and her inability to understand the importance of taking her medications. The member was not taking any of her medications, which included daily routine medications to treat her high blood pressure, diabetes and cholesterol and her chemotherapy to shrink the residual tumor. The member did not understand the rounds of her medications and what day to take what medications.
Per the member’s request, the navigator started attending her appointments with her and assisted her with getting back on all of her medications. The navigator was able to establish a relationship with the member’s oncologist, and they started to share more information as the appointments went on. The oncologist thanked the navigator for the dedication and compassion that First Choice VIP Care Plus has to offer.
The navigator requested and was given a referral from the oncologist for home health, so we were able to provide services to maintain the member’s blood pressure and help her keep up with medications. The navigator also contacted the case manager for the Community Long-Term Care Waiver Services Program, who quickly came out to visit the member. She immediately started receiving Meals on Wheels, in-home help to clean her home three days a week and a much-needed raised toilet seat as part of the services which would now be available to her through the waiver program.
The navigator was also able to set up an appointment with a new PCP chosen by the member, and the First Choice VIP Care Plus team was able to conduct a meaningful multidisciplinary team meeting. The same day, the member gave the navigator a notice from the Department of Social Services which stated she did not return her Medicaid recertification and would be losing her Medicaid benefits, meaning she would not be able to keep all of the much-needed services. The navigator assisted the member with the recertification paperwork and took it to the Department of Social Services, where she asked to speak to a supervisor. The navigator waited for a little over an hour to speak to her, explaining the member’s situation and medical condition, and that without Medicaid these services would not be available to her. The supervisor was gracious enough to recertify her that day. Both the navigator and the supervisor became overwhelmed and cried knowing they were able to help this member in a significant way.
Winter 2015 | 10The Advantage
Winter 2015 | 11The Advantage
Required annual Model of Care trainingFirst Choice VIP Care Plus’s Model of Care is an integrated care management approach to health care delivery and coordination for dual-eligible (eligible for both Medicare and Healthy Connections Medicaid) individuals.
The Model of Care is a high-quality, patient-centric medical care delivery system that involves multiple disciplines coming together to provide input and expertise for a member’s ICP. This plan is designed to maintain the member’s health and encourage members’ involvement in their health care. Contractually, providers are required to participate annually in Model of Care training and may do so in one of the following ways:
• Providers may attend Provider Orientation and training seminars held statewide each year.
• Providers may contact their account executive for on-site Model of Care training.
• Providers may request to have a Model of Care webinar conducted for their site.
• Providers may take an online version of the training.
• More information on the Model of Care and the annual training requirement is available in the provider manual.
ADA surveyAs a participating plan of the Healthy Connections Prime Medicare-Medicaid program, we are required to provide our Healthy Connections Prime members with meaningful access to medical programs and services. We are required to reasonably accommodate members and ensure programs and services are as accessible (including physical and geographic access) to individuals with disabilities as they are to individuals without disabilities.
To gather this information, we are requesting you complete a simple 15-question ADA Assessment Survey for each office location. To ensure you complete this process accurately, please follow the steps below:
1. Please visit our website at www.firstchoicevipcareplus.com.
2. Select the Provider tab at the top of the page.
3. Follow the pop-up or select Provider Self-service Tools.
4. Select the ADA Attestation link and choose “this assessment” to start the survey.
Complete the survey.
5. Question 2 of the survey asks you verify your provider demographics in our online provider directory. Do this by visiting the Searchable Provider Directory also found under the Provider Self-Service Tools.
6. Repeat this process for each provider location.
A fillable PDF of the survey is also available under the ADA Attestation link. If you prefer to complete the survey this way, please return it by email or fax to:
[email protected] or fax to 1-855-306-9764.
We will inform members of providers’ ability to accommodate special needs through the provider directory. Through a system of icons in the provider directory, members will be able to identify specific levels of accommodations at provider sites. Thank you in advance for your time completing the survey for each of your locations. If you have additional questions, please email us at the address above or contact Provider Services at 1-888-978-0862.
Winter 2015 | 11The Advantage
Winter 2015 | 12The Advantage
Is your information current on the CAQH database? This past spring, the Council for Affordable Quality Healthcare (CAQH) launched its new CAQH ProView database. If you are a CAQH user, you may have received notifications on the action items listed below to help prepare you for the transition from UPD to ProView. CAQH alerted providers to the following:
• Providers with incomplete applications need to complete and attest to any outstanding applications prior to the transition to CAQH ProView. Unattested data will not convert into CAQH ProView.
• CAQH ProView requires an email address for all providers as a primary method of contact.
• Providers must enter and complete their information online. Paper versions of the credentialing application are no longer accepted.
If you have not already done so, please follow CAQH instructions so we may continue to download your information for recredentialing purposes. The health plan’s access to your current and complete information via CAQH ProView will facilitate a smooth and timely recredentialing process.
Winter 2015 | 12The Advantage
Winter 2015 | 13The Advantage
FCVIPCPSC-1522-42
www.firstchoicevipcareplus.com
Just for fun
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Diabetes superfoods!Unscramble these diabetes superfoods!
Winter 2015 | 13The Advantage
