October 2017
From the Chief Medical Officer, Jonathan Welch, MD
Welcome to the fall issue of Provider News. Since I began my role as Chief Medical Officer last spring, the health care delivery system has remained in a state of flux on the national and local levels. Despite repeated attempts, Washington has yet to replace the Affordable Care Act. Fortunately in Massachusetts we’re moving forward with addressing the issues of health care quality and costs within the MassHealth population. On March 1, 2018, Massachusetts will go live with Accountable Care Organizations (ACOs). BMC HealthNet Plan and BMC Health System have partnered with several providers and formed four accountable care partnership plans in the Bay State: BMC HealthNet Plan Community Alliance, BMC HealthNet Plan Mercy Alliance, BMC HealthNet Plan Southcoast Alliance, and BMC HealthNet Plan Signature Alliance. The ACO program is a major component in the state's five-year innovative 1115 Medicaid waiver, bringing in $1.8 billion in new federal investments to restructure the current MassHealth system. ACOs will receive more than $100 million in new investments throughout the remainder of 2017 to support the transition of health care providers delivering value-based care. As a managed care organization, we are fully committed to the effort at improving patient care and reducing costs.
Please take advantage of the information you’ll find in this edition of Provider News since it covers both administrative and clinical topics. Treating ADHD, screening for diabetes in patients taking antipsychotic medications, and administering HPV vaccinations to young males are current topics in the field that we discuss in this newsletter. For those of you on the administrative side, you’ll note that we’re conducting routine audits to ensure that billed services match the services rendered. There also has been a change to the code used by community health centers and federally qualified health centers when billing for a clinic encounter visit.
I’d also like to remind you that your dedicated Provider Relations Consultant continues to be the best source of information about our organization, and also the person to whom you can turn to with questions or suggestions. I encourage you to go to the Providers page where you’ll find the Provider Manual, policies and other resources to help you care for your patients, as well as the provider portal where you can log in to conduct business with us online.
As always, thank you for the quality care you give our members.
Audits Help Prevent Billing Errors
BMC HealthNet Plan conducts routine audits to ensure that services billed to us match services rendered according to medical record documentation. We identify audit samples by analyzing billing patterns to detect services that are prone to incomplete or inaccurate documentation, incorrect coding and/or billing, potential non-compliance with our reimbursement guidelines and prior authorization policies, and lack of medical necessity. We also select audit samples from billing trends and practices that are outside of the norm (i.e., outliers).
In addition to referencing our requirements, we keep abreast of issues identified by agencies such as the Office of the Inspector General, Medicare Recovery Audit Contractor Program, Massachusetts State Auditor’s Office, and the State’s Medicaid agency Program Integrity Units. You can find information about common billing errors and the audit findings of these agencies online at their respective websites.
Remember, awareness of these types of identified issues may help ensure positive audit findings.
CHCs, FQHCs To Use New Billing Code For Clinic Visits
Effective October 1, 2017, BMC HealthNet Plan will require community health centers and federally qualified health centers to use the HCPCS code T1015 when billing for a clinic encounter visit. We will no longer reimburse the clinic visit rate for 99201-99215. Claims for clinic visits must be billed with T1015 in addition to the pertinent CPT/HCPCS code(s) that identifies the services provided.
The reimbursement policy, Community Health Centers and Federally Qualified Health Centers, 4.107, has been updated to include these new billing guidelines. Please review the updated policy located on the Policies page.
CBHI Online Training Available for Medical and Behavioral Health Providers
We encourage outpatient medical and behavioral health providers to participate in a 20-minute online Children’s Behavioral Health Initiative training – through MassHealth – about care coordination between these two provider types. An Interactive Resource for Coordinating Care for MassHealth Youth in Outpatient Therapy was designed to accomplish several goals:
- Outline the basics of the hub service system
- Describe the logistics of hubs in terms of complexity of needs
- Illustrate care coordination activities within each hub
- Clarify the outpatient provider’s relationship to youth within each hub
- Explain how to use consult codes that support care coordination activities
Find out more about the online training.
Your Responsibility When Treating ADHD
Medication to treat children’s Attention Deficit/Hyperactivity Disorder (ADHD) can help control symptoms of hyperactivity, impulsiveness and inability to sustain concentration. If you prescribe medication to treat ADHD, please schedule a follow-up visit for your patients within 30 days of the initial treatment. We recommend that children be seen at least two more times during the year to monitor the effectiveness of the medication, and so you can answer questions for parents and caregivers and adjust the treatment plan.
Access a helpful resource to learn more about ADHD.
The Centers for Disease Control and Prevention also offers important information on its website regarding medication and behavioral therapy for those affected by ADHD.
Prescribing Medications and Monitoring Compliance
Regardless of the medication you prescribe, your patients need to understand the importance doctor patient consult of having the prescriptions filled and adhering to dosage and timing. It’s also important for you to monitor their adherence. As you know, this helps ensure a successful course of treatment and avoid relapses.
There are times when your patients may be unaware of a medication’s purpose and efficacy. That’s why you should review with them how to take the medications you prescribe, and instruct them when to have a medication refilled. This is particularly beneficial for those patients who have chronic illnesses. Remind your patients that they need to continue taking the medication even when they begin to feel better or if they do not feel better right away.
Tips on Helping Patients Adhere
To make it easier for your patients to take their medications, you should make the following recommendations:
- Purchase pill boxes indicating the days of the week to ensure they take the medication each day.
- Download medication reminder apps to their smartphones. This is especially helpful for younger people who may be more attuned to doing things through their smartphones.
- Ask their pharmacy to call or send a text message when a prescription is refilled automatically to ensure your patients don’t run out.
More Information
Here are some links to medication adherence websites to assist you with your patients and their medication adherence.
- American Family Physician: Medication Adherence
- Department of Health and Human Services: Adherence and Hypertension
HEDIS and Prescription Medications
Among health plans there are certain drug therapies that HEDIS (Healthcare Effectiveness Data and Information Set) measures. These include:
- Statin therapy for members with diabetes and those with atherosclerotic cardiovascular disease who were prescribed and remained on the statin 80% of the time
- Members with asthma who are prescribed a controller and have an adherence rate of at least 75%
- Members diagnosed with depression who stay on their antidepressants for six months
Please be aware of these as you prescribe medications. As always, thank you for the work you do to ensure quality care for our members.
It’s Time For Flu Vaccinations
As the changing seasons bring cooler weather, the threat of influenza also increases.Vaccine Bottle 262x174 We encourage and support the vaccination of all our members, especially those in the groups targeted by the Centers for Disease Control and Prevention. These include individuals at high risk for developing flu-related complications and people with certain medical conditions. Please review the information from the CDC.
Girls AND Boys Should Receive HPV Vaccines
The human papillomavirus (HPV) vaccine has been proven to be as important for boys to receive as it is for girls. A report from the Centers for Disease Control (CDC) states that the vaccine can protect boys against certain HPV-related cancers. Every year over 9,000 males are affected by cancers caused by HPV infections.
The HPV vaccine has been carefully studied and determined to be safe. It’s recommended for boys ages 11 and 12 because the vaccine produces a high immune response at this age. The CDC offers valuable information about HPV vaccinations.
We strongly urge providers to discuss the importance of the HPV vaccine with the parents or guardians of young patients, both girls and boys.
Screening For Diabetes: Early Diagnosis Is Key
According to the National Diabetes Statistics Report, 2017 from the National Center for Chronic Disease Prevention and Health Promotion, an estimated 9.4% of the U.S. population has diabetes. This breaks down to 23.1 million people diagnosed and 7.2 million that are undiagnosed.
Some antipsychotic medications increase the risk of diabetes and have been added to the list of common risk factors. It’s important to screen for diabetes in those patients who have schizophrenia and bipolar disease and who are on antipsychotics.
Remember, early diagnosis of diabetes leads to effective treatment!
Closing Care Gaps with Text Messages
Our innovative text messaging program for members is gaining popularity. 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.
Let your BMC HealthNet Plan patients know that we can text them with reminders and educational information on the following:
- Hypertension
- Diabetes
- Breast cancer screening
- Cervical cancer screening
- Asthma
- Well visits
- Smoking cessation
- Flu shots
- Medication adherence
- 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.
If members want to receive this beneficial information, they should text HEALTH to 85886.