April 2017

Read our April 2017 issue of Provider News.

Meet our new Chief Medical Officer, Dr. Jonathan Welch

“At its core, my decision really was being able to infuse my deep interest in science with a human connection.” This is how Dr. Jonathan Welch, BMC HealthNet Plan’s new Chief Medical Officer, describes his reason for becoming a physician. “For me they went hand in hand.”

Dr-Jonathan-Welch In his role Dr. Welch leads the Office of Clinical Affairs (OCA), which includes Pharmacy, Care Management, Utilization Management, Provider Audit/Special Investigations Unit, Quality, and Behavioral Health Services. This entails providing strategic direction on quality improvement, population health, and cost saving initiatives. His vision for the OCA is based on the MassHealth delivery system changes underway in Massachusetts. “As the state and health care entities move forward reshaping how health care entities deliver services and support to MassHealth recipients, the Office of Clinical Affairs will expand our collaboration with providers. Our members will benefit when we and our provider partners learn from each other.”

Dr. Welch’s responsibilities also include clinical oversight of BMC HealthNet Plan’s ConnectorCare/Qualified Health Plans (QHP) and Senior Care Options programs, and he embraces the variety of challenges this represents. “My background includes patient centered innovation and population health. This experience is invaluable to helping ensure quality care and coverage for such a diverse membership as we have at BMC HealthNet Plan.”

In addition to his previous work as a consultant designing bundled payments for state Medicaid programs, the Wisconsin native has been an emergency department attending physician in Boston for five years, a position he continues today. In addition, he previously was an instructor at Harvard Medical School. “I went into emergency medicine because I enjoyed the challenge of being in the moment – of having to thoughtfully evaluate, diagnose and treat a patient in a sometimes chaotic environment.”

Dr. Welch’s ongoing clinical experience also adds insight to his role as Chief Medical Officer. “A patient in an emergency room begins a journey that goes beyond physical or emotional healing – that person is now navigating a system. As a practicing physician, I have a front row seat to see how the system succeeds and where it needs improvement, especially when a patient has a chronic condition but no primary care provider. And as Chief Medical Officer, I use that knowledge to help improve the experiences of our providers and members.”

Member and patient focus is also at the foundation of how Dr. Welch approaches ensuring and improving quality coverage and care. “For BMC HealthNet Plan to remain successful at being a quality-driven organization, it’s important that we look at care and coverage through the eyes of our members. We always must ask if they’re receiving appropriate, timely care in the way they need us to in order for their health to improve.”

Members are Now Receiving Text Messages to Help Close Care Gaps

In our effort to help close care gaps, we have implemented an innovative text messaging program for members. We have partnered with HealthCrowd, an Association for Community Affiliated Plans (ACAP) preferred vendor, to encourage health screenings for select chronic conditions and preventive care.

These programs and campaigns include health reminders and basic health education on hypertension, diabetes, breast cancer screening, cervical cancer screening, asthma, well visits, smoking cessation, flu shots, medication adherence and immunizations. BMC HealthNet Plan’s Medical Director reviews and approves the clinical content of the text messages in accordance with our approved clinical practice guidelines. All messages are written at a fourth-to-sixth grade reading level to help ensure reading comprehension.

Sign Up to Use HealthTrio Connect — Our Online Secure Provider Portal

HealthTrio Connect, our online provider portal, will save you time, reduce costs and improve patient satisfaction so you can spend more time caring for your patients. Once you’re set up with your secure login and password, you’ll have access to these functions and more:

Member eligibility
Viewing claims status with enhanced detail information including claims that are pending adjudication
Submitting claims
Submitting online prior authorization requests
Viewing the status of authorization requests submitted by fax, phone, online or postal mail
Requesting important reports such as PCP Panel, Quality Reports (EPSDT, Diabetes and Asthma Treatment reports), Daily Inpatient Census, Emergency Room Frequent Users, and many others
Accessing enrollee health record information

If you already have a HealthTrio Connect user ID, you can use your current login information and add BMC HealthNet Plan as a plan.

Visit our HealthTrio Connect login page to get started.
On the registration page, click to login. You’ll be directed to enter the user name and password you currently use, and then follow the instructions to add BMC HealthNet Plan as a payer plan to your current credentials.

If you do not have a HealthTrio Connect user ID, you must create one.

You still must register with HealthTrio Connect.
Visit the HealthTrio Connect website.
You’ll be directed to the registration page to complete the easy registration process.

If you have any questions, please call your dedicated Provider Relations Consultant, or call our provider line at 888-566-0008.

At bmchp.com you also have access to a variety of information for which you do not need a login. These include our Provider Manual, reimbursement and medical policies, forms and documents, prior-authorization matrix and many other resources and tools.

BMC HealthNet Plan Awarded CORE Certification that Affirms Secure Electronic Administrative Functions

After more than a year of preparation, we are pleased to inform you that BMC HealthNet Plan has received CORE (Committee on Operating Rules for Information Exchange) Certification for Phases I and II from the Council for Affordable Quality Healthcare (CAQH). The federal Department of Health and Human Services requires health entities that create, transmit or use administrative functions such as electronic funds transfers, electronic remittance advices and member eligibility to meet CORE Certification. By obtaining these two levels of certification, we demonstrate our ability to follow business rules and underlying standards for secure and successful data exchange, as well as to adopt voluntary national data exchange rules.

We currently are undergoing the process to receive Phase III certification.

CAQH is a non-profit alliance of health plans and related associations working together to streamline the business side of health care.

All-in-One Care Gap Report

There are multiple reasons why your patients sometimes miss the preventive and chronic condition screenings, tests and medications that are valuable to their health. To help ensure that they take advantage of these services, we have developed a Care Gap Report – based on our claims data – to identify members who may have the following gaps in care:

Breast, cervical, or colorectal cancer screening
Annual well visits
Diabetes screenings including HbA1c, nephropathy or eye exam

We ask that you use this report to identify and close possible gaps in preventive care and chronic conditions for your patients. As always, we appreciate the quality care you provide to our members.

Make Sure to Use CPT® & HCPCS Modifiers Appropriately

Providers submit claims for appropriately documented medical, surgical, diagnostic and related procedures, services and items using standardized Current Procedural Terminology (CPT)® codes developed and maintained by the American Medical Association. Claims also are submitted using Healthcare Common Procedure Coding System (HCPCS) codes developed and maintained by the Centers for Medicare and Medicaid Services (CMS). However, these codes don’t always provide the specifics of a procedure, service or item that are necessary to facilitate appropriate reimbursement or prevent claim denials. Instead, this important information is communicated using standardized CPT® or HCPCS modifiers, which are two-character suffixes appended to a CPT® or HCPCS code, respectively.

Not all CPT® or HCPCS codes or all circumstances require the use of modifiers. It’s not only important to understand when a modifier should or should not be used but also to know which modifier accurately represents the documented procedure, service or item. Payers, including the Centers for Medicare & Medicaid Services, have identified incorrect use of modifiers as one of the top billing errors. Ensuring that you choose the appropriate modifier for the services provided – and use it correctly – will help you avoid claim denials and the inadvertent submission of a false claim.

For guidance, please refer to CPT® and HCPCS guidelines and BMC HealthNet Plan’s online reimbursement policies.

Providers Reimbursed for Completed ACOG Prenatal Assessment Forms

Given the critical importance of prenatal care, BMC HealthNet Plan continues to offer a $25 reimbursement to all contracted OB/GYN and Family Health practitioners who return a completed ACOG (American Congress of Obstetricians and Gynecologists) Prenatal Assessment Form for each pregnant member after her first prenatal visit. This allows us to offer care management in a timely manner, and provides an opportunity to identify high risk members who could benefit from care management.

Reaching Out to Members to Ensure Medication Adherence

We’re working to help our members overcome barriers that impede their adherence to taking prescribed medications. Our current focus is on members who take asthma controller and antidepressant medications.

Toward that end, we’re conducting outreach calls to members with persistent asthma who are not consistently taking their controller medications. In addition, we are mailing information to members newly diagnosed with depression who have started an antidepressant medication. The messages emphasize the importance of medication adherence and encourage members to speak with their doctors before stopping or making any changes.

We’re also providing members with additional tips they can employ to help them continue taking their medications. Some of these include:

Setting a reminder alarm on their phones
Downloading an application that reminds them to take the medication
Asking the pharmacy for refill reminder calls or text messages

We encourage you to continue having these important discussions with your patients to reinforce the messages.

Diapers Available to New Mothers

Any BMC HealthNet Plan member who has delivered a baby and has had her postpartum visit within three to eight weeks after delivery is eligible to receive a free box of diapers. The member must have her OB/GYN or Family Health practitioner complete, sign and return a simple form at the time of the visit. To speed up the process, the provider can fax the form back to us during the member’s postpartum visit. Access the form and instructions.

Antibiotics Are Not Always Necessary

Do your patients really need antibiotics for respiratory tract infections?

Physicians, public health professionals and patients are increasingly concerned about overusing antibiotics. Wide use of antibiotics can breed “superbugs” that become antibiotic resistant. These medications are usually unnecessary for acute respiratory infections and acute bronchitis because these conditions most often are viral.

What should you do when patients with acute viral bronchitis ask for antibiotics? You may need to tell them that:

Antibiotics will not help acute bronchitis caused by a virus.
Antibiotics can cause harm if used unnecessarily because bacteria can become resistant.
Antibiotics can cause side effects such as headaches, intestinal issues and rashes.

You can find some helpful information to provide to your patients at the Consumer Health Choices website.