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November 2006
In this newsletter you will find the R4E Rewards results for this year along with an historical review of HPHC Rewards. There is information about MedNet's membership with HCAS and plans to use their credentialing program in 2007 along with news of several new products being rolled out by HPHC and UHC.
Rewards for Excellence Results are in!
R4E Rewards
This year, MedNet will again receive significant funding from Harvard Pilgrim Health Care for outstanding performance in service year 2005. As is evident in the grid to the right, our scores were at or above the target 90th percentile of national HEDIS results in four out of six of the chosen measures. The combination of superior clinical performance and increased HPHC membership member months (MM) produced a R4E award of $84,894 to MedNet. Individual physician scores have not yet arrived, but once they do, we will be distributing your earned share of these funds.
Analysis of the Results
This year, we significantly improved our asthma management score taking us from 73% compliance and no award last year to 92%, well above the 78% award threshold this year. At $.50 per MM, that category produced a significant increase over last year’s earnings. On the negative side, we lost ground in the two Depression categories. We just missed the 90th percentile in the 6 Month Rx Management measure, due to post prescription patient follow-up not including the full required number of visits (3) with the prescribing provider during the first 3 months of new Depression treatment. With a MM count of 67,915, this represented a $50,936 loss in potential reward dollars. Had all goals been met, MedNet’s potential reward amount would have been $135,831.
Because our information is based on HPHC paid claims, there is a significant lag in the flow of information and our ability to monitor it. By the time we are able to identify newly diagnosed patients the 3 month monitoring window is nearly over, so we must place the burden on your shoulders to make sure the extra patient monitoring occurs.
Areas of Focus for R4E Program
- Diabetes 1: Annual HbA1c
- Diabetes 2: annual Retinal Eye Exam
- Diabetes 3: Annual Cholesterol (LDL) Screening
- Diabetes 4: Annual Nephropathy Screening*
- Asthma: Appropriate Rx Plan in place
- Depression: Optimal Practitioner Contacts & New Rx Mgmt
- Depression: Effective 6 Mo Continuation of Rx
- Chlamydia Testing (ages 16-26): At least one test for sexually active females
HPHC selects from the above measures for its ongoing annual rewards program. If you need more in depth information, contact Penny Thomas at 207-773-5116 Ext 118.
R4E over the Years
MedNet has participated in Harvard Pilgrim’s Rewards for Excellence Program since 2003. Annual awards are based on a prior year’s performance for selected HEDIS measures. The attached grid shows the historical relationship between the total dollars that MedNet could have earned vs. the actual dollars earned each year since the program’s inception in Maine. Rewards are based on performance at or above the 90th %ile of national HEDIS scores multiplied by the member months for that reporting year. As you can see, the dollars awarded have risen over time, but there is still room for improvement.
From the Desk of the CEO: Coming Next Spring
MedNet has recently joined Healthcare Administrative Solutions, Inc., (“HCAS”), a Massachusetts nonprofit corporation founded in January 2005 by several health plans in Massachusetts to collaborate on administrative simplification initiatives. The sponsoring plans are Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Tufts Health Plan, Fallon Community Health Plan, Neighborhood Health Plan, and Network Health.
HCAS works to facilitate collaboration among health care organizations by centralizing or coordinating analogous, non-competitive tasks and processes. Its objective is to increase the efficiency of health care operations by reducing redundancy and, where possible, unnecessary costs, thus enabling health plans, hospitals, and health care practitioners to dedicate more of their resources, time, and attention to serving their members and patients.
The first such pursuit is a collaboration to centralize and streamline the provider credentialing process. HCAS has contracted with Ingenix, a national credentials verification organization (CVO), which will allow health care providers to submit a uniform credentialing application to Ingenix via the CAQH (Council for Affordable Quality Healthcare) website, www.caqh.org. This central repository for credentialing information will enable providers to complete the process once for multiple health plans. Each plan will then make independent decisions regarding a provider’s eligibility for participation in its network.
Other benefits of the HCAS initiative include:
- Reduction of administrative costs for providers and health plans
- Reduction of time spent on administrative tasks for providers and health plans
- Improved credentialing turnaround
For further information, visit the HCAS website at www.hcasma.org/solutions.html.
Providers’ Corner
UnitedHealthcare News
UnitedHealth Group has recently combined the Medicare Advantage plans offered by UnitedHealthcare, PacifiCare, John Deere Health Care, and Oxford Health Plans to create a new and improved health care enterprise that will continue to be focused exclusively on Medicare customers. The newly combined organization as been named SecureHorizons by United Healthcare.
If you have any questions regarding United Healthcare’s Medicare replacement products, or would like to become a participating provider for SecureHorizons enrollees, contact MedNet’s Provider Relations Department at (207) 773-5116, opt. 3.
HPHC News
Harvard Pilgrim Choice Plus and Harvard Pilgrim Options
As of January 2007, Harvard Pilgrim Health Care and United-Healthcare are jointly offering two PPO plans, Choice Plus and Options. Choice Plus and Options members will present co-branded identification cards, displaying both the Harvard Pilgrim and UnitedHealthcare logos. Members will access their care through the Harvard Pilgrim network in Massachusetts, Maine, and New Hampshire, and UnitedHealthcare’s network in all other states. Other selected networks will deal with some specialized services such as chiropractic, pharmacy, and behavioral health. It is critical, therefore, that your staff examine the ID card for the correct Payer ID# and confirm the billing address on the back for peak billing efficiencies.
Harvard Pilgrim will be responsible for the following services to medical providers for the Massachusetts, Maine, and New Hampshire Choice Plus and Options members.
- Managing credentialing, contracting, provider relations, fee schedules, and payment policies
- Verifying member eligibility, benefits, and co-payment through HPs on-line tools or the Provider Service Center
- Processing notification transactions and providing care management
- Administering benefits and paying claims
All questions, therefore, about claims or plan specifics should be directed to Harvard Pilgrim’s Provider Service Center or their website listed below.
First Seniority Freedom Plan in Mass & NH
Harvard Pilgrim is also rolling out in January 2007, First Seniority Freedom. It will replace the current First Seniority plan offered to seniors living in Essex, Middlesex, Norfolk, and Suffolk Counties in Massachusetts and selected towns in Hillsborough County in New Hampshire. The long- term plan is to offer it in Maine as early as 2008.
This plan is a PFFS (Private-Fee-for-Service) product, so you are free to provide service without a contract as long as you are an eligible Medicare-participating physician. It is a Medicare Advantage (not a Medicare supplement) plan, so you submit only one claim. As always, pay particular attention to the member’s ID card for Payer ID and the billing information.
For additional information on these plan offerings, visit Harvard Pilgrim’s website at www.harvardpilgrim.org/providers. or contact their Provider Service Center at 800-708-4414.
MedNet Provider Changes
Our patients rely on accurate information when locating a MedNet participating provider. That is why it is important that you communicate any changes in address, name, telephone or fax, Tax ID number, or group practice as soon as possible.
All notifications should be sent to:
Provider Relations Dept
Medical Network, Inc.
PO Box 15253
Portland, ME 04112
Or fax to Provider Relations: 207-773-1739
If you have any questions, please call MedNet Provider Relations at (800) 556-1144 option 3.
Apply for your NPI now!
As of December 1, 2006, there are only 174 days until the National Provider Identifier compliance date! All MedNet Providers are required to comply with the NPI provision of the HIPAA regulation, and May 23, 2007, is the deadline for compliance. You can apply for your NPI online through the Centers for Medicare and Medicaid Services (CMS) website at http://cms.hhs.gov/NationalProvIdentStand.
Tips for NPI Compliance Readiness
- Learn about NPI (the web has abundant Information under HIPAA NPI)
- Apply for your NPI now at the website noted above
- Contact your Practice Management Systems vendor and discuss changes they may be making to accommodate NPI. Find out when and how these changes will be available.
- Contact your clearinghouse or billing agency to determine how they are preparing for NPI and how their changes will affect you.
- Prepare your staff for the coming changes.
Get started now to allow time for a smooth transition within your organization.
Once you have your new NPI, please forward it to Carole, our Credentialing Specialist, at 207-773-5116 ext 108 or at cbelliveau@mainemednet.com.
Direct your questions to Robert Hillman at 773-5116 ext 130 or at rhillman@mainemednet.com.
MedNet Joins MHMC
For several years MedNet has closely followed the progress of the Maine Health Management Coalition and the growing recognition of its Pathways to Excellence (PTE) program among employers, health plans, and providers. Recently MedNet opted to join the Coalition in participation with some 40 businesses, public sector employers, physician groups, hospitals, and healthcare insurers that comprise the MHMC.
MHMC is a non-profit organization whose mission is to bring the purchaser and provider communities together in a partnership to measure and report on the value of healthcare services, thereby enabling employers and employees to make informed decisions. Its primary goal is to promote excellence in medicine while controlling the ever-increasing spiral of healthcare costs. It’s a firm belief that excellence can generate an economic impact that is good for everyone.
MHMC measures performance through its PTE surveys and publishes the results in summary form for public use. The results of last year’s survey, expressed with blue ribbon designations for each practice location, are available on the Coalition’s website. You can view the results of Maine’s Primary Care Practices, as well as the Hospital Patient Safety study, at www.mhmc.info to see what information your patients now have available to them.
Primary care practices are scored in three main clinical categories. The first centers on the use of Clinical Office Systems to support the quality of patient care. PCP groups self-report on their use of Electronic Medical Records, Electronic Prescribing, maintenance of a Chronic Illness Registry, etc. In 2006, 270 practices have completed the survey, a 7.5% increase from last year. As refinements in the PTE program have been implemented, the second and third categories, formerly selected HEDIS process measures based on paid claims data, have transitioned to practice-reported outcomes measures for diabetes care, pediatric immunization, and practice-reported process measures addressing the care of cardiovascular disease and pediatric asthma. It’s evident that employers and health plans are beginning to adopt a tiering of benefits approach, based on quality and cost, in their plan design and to structure their quality rewards program on Pathways to Excellence performance. Moreover, the MHMC is now developing clinical quality measures applicable to various specialty practices. As a result, MedNet is exploring the feasibility and methodology of offering pay-for-performance programs by its plan administrator clients or employer groups.
MedNet’s Provider Relations Representatives
MedNet’s goal is to develop strong working partnerships with all our participating providers. We want to meet you. Whether you are new to the network or have been participating for years, our Provider Relations Representatives are available to visit your office. We will provide a MedNet orientation to any new staff or a refresher course to the more senior members of your practice. If you are interested in this service, or if you have any questions, please contact our provider relations department at (800) 556-1144.
A Message to your Billing Department
As Medical Billing Professionals, you all know the importance of keeping your Practice Management Software up to date. Incorrect patient registrations can cause delays in your receipt of payment and often is labor intensive to correct after the fact. To access MedNet’s most current list of Payers and participating employer groups, along with appropriate claims submission addresses, check our website at http://www.mainemednet.com/clients.asp.
Additionally, MedNet has established electronic connectivity with the following payers for the purposes of repricing participating member claims. Connecting to our largest payers electronically ensures quick and efficient processing of MedNet participating enrollee claims.
For questions or more information about EDI connectivity with MedNet’s participating payers, contact Robert Hillman at (207) 773-5116, ext 130.
HPHC & HPI Reminder
The purchase of Health Plans Inc. by Harvard Pilgrim Health Care, effective January 2006, has changed the way you interface with enrollee plans utilizing MedNet as their network option.
HPI has offered the option to utilize the HPHC provider network to all of their employer groups nn Maine, Massachusetts, and New Hampshire at renewal times throughout 2006.
Because MedNet serves as HPHC’s principal network in Maine, the vast majority of health care professionals, with the exception of behavioral health, participate with HPHC through the MedNet agreement. However, HPHC contracts independently with hospitals and certain ancillary institutional providers in Maine.
For those employers choosing the HPHC network, new member identification cards are dual-branded with both HPHC & HPI logos. Claims for members using the HPHC network should be sent either electronically or by mail directly to HPI.
Enrollees accessing the HPHC network utilize the PacifiCare Behavioral Health network for mental health and substance abuse services.
Some Health Plans, Inc. employer groups have chosen to continue utilizing MedNet’s provider network directly, in which case we continue to list these “direct” groups on our Client Summary available to you on our website at www.mainemednet.com.
EMR & Office Efficiencies
The results of the MHMC Clinical Office Systems survey showed 6-10% of the Primary Care Practices in Maine are either using or are in the process of implementing Electronic Medical Records (EMR), and a far greater percent are using some form of electronic Rx. This is an exciting trend and one that we hope will continue to spread throughout Maine.
EMR is now recognized as the best way to optimize communication and efficiencies in the clinical setting. There is an obvious clinical gain as well as office workflow and staff communication gains for your practice. It is an amazing tool that can revolutionize your workplace and dramatically enhance your ability to offer top-notch medical care for your patients. Clearly it is no longer the wave of the future, but the trend of the present.
There are a variety of products available to fit any size practice from solo to large multi-specialty groups. The cost and method of delivery varies from product to product. One method that is gaining in momentum is the ASP model of delivery. The ASP (Application System Provider) model is one where the vendor is your data warehouse and you pay a monthly fee for access (either by provider or by transaction count). This model saves the provider from having to purchase the software up front and from needing a strong IT staff to maintain the server center that would be required otherwise. The other option, of course, is to buy the software and keep control 100% within your own practice. As is always the case, each has an abundant list of pros and cons that have to be taken into consideration in the decision making process.
All EMR vendors will tell you that their software will save you money. Some even come up with five and six-figure ROIs to dazzle you. The truth of the matter is that for the first year or more, there is no cost savings. In fact, there most likely will be an increase in spending as you upgrade your IT infrastructure, do your project planning, train your staff and providers, and deal with lost productivity during the go-live period. On top of that, there is a great deal of stress and long hours of dedication and hard work involved in the preparation and implementation of each. The good news though, is that once you go through that often chaotic and difficult period, the gains are immense. There are savings, but they are soft dollars and impossible to measure. In spite of that, we have yet to meet a physician who would “go back” once everything is up and running.
So, what is the gain? It’s just plain good medicine. Providers have patient information at their fingertips. Not only that, but comparative studies of lab results and a complete list of prescription information are all a keystroke away. No more poring over hand written, illegible, and often disorganized charts to find information. No more mountains of charts in your office and no more buried desk-tops. Disease Management and HEDIS measure tracking are all readily available. In many cases, you can access the data from the comfort of your home before you even leave for the office.
We interviewed and gathered excerpts from a couple of practitioners who have been using EMR for five or more years now and this is what they have to say.
Dr. Stephan Babirak, from the Maine Center for Endocrinology & Diabetes in Scarborough, has been using an EMR for five years. The implementation has been a gradual one and some of their providers are just recently up and running. His office chose to use a combination of electronics and paper. They store the office visit and office communication in the electronic medical record, but store a paper backup and the outside reports in the paper chart. He finds he seldom needs the chart, but it is there in its entirety if he needs it.
Dr Babirak agreed that implementation was a painful process but one that has paid for itself time and time again. One of the biggest boons, he said, has been the improvement in his office staff communication levels. They are all on “the same page” at all times with all patients, and that makes for an efficient and smooth running office. It also adds up to great patient care.
Dr. John Baker, from Newport Family Practice in Newport, stated that his office is 100% paperless. All information about their patients resides in electronic format. This requires scanners and other means of getting outside and ancillary data into the system. He too stated that it was a difficult journey, but the gain far outweighs the pain. He stated at a recent meeting that they are finding that while they have not in the past seen a savings in staffing levels, they have now reached a level of efficiency such that they have been able to hire more providers without adding staff to support them. EMR is an integral part of the workflow at both of these practices and neither physician would ever give it up.
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PO Box 15253, Portland, ME 04112 Tel: 207 773-5116
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