Assuming the role of Medical Director for BMC HealthNet Plan is a welcome challenge for John Wiecha, MD, MPH. “I have focused my career on the medical needs of underserved populations, starting in urban New York City as a medical student, in Worcester during residency training, as a staff member of a community health center, and more recently as a family physician at BMC,” said Dr. Wiecha. BMC HealthNet Plan provides managed care coverage for over 225,000 members across Massachusetts.

As Medical Director, Dr. Wiecha will contribute to a wide range of areas, including utilization review, care and population management, concurrent review, credentialing, quality, appeals and grievances, pharmacy management and network management. He also represents BMC HealthNet Plan’s Office of Clinical Affairs in supporting the development and maintenance of relationships with health care providers, governmental organizations, regulatory groups, and other external stakeholders.

Experience in Family and Preventive Medicine

Dr. Wiecha’s educational and professional background include receiving his MD from the State University of New York at Stony Brook School of Medicine, and serving residencies in family medicine and preventive medicine at UMass Medical Center in Worcester. In addition, Dr. Wiecha conducted research in the areas of population health, chronic disease and medical education, with grant support from numerous foundations and government agencies, including several projects with the World Health Organization in Geneva. Since 1998 Dr. Wiecha has been a family physician practicing at Boston Medical Center. He also teaches at Boston University School of Medicine where he was appointed as an Assistant Dean of Academic Affairs.

Going Forward

Given his experience and the expectations of the Medical Director position, Dr. Wiecha’s areas of focus will include quality improvement and clinical resource management. “I look forward to working with the talented staff at BMC HealthNet Plan/Well Sense Health Plan and our dedicated provider network to promote innovative strategies for quality improvement and population health,” he said. “In addition, I hope to contribute the experiences I’ve had in health care technology, not only to improve quality, but also to help lessen the administrative burden on providers.”

When Dr. Wiecha was asked what network providers could expect of him, he responded, “I’m committed to help our Plan providers deliver excellent patient care. We share the goals of excellent quality of care and access, and we must keep lines of communication open to maintain these high standards. It’s essential to continue to provide support to both our members and our providers.”

We’re pleased to announce that BMC HealthNet Plan’s Medicaid HMO has achieved Excellent Accreditation status from the National Committee for Quality Assurance (NCQA) based on the results from our recent submissions to NCQA of HEDIS® and CAHPS® data. Excellent Accreditation is the highest status awarded by NCQA. We also maintained Accredited status for our Qualified Health Plan coverage. Accredited is the highest status currently available for Qualified Health Plans.

In addition, Boston Medical Center HealthNet Plan received a rating of 4.5 out of 5 for our Massachusetts Medicaid product in the National Committee for Quality Assurance’s Medicaid Health Insurance Plan Ratings 2016-2017. This rating gives BMC HealthNet Plan the distinction of being one of the highest rated Medicaid health plans in the nation.

It’s common practice for a physician to attend a conference and learn about a new medical procedure, test or device. A conference presenter or manufacturer may educate you about how to code and bill for the procedure, test and/or device. However, that information sometimes will contain a disclaimer as to whether or not a given insurer will accept or cover the code(s).

Don’t assume that the information you receive is always correct. Be sure to select the name of the procedure or service that accurately identifies the service performed; don’t select a CPT code that merely approximates the service provided. If a specific code does not exist, then report the service using the appropriate unlisted procedure or service code. When inquiring as to whether a device or test and any associated procedures is a covered benefit, don’t limit your questions to whether a CPT and/or HCPCS code itself is covered. You should also ask whether it is covered by the member’s insurance plan and for the diagnosis, and if the code requires prior authorization. This will ensure that you code and bill correctly.

As we announced in March, BMC HealthNet Plan has closed its regional offices in Springfield and New Bedford, effective September 30. Through flexible work arrangements, our employees in Springfield and New Bedford will continue supporting you after that date.

• They will continue to be available throughout the state to visit provider offices and to offer the dedicated support you expect from us.
• We remain fully committed to our providers and members in these areas of Massachusetts.

If you have any questions, please contact your dedicated Provider Relations Consultant.

As you may be aware, the Massachusetts Division of Insurance released guidance on August 9 requiring that health plans accept and providers use three standard prior authorization forms in reviewing requests for imaging services, and one standard prior authorization form for reviewing requests for prescription drugs, not including hepatitis C treatments or Synagis.

This currently applies only to BMC HealthNet Plan’s Qualified Health Plans.

The four forms cover the following areas:

• Medication Prior Authorization Requests
• Cardiac Imaging (Myocardial Perfusion Imaging “MPI”, Stress Echocardiogram, Multiple Gated Acquisition Scan “MUGA”, Transthoracic Echocardiogram “TTE”, and Transesophageal Echocardiogram”) Prior Authorization Requests
• PET – PET CT Prior Authorization Requests
• CT/CTA/MRI/MRA Prior Authorization Requests

These forms were developed as part of the work of the Mass Collaborative, which includes BMC HealthNet Plan along with other health plans, clinicians and hospitals.

The Division’s bulletin requires that health plans begin accepting the paper version of these forms by no later than November 7, 2016 (90 days following the Division’s guidance) and electronic versions on February 9, 2017 (six months following the Division’s guidance).

For more information, please contact your dedicated Provider Relations Consultant.