October 2016

Read our October 2016 issue of Provider News.

Welcome to John Wiecha, MD, MPH, BMC HealthNet Plan's New Medical Director

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 ofJohn-Wiecha 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.”

Excellent Accreditation and 4.5 Rating from NCQA

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.

Accurate Coding and Billing for New Procedures, Tests or Devices

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.

Continuing our Commitment to Providers and Members in Western and Southeastern Massachusetts

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.

Specific Prior Authorization Forms Have Been Standardized

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:

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.

App Available to Help Victims of Domestic Violence

October is Domestic Violence Awareness Month. BMC HealthNet Plan wants to bring attention to this critical problem by promoting the free RUSafe app. We encourage you to share this information with patients you feel may benefit from it. The RUSafe app is a tool that helps victims escape domestic violence situations. It directs them to the nearest qualified crisis center and provides targeted services and legal advocacy while helping them transition to a safe environment.

How it Works

The person accessing the app will be asked to answer a series of questions about her/his relationship. The app will calculate the responses and alert the user if there is cause for concern. In addition, the app will allow the user to call the RUSafe 24-Hour Hotline. If the user is in immediate or lethal danger, she or he can call 911 directly from the app.

Anyone can download the RUSafe app for free at the Apple Store for iPhones and Google Play for Android phones. The RUSafe app comes from the Women’s Center & Shelter of Greater Pittsburgh. For more information about the app or domestic violence, visit RUSafe.net.

Closing Gaps in Care

Since July, BMC HealthNet Plan has been outreaching to a subset of members who have had “gaps in their care,” meaning that they have not received care in the past 12 months for certain services, including:

  • Diabetes eye exams, HbA1c testing, neuropathy screening
  • Well visits
  • Cervical, breast and colorectal cancer screenings
  • Asthma controller medication regimen

The goal is to encourage these members to take an active role in their health care and connect with their primary care providers to discuss appropriate screenings and medication regimens during their next visits. As part of this effort, we are developing reports for providers that will highlight the care gaps for members in their patient panels. These reports will be mailed out as soon as they become available.

Providers Can Significantly Affect the Lives of Patients with Asthma

Health care providers are a key resource to help individuals with asthma successfully manage their condition. When you speak with your patients affected by asthma, make sure to cover the following topics:

  • Identifying and avoiding asthma triggers
  • Differentiating between rescue and controller medications
  • Adhering to controller medications. Consider using an asthma action plan to review these topics at each office visit.

If your asthma patients are children, make sure their caregivers have additional information or training in topics such as:

  • Identifying asthma symptoms
  • Managing an acute asthma attack
  • Ensuring that the child avoids asthma triggers

Also be sure to prescribe spacers for children with asthma, and make sure that the caregivers understand how to use these important tools.

Asthma Control Test

To help your patients monitor their asthma, BMC HealthNet Plan and the American Lung Association recommend the asthma control test (ACT), a five question survey your patients can download, print and complete. Make sure to review and discuss the results with your patients.

As always, you should refer to the Asthma Clinical Practice Guidelines that we have endorsed. If you have BMC HealthNet Plan members with asthma whom you believe would benefit from care management, please contact us at 866-853-5241. Care managers will work with you and your patients to assess their health status, develop an asthma action plan, provide educational materials and provide continuing care management support.

Schizophrenia and Bipolar Disorder Increase the Risk of Diabetes

Your patients with schizophrenia and bipolar disorder are at a higher risk of developing diabetes and other serious health conditions. This risk is attributed to antipsychotic medications, which can cause considerable weight gain and changes in metabolism. Both can lead to diabetes.

Because of these factors, we urge providers to regularly screen these patients for diabetes. Those who have been diagnosed with diabetes should be monitored regularly for diet, weight, blood glucose levels and blood pressure.

HPV Vaccines Are for Girls AND Boys

Much of the focus of human papillomavirus (HPV) prevention has been on preteen girls; however, the vaccine is just as important for boys. The Centers for Disease Control (CDC) reports that the vaccine also can protect boys against certain HPV-related cancers. According to the CDC, every year over 9,000 males are affected by cancers caused by HPV infections.

The HPV vaccine, which has been carefully studied and determined to be safe, is recommended for boys ages 11 and 12 because the vaccine produces a high immune response at this age. That’s why we strongly encourage providers to discuss the importance of the HPV vaccine with the parents or guardians of young patients, both girls and boys.

For PCPs: Physician Decision Support Line

Please be aware that Beacon Health Options, behavioral health partner of BMC HealthNet Plan, offers a Physician Decision Support Line for primary care providers who wish to discuss behavioral health issues with Beacon psychiatrists. Topics include psychopharmacology, treatment alternatives and when it is appropriate to refer patients for a psychiatric assessment.

To reach Beacon’s Physician Decision Support Line, call 866-647-2343.

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