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January 2008
We're back.
It's been a wild and outrageous holiday season here at MedNet, but we've finally finished digging the last team member out of the snow. The January Newsletter is online and chock-full of updates on all of your favorite subjects.
Now let's go make it a winning and well informed year!
News From Deidre & Jeff
MedNet Presence at MMA Annual Session
MedNet exhibited this past September in Bar Harbor, Maine at the Maine Medical Association Annual Session. Our Provider Relations Consultants enjoyed the chance to meet face to face with many Maine providers. Our giveaways this year were iPod Shuffles. The winning business cards that were drawn were; Dr. Martha Stewart, DO from Houlton, Dr. Samuel Solish, MD, Portland, Dr. David McDermott, MD, Dover Foxcroft and Dr. Daniel Hale, MD from Lewiston. Thank you to all who participated and congratulations to our winners!
MedNet attended “Quality Counts” 5th Annual Conference
MedNet also exhibited at Quality Counts on December 7, 2007, at the Augusta Civic Center. The theme at this conference was “Aligning partners for Quality”. Again, MedNet had a drawing for iPod Shuffles and the winners were Pamela Beaule and Ralph Jordan. Congratulations!
Client Summary List and Fee Schedules Available
MedNet’s Client summary is a valuable tool for your Registration Team. For an updated list contact our Provider Relations Department and we will fax or Email (via secure mail) the list to you. This report provides Payer or TPA names, their current employer groups, addresses for claims submittals, and helpful telephone numbers.
Our Provider Relations Dept. can also send you a Fee Schedule based on your specialty codes. We maintain sample files of the most commonly used CPT codes by specialty with all the appropriate fee schedules applicable. Let us know if you would like us to add some special codes for you. We can send the file to you via fax or secure email.
Knowing Me, Knowing You...
Our goal as MedNet Provider Relations Consultants is to support the Physicians and their office staff in the attempt to streamline problem resolution and answer any questions, concerns and educational needs that arise on a daily basis. We encourage you to call Provider Relations at (800)556-1144 Option 4 for assistance or to set up a time for a Consultant to visit your office. We are happy to do a MedNet orientation or refresher course for your office. We also are more then willing to simply come and sit with you, to answer any questions that you have.
As Provider Relation Consultants we receive many different types of questions. The confusion around MedNet’s role in the market place is a common one. We would like to explain a little about what MedNet is.
We are a physician owned PPO network. What this means is that MedNet has a comprehensive network of participating Maine providers and facilities. Payers and TPA’s contract with MedNet to lease our network of Maine providers for their subscribers.
MedNet credentials and thereafter maintains credentialing activity for all participating providers according to NCQA standards.
Our Provider Rep Team, in most cases, acts as the liaison between the provider offices and the insurance company. A few of our payers, like Harvard Pilgrim, simply lease our network and offer their own provider relations services.
So, even though you see MedNet’s logo on the back of patients’ insurance cards, we are not an actual insurance company. We do not handle patient eligibility nor do we adjudicate claims. We are, simply, a network through which assorted insurance companies work in Maine.
MedNet is currently gathering contact names and e-mail addresses from our participating Providers, Facilities, Hospitals etc. This will allow us to provide you with information in a more efficient and timely fashion.
Please e-mail the name of your contact person/persons and e-mail addresses to DDEROCHE@MAINEMEDNET.COM.
Your information will be maintained and used for MedNet business only.
Our Provider Rep Team is available most weekdays from 8:00AM to 5:00PM. Call us at (800)556-1144 Option 4 or (207)773-5116 Option 4 with your questions, requests, and concerns.
UnitedHealthcare News
Outpatient Radiology Notification Required as of 12/03/07
As mentioned in our Spring 2007 newsletter, UnitedHealthcare (UHC) has launched a new Radiology Notification Program for all advanced outpatient imaging procedures to include CT, MRI/MRA, PET and Nuclear Medicine. The activation date was December 3, 2007. All participating physicians, facilities, and allied healthcare professionals are required to comply with UHC’s newest notification procedures.
Ordering Providers can obtain a notification number in one of following three ways. Phone: 1-866-889-8054
Fax: 1-866-889-8061
Online: www.unitedhealthcareonline.com click Notifications and then Radiology Notification Submissions & Status.
Rendering Providers should verify that notification is on file by calling 1-866-889-8054, Option #2 or by email listed above. If the Rendering Provider finds no notification on file, the Rendering Provider may contact UHC to obtain the notification via the channels noted above.
Claims without Notification numbers have been denied as of 12/03/2007. For more information contact MedNet Provider Relations at (207) 773-5116 Option 4 or (800) 556-1144 Option 4.
Expansion of SecureHorizons into Androscoggin County for 2009
SecureHorizons by UnitedHealthcare has partnered with MedNet to develop Androscoggin County, making its Medicare Advantage plans available to Medicare enrollees in that county in early 2009. Previously, MedNet successfully assisted UnitedHealthcare in the development of a Medicare Advantage provider network in four Maine counties (Cumberland, Kennebec, Sagadahoc, and York). Providers interested in participating with SecureHorizons’ Medicare Advantage products, either in Androscoggin or the original four counties, should contact MedNet at 207-773-5116 Option 4.
Nat’l Imaging Accreditation Deadline Is 03/01/2008
Remember that UnitedHealthcare has stated that all stand-alone (out-patient) diagnostic imaging facilities and physician offices that use CMS 1500 claim forms will be required to abide by the accreditation requirements defined by the American College of Radiology (ACR) and /or the Intersocietal Accreditation Commission (IAC) as a condition for reimbursement. The UHC initiative is focused on facilities offering CT, CTA, MRI, MRA, PET, Nuclear Medicine, Nuclear Cardiology and/or Echocardiography at this time.
These facilities have until March 1, 2008 to submit their applications. Please direct questions about the application process to ACR at www.acr.org or (800)770-0145 or the IAC at www.intersocietal.org or (800)838-2110. Email radiology@customerelation.com or call (800)637-5792 with questions about the UnitedHealthcare accreditation initiative.
Harvard Pilgrim Health Care News
Dirigo Partners with HPHC
According to a news release from Governor Baldacci’s office in September 2007, Harvard Pilgrim Health Care will be the new carrier of the DirigoChoice health insurance product starting January 1, 2008. Negotiations are now underway to finalize contract agreements and secure approval through the Bureau of Insurance. There are about 15,000 DirigoChoice members at this time. For more information go to the website at www.dirigohealth.maine.gov/2008_transition.html
First Seniority Freedom to be offered in Maine in 2008
HPHC has announced that it will offer First Seniority Freedom statewide in Massachusetts, Maine, and New Hampshire in 2008. They have just completed a series of information sessions but may have web conferences available for those who missed these meetings. For more information on the features of this plan go to HPHC website at www.harvardpilgrim.org/providers and click on the link for First Seniority freedom. You can also call HPHC at (800)708-4414 with questions.
New Provider Appeal Form
A new, interactive, version of the Provider Appeal Form was introduced in July 2007. Beginning January 1, 2008, providers must use this new version when submitting provider appeals. Provider appeals received after January 1 with the old version of the form will be submitted for processing as a first time claim submission. Harvard Pilgrim also created a Quick Reference Guide with instructions for filling out the new appeal form. For more information on the new Provider Appeal Form and Quick Reference Guide, please refer to the Provider Manual, at www.harvardpilgrim.org/providers
R4E Results Poor for MedNet’s Local Care Unit
The report is in for HPHC R4E program covering DOS (Date of Service) year 2006. MedNet scored significantly lower than expected due to HPHC’s demands for outcomes on two Diabetes tests as a qualifying factor. Obviously, gathering that information is difficult for MedNet to accomplish since, unlike the other LCU’s (Local Care Units) in Maine, we do not have access to patient charts or EHR.
The criteria for Rewards for 2007 are reported to be the same as for 2006. Once again HPHC’s plan is to require outcome reporting. MedNet intends to make some changes this year in an effort to improve the R4E funds. In February 2008, HPHC will deliver to MedNet pertinent information about your patients with Diabetes. They will be looking for test results for LDL to be less than 130 and for HbA1c results to be less than 9. MedNet will forward this information to the PCP’s with the hope that they will fill in the requested information and forward the information back to MedNet for tabulation and delivery to HPHC. The difficulty is that we will have only one month to accomplish the task The good news is that very few PCP’s will have more than three patients to pull charts on and fill in the blanks. We do encourage all of you to do your part with the hopes that there will be an increase in the funding so that we can share the rewards with our hard working HPHC PCP’s who take care of the HPHC HMO patients in Maine. Refer to page 6 for an overview of the HPHC R4E measures.
Like HPHC, most of the large payer groups are putting pressure on providers for information beyond the paid claims data they have used in the past. For more information go to page 7 and read the article on the Maine Health Management Coalition.
Feel free to email Penny Thomas at pthomas@mainemednet.com or call her at 773-5116 Ext 118 with your questions and comments.
2007 & 2008 Rewards for Excellence News
Enhancing your HPHC R4E
For the last six years MedNet primary care physicians, through Harvard Pilgrim Health Care, have participated in the Rewards for Excellence Program. Rewards programs based on quality of care seem to be in place for all of the major insurance carriers for fully insured products as well as for ASO products and services. Requests from insurers for results are beginning to paper the walls of medical records rooms. The demand to allocate more resources to testing, screening and results reporting can no longer be ignored. Why? Well, 1. the assumption is that quality care equals less expensive care. 2. consumers demand more information regarding physicians and quality of care and 3. insurers strive to get and keep their accreditation with the National Committee for Quality Assurance (NCQA).
NCQA’s programs and services reflect a straightforward formula for improvement: Measure. Analyze. Improve. Repeat. NCQA makes this process possible in health care by developing quality standards and performance measures for a broad range of health care entities. These measures and standards are the tools that organizations and physicians can use to identify opportunities for improvement. The annual reporting of performance against such measures has become a focal point for health plans, which use these results to set their improvement agendas for the following year, and the healthcare services consumer.
For the past two years HPHC has used the following HEDIS measures to calculate the results of their Rewards 4 Excellence Program. The key change from prior years is the additional request of patient test outcomes (listed below) to their reporting requirements. It no longer is enough to simply do all of the diabetes annual testing, as they now want to see positive outcomes as well due to the CAQH pressures mentioned above. Obviously, MedNet does not have access to this data from our Local Care Unit PCP’s, so our Rewards 4 Excellence funds have significantly diminished for 2006 and may continue for 2007 dates of service.
Diabetes Measures and R4E Desired Outcomes (where applicable)
- Annual HbA1c testing with Outcomes <9%
- Annual LDL testing with Outcomes <130 mg/dl
- Annual Retinal Eye Exam
- Annual Nephropathy Testing
- Depression Measures - Optimal Practitioner Contacts for New Medication Management (ages 18+)
- Three follow-up visits to monitor progress, including one with a prescribing practitioner, during the 12 week acute treatment phase plus a 6 month follow-up visit.
- Chlamydia Testing (ages 16-25) performed annually on sexually active females
- Asthmatics (ages 5-56) : use of appropriate medications for people with persistent asthma
- Breast Cancer Screening (ages 50-69) performed annually
- Cervical Cancer Screening (ages 19-64) performed every one to two years
AND REMEMBER - Document Results!
Whether or not you are using electronic medical records software with an outcomes reporting feature, you will be asked for testing and screening results. Results have not played a part in past Rewards for Excellence programs but retrospectively did for 2006 (see the Outcomes article on page 3) and will for 2007 DOS. We expect to see some changes for 2008 DOS (dates of service) that will put even more demands on providers to report and record well-care and chronic illness care in order to reap benefits from all of the major insurance payers. If you have any questions, or require advice or assistance with this program, please contact Penny Thomas at pthomas@mainemednet.com or 800-556-1144 x 118 Good Luck!
ME Health Management Coalition News
Pathways To Excellence News
It is important that you all be aware of the work that the Maine Health Management Coalition (MHMC) has been doing and the tremendous impact it is having through its Pathways to Excellence (PTE) program. In a nutshell, they are a group of larger employers, physicians, hospitals, and payer groups who have banded together to do something about the quality and rising cost of healthcare in the state of Maine. Their goal is to improve health care to such a high degree that there is true savings in avoiding catastrophic events, improving attendance at work, enhancing the quality of life for patients and employees, and improving compensation for providers. In theory it is a true win-win all around for employers, providers, patients, and payers.
PCP’s were the first providers they focused on and with input from the whole group, a set of standards were established and a method of gathering information from PCP’s was generated. All PCP groups and solo PCP practitioners in the state of Maine were contacted and asked to answer a fairly extensive questionnaire that covers three main categories: clinical office systems and IT Infrastructure in place, specific Disease Management tracking with a show of outcomes for critical testing of Diabetic patients, and patients with Heart Disease Unlike all previous tracking of HEDIS measures done by the big insurance companies where paid claims was the sole data source, this new program relies on self reporting by the PCP’s office. The cost of engaging with MHMC is time and energy of staff only, as there is no actual cash fee to date.
The annual reported information from each group is scored and blue ribbons are awarded based on accomplishment of each of the high standards for clinical office efficiencies along with solid clinical procedures and outcomes for the two disease states studied. Member employer groups committed to educate their employees about these findings and some employers set up incentive programs that encourage the use of blue ribbon groups as PCP’s.
Until recently, this group set its own standards (based on solid HEDIS measures, NCQA measures, and the national trends in the industry). Recently, with the growing interest nationwide, there is pressure to align their results and standards with NCQA to have uniform measures. MHMC has made that decision to move to NCQA and Bridges to Excellence (BTE) in 2008 and 2009. Current blue ribbons on the website will be grand fathered through 2008. PTE will conduct its office system survey again in March 2008. For adult practices, PTE will offer Bridges to Excellence for diabetes and heart disease starting in March-April 2008. NCQA certification can be applied for at any time. Because neither BTE nor NCQA currently offer Pediatric process or outcome metrics, PTE will continue its own data collection for Pediatric immunizations and asthma until an option becomes available.
More and more of the large insurers are looking to this type of standard in their compensation plans and rewards programs. There is some talk that HPHC will switch to MHMC findings for their own R4E cash awards in 2008. With that in mind, we strongly urge all of our provider groups and solo practitioners to get involved. As you can see on the website, there are many practitioners who do not respond. Your future compensation rates could hinge on reporting and achieving excellence and the high visibility that accompanies it.
Go to MHMC’s website (www.mhmc.info) to see results of 2007’s information tabulation and think about getting involved in March of 2008.
O Boy! We Need Help! ...well, that's not news
Please Help Us Help You
At our recent Annual MedNet Business Strategy meeting our staff approached the provider members with an open discussion about the state of practicing medicine in 2007. Typical topics arose around the increasing burden of paperwork, demands by insurance companies for more and more sophisticated data mining, diminishing payment rates, pressure to expand their IT infrastructures, the high cost of acquiring and using electronic tools like ePrescribing, EHR, and Disease Management Registries, and a myriad of other issues that seem to make practicing medicine more of a challenge than it was a generation ago.
As a local physician owned and operated company, the MedNet team is searching for ways we can add value and other services for our provider base. Without the resources that Anthem, Cigna, Aetna and the other large payers have, we are looking for our own unique ways to offer support. Our first step has been to hire Lisa Liponis as Director of Business Development. Her job is to explore the possibilities, and develop programs as approved by the Board of Directors.
In the not too distant future, Lisa will be mailing out a questionnaire to your offices. Our hope is that you will take a moment to read it and respond to the questions. We will provide a self-addressed, stamped envelope for your convenience or you can fax it back to us to Lisa’s attention. Our goal is to get a general consensus of the most urgent issues or areas of concern in your practices. This will help us narrow down the types of activities we will pursue in 2008. Naturally, as we get deeper into the process, more questions will arise, but it is important that we get started and we cannot do it without your help. Contact Lisa at 773-5116 Ext 106 or email her at lliponis@mainemednet.com with questions or comments.
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