The Point Issue 1 2023

For more of The Point Provider Newsletter

IN THIS EDITION:

Stellar Patient Experience: Thank You for Your Part

Optum UM Management

Medicare Advantage: Notice of Changes to Out-of-Network Cost Shares after COVID-19 Public Health Emergency

Save Time with Digital Authorization Management

Chlamydia Screening

New HEDIS^® Measure for Medicare Star Ratings

JUST FOR KIDS. HEDIS^® Measures for Pediatric Weight Assessment and Counseling:

Pediatric Behavioral Health: Important HEDIS^® Reminders

REMINDER: EXCLUSIONS for Medicare Statin Use in Persons with Diabetes (SUPD) Quality Measure

Controlling Hypertension—Closing Gaps in Care

HEDIS^® Medical Records Requests

March was Colorectal Cancer Awareness Month

COMPREHENSIVE VISIT PROGRAM CONTINUES IN 2023

Stellar Patient Experience: Thank You for Your Part 

In the fall of 2022, Martin’s Point Health Care received our 2023 CMS Star Ratings for our Generations Advantage plans (Medicare Advantage) and our 2022 NCQA Health Plan ratings for our US Family Health Plan (TRICARE Prime^®). The results of the Consumer of Healthcare Provider and Systems (CAHPS^®) survey, performed in the spring of 2022 and reflecting the experience our members had with us and their providers through 2021, constitute an important part of these CSM and NCQA ratings.

First, we want to thank you, as our network providers, for the quality of care you provide to our health plan members. Due to your hard work, we were able to achieve five stars in the ‘Member Experience with Health Plan’ element of the Medicare Star Ratings. As shared in our previous issue, many of the questions that make up the patient-experience measures are based on the experience our patients have with their providers, ranging from getting care when needed to appropriate care coordination.

At Martin’s Point, our mission is to deliver the care every person deserves. This would not be achievable if not for our network of dedicated health care professionals who work tirelessly to ensure our members receive the care they deserve.

*Scores are scaled means and percentiles are based on 2022 SPH Book of Business.

Optum UM Management

Effective March 1, 2023, Optum is now managing prior authorization requests for:

Radiation Oncology: Selected radiation oncology treatments and procedures (In and Out of Network)

Medical Oncology: Selected IV/infusion chemotherapy/systematic therapy, supportive care therapies, and therapeutic radiopharmaceuticals (In Network Only) 

Specialty Part B Drugs (Non-Oncology): All Part B non-oncology specialty drugs requiring authorization (In Network Only) 

Prior authorization requests must be submitted for dates of services on or after March 1, 2023. Requests can now be submitted through the Optum Portal.

Authorizations active prior to March 1, 2023, will remain in effect through the approved dates of service. You will not need to submit a new request until the existing authorization expires or all authorized units are used.*

*EXCEPTION: For members currently receiving authorized radiation treatment, new authorization will be required for treatment dates of service that go beyond June 30, 2023.

For more information about the new process or for answers to questions, please visit our dedicated Optum webpage or contact us at 1-888-732-7364.

Thank you for your assistance with this effort and for the excellent care you give our health plan members.

Medicare Advantage: Notice of Changes to Out-of-Network Cost Shares after COVID-19 Public Health Emergency

On February 9, the Department of Health and Human Services (HHS) announced the Public Health Emergency (PHE) for COVID-19 will end on May, 11, 2023. During the Public Health Emergency, COVID-19-related services (testing, vaccines, and treatments approved by the US Food and Drug Administration) are covered at no cost to members whether received in or out of network.

To align with CMS guidance, after May 11, 2023, network requirements will return for all services except those designated by CMS and cost sharing will be applied based on the member’s plan benefits.

For Generations Advantage Prime (HMO-POS) and Select (PPO) plans—members receiving covered services from out-of-network providers will be subject to out-of-network cost shares.*

For Generations Advantage Value Plus (HMO), Alliance (HMO) or Focus DC (HMO SNP) plans—there is no coverage for services performed by out-of-network providers.*

*EXCEPTION: For ALL Generations Advantage plans, urgent and emergency care are always covered with in-network cost shares, even if received out of network. In addition, if there are no in-network providers who can deliver a particular service in a member’s area, the service can be evaluated by the health plan for in-network cost sharing.

For Generations Advantage network provider information regarding COVID-19 benefits, etc., please visit the current CMS Emergencies guidance.

Save Time with Digital Authorization Management

Martin’s Point offers digital authorization management through TruCare ProAuth—an intuitive and interactive tool guiding you through the submission process. Time-saving features include:

Electronic submissions of authorization requests and supporting clinical documentation

Real-time status updates of submitted requests

Authorization pre-screening—instant notification if an authorization is not required or a duplicate authorization exists

All providers with access to the Martin’s Point Provider Portal will be able to enter authorization requests through ProAuth for Generations Advantage and/or US Family Health Plan members.

If your organization does not currently have a local administrator for the Martin’s Point Provider Portal but would like to have access to ProAuth, please follow this link to register for access: https://mphc.force.com/AdministratorDesignation/s/

Martin’s Point strongly encourages you to use the TruCare ProAuth tool for all authorization requests.

NOTE: ProAuth is not used for behavioral health or advanced imaging services.

Behavioral health authorizations go through our Behavioral Health Care Program (BHCP). BHCP can be contacted at 1-888-812-7335 for US Family Health Plan members and 1-800-708-4532 for Generations Advantage members.

Advanced imaging (CT, MR, PET) and nuclear medicine authorizations for our Generations Advantage members for the following services go through our partners at eviCore at 1-888-693-3211.

Chlamydia Screening

Did you know?

Chlamydia is one of the most prevalent sexually transmitted infections (STIs) in the United States.

Chlamydia is most common in persons in the 15-24-year age group.

Despite being the most-reported STI in the US, it is also underreported because most people who have chlamydia are asymptomatic. The dangers of untreated chlamydia include spreading disease to multiple partners, pelvic inflammatory disease, tubal factor infertility, ectopic pregnancies, and chronic pelvic pain (CDC).

The CDC recommendations are as follows:

Sexually active members 25 years of age or younger, recommended for routine chlamydia screenings: Yearly testing. Retest when patient has new sex partner regardless of timing.

Pregnant persons: Test at first prenatal exam. If at high risk of infection—from changing sex partners or regular partner might be infected—test again later in the pregnancy.

All persons at high risk: People with multiple sex partners, who don't always use a condom; and/or who have anal/oral sex should receive frequent chlamydia screening. Other markers of high risk are current infection with another STI and possible exposure to an STI through an infected partner.

As you schedule wellness visits for the year, please look closely at this age group and consider doing a chlamydia test in office. The CDC, CMS, and NCQA recommend yearly chlamydia testing for prevention, discussion, and treatment to help decrease the spread and limit the damage that can be caused by untreated chlamydia.

Martin’s Point continues to include chlamydia as a Quality measure in our 2023 Primary Care Performance Payment Model. Providers who participate in our Primary Care Performance Payment Model are eligible for a $25 payment during the 2023 calendar year for each screening performed on members between the ages of 16-24 years who are identified as sexually active and recommended for routine chlamydia screenings.

_{Resource: Centers for Disease Control Detailed Fact Sheet. 04/12/2022. https://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm}

New HEDIS^® Measure for Medicare Star Ratings:

Follow-up within 7 Days after ED Visit for People with Multiple High-Risk Chronic Conditions

The CMS Star Ratings releasing in October of 2023 (Star Rating 2024) will reflect a new HEDIS measure: Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions. The measure looks to capture the percentage of members 18 and older who have two or more chronic conditions who had a follow-up service within 7 days of an ED visit. The ED visit does not need to be for the diagnosed chronic conditions to warrant a visit within 7 days.

Diagnoses that are eligible for this measure (if same bullet, it counts once):

COPD and asthma

Alzheimer’s disease and related disorders

Chronic kidney disease

Depression

Heart failure

Acute myocardial infarction

Atrial fibrillation

Stroke and transient ischemic attack

There are many visit types that fulfill this measure, some examples of these follow ups are:

Outpatient visit

Telephone visit

Case management visit

E-visit or virtual check in, or telehealth visit

Outpatient or telehealth behavioral health visit or community mental health center visit

JUST FOR KIDS
HEDIS^® Measures for Pediatric Weight Assessment and Counseling:

Correct BMI documentation in EMR ensures your efforts are acknowledged!

Health care providers play a key role in guiding children and adolescents toward healthy behaviors—especially in promoting healthy weight and physical activity. Using the HEDIS-directed medical record documentation will help ensure the quality of care you provide to your young patients is accurately reflected (please see details below).

The HEDIS measure of Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC) was developed to address the growing percentage of obese children. The measure assesses the records of children ages 3 through 17 years who had an outpatient visit in the past year. The three sub measures: BMI; nutrition counseling; and physical activity counseling can be captured in the patient’s EMR at a well-child visit and sick visits.

BMI: The BMI sub-measure is frequently identified as “unable to capture” due to BMI data being recorded in a way that doesn’t satisfy the HEDIS requirement. We believe this accounts, in part, for the 2021 rates for Martin’s Point network providers for this sub-measure to come in at 76% (the 50th percentile of the benchmark rating). To meet the documentation requirement, the measurement of BMI must include height, weight, and BMI documented as a percentile or plotted on a growth chart at least once per year. Documentation of BMI value alone or ranges and thresholds, such as 85-95% or >95% are not HEDIS acceptable.

Nutrition or Physical Activity: These sub-measures can be satisfied by a check list, documentation of assessment of eating habits and exercise, or by documentation of counseling, educational materials provided, or referrals made regarding these two topics.

Pediatric Behavioral Health: Important HEDIS^® Reminders

At Martin’s Point Health Care, we want to ensure our pediatric health plan members receive the highest-quality care as recommended by National Committee for Quality Assurance (NCQA) HEDIS Technical Specifications. Below are two important behavioral health measures for pediatric patients.

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)

APM Measure Description: The percentage of children and adolescents 1–17 years of age who had two or more antipsychotic prescriptions and had metabolic testing. Three rates are reported:

1. The percentage of children and adolescents on antipsychotics who received blood glucose testing.
2. The percentage of children and adolescents on antipsychotics who received cholesterol testing.
3. The percentage of children and adolescents on antipsychotics who received blood glucose and cholesterol testing.

Why should you be concerned? Antipsychotic medications can increase a child’s risk for developing serious metabolic health complications including weight gain, diabetes, and dyslipidemia. Given the potential lifelong consequences of these conditions, metabolic monitoring is important to ensure the ongoing health of these patients. Please schedule any necessary lab testing for your pediatric patients on antipsychotics to monitor for potential metabolic side effects.

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)

APP Measure Description: The percentage of children and adolescents 1–17 years of age who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment.

Why should you be concerned? Antipsychotic medication should only be started after psychotherapy is tried as a first-line treatment. Examples include individual, group, art, play, dance, or in-school therapy. Should you have a Martin’s Point health plan pediatric patient who you know has started with a behavioral health provider prior to starting an antipsychotic medication, please share the start date and the behavioral health provider name with our HEDIS team.

Please fax or secure email the information above, plus any supporting documentation, to the following:

Fax records to 1-207-828-7853, ATTN: HEDIS, feel free to call Health Plan Quality at 866-484-2788 to alert them of the fax.

Secure email records to: Email: [email protected]

Martin’s Point Behavioral Health Care Management Program

A care manager can also help address any ongoing behavioral health needs. If you think your patient would benefit from the help of a behavioral health care manager through their Martin’s Point health plan, please have them call 1-877-659-2403.

REMINDER: EXCLUSIONS for Medicare Statin Use in Persons with Diabetes (SUPD) Quality Measure

For patients meeting the exclusion criteria, adding the appropriate ICD-10 code to claims can reduce false provider alerts.

The Pharmacy Quality Alliance updated the exclusions for the Medicare SUPD quality measure beginning in 2022. Measure description: The percentage of individuals ages 40 to 75 years who were dispensed at least two diabetes medication fills and received a statin medication during the measurement year (January 1 – December 31 of a given year).

EXCLUSIONS INCLUDE: Members enrolled in hospice or who have end-stage renal disease (ESRD), rhabdomyolysis and myopathy, liver disease, pre-diabetes, polycystic ovary syndrome (PCOS), and/or are pregnant, lactating, or undergoing fertility treatments.

If your patient meets any of the listed criteria, adding the appropriate ICD-10 code to claims for a visit for a diabetes, cardiovascular, or annual wellness visit, or via annual code recapture, can help Martin’s Point Generations Advantage maintain accurate information and properly exclude them from this measure calculation. It should also reduce false alerts to providers and members.

 

^{ICD-10 code list is illustrative and not comprehensive.}

Controlling Hypertension—Closing Gaps in Care

Automated home readings count, too—please include these in your patient’s EMR!

To support the management of hypertension, the National Committee for Quality Assurance (NCQA) developed the Controlling High Blood Pressure measure. The goal is for anyone with a diagnosis of hypertension between the ages of 18-85 to have adequately controlled blood pressure, defined as <140/90. CMS also finds value in this measure and made it a part of their Medicare Star Rating assessment.

What blood pressure reading is used to determine gap closure?

The last recorded reading of the measurement year is the one that counts toward gap closure. EXCEPTION: When multiple readings are performed on the same day, the lowest diastolic and lowest systolic numbers are used.

We understand that multiple factors, including ‘white coat syndrome’ can cause an elevated blood pressure reading at a physician’s office. That’s why we would like to share that automated readings by patients count, too! To close a quality gap, the automated home readings must be captured in a patient’s electronic medical record. To support interoperability changes, we encourage staff to enter the patient's automated home blood pressure readings into the patient’s EMR flow sheet vs. scanning in the numbers or embedding in a narrative note. Thank you!

RELATED HEALTH PLAN BENEFIT! To help support the management of hypertension, our Medicare Advantage plans include a CVS over-the-counter quarterly stipend that members can use toward an automated blood pressure device.

HEDIS^® Medical Records Requests

Martin's Point Health Care will be faxing HEDIS-related medical record requests to network providers from January through early May 2023. We ask for your support in responding to the request as quickly as possible to allow a timely audit by our reviewers.

We will include a phone number for your use should you have any questions and a secure fax number and physical mailing address to expedite delivery of your records to Martin's Point.

The HEDIS fax number is 207-828-7853 and is only monitored January 1 to May 9. Please remember that medical records should never be faxed to the Provider Inquiry department. Thank you for your assistance with this effort and for the excellent care you give our health plan members.

_{HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)}.

March was Colorectal Cancer Awareness Month

Time to check in with your 45-year-old patients!

The American Cancer Society, Medicare, and TRICARE have lowered the minimum age for colorectal cancer screening from 50 to 45.

Colorectal cancer is the second-leading killer for cancers affecting both men and women in the US. Screening guidelines have recently been updated due to an increase in the rates of colorectal cancer cases in people under the age of 50. This increase, with the shift in the median age of colorectal cancer patients from 72 in early 2000s to 66 in 2020, has prompted the change in recommended initial screening age.

Colorectal cancer screenings are currently recommended for those 45-75 years old.

There are several screening options for colorectal cancer with different frequencies of testing.*

• Stool Tests
  • Guaiac-based Fecal Occult Blood Test (yearly)
  • Fecal Immunochemical Test(FIT) (yearly)
  • FIT-DNA (every 3 years)
• Visual Tests
  • Colonoscopy (every 10 years)
  • Flexible Sigmoidoscopy (every 5 years)
  • CT Colonography (every 5 years)

COMPREHENSIVE VISIT PROGRAM CONTINUES IN 2023

Improving Quality and Medical Documentation through Annual Comprehensive Health Assessments

We are pleased to announce that we will continue our Comprehensive Visit Program for 2023. This program supports the annual assessment of the health status of Martin’s Point Generations Advantage members—promoting health while ensuring compliance with CMS documentation requirements for Medicare Advantage plans.

There are a few changes from 2022. Please note that we are reverting to our standard pre-Public Health Emergency Comprehensive Visit Program guidelines and returning to requiring completed Comprehensive Visit Forms be returned within sixty (60) days from the date of service.

Eligible Visit Types

For 2023, the Comprehensive Visit Form can be completed during one of the following visit types:

Comprehensive Visit Form Return Deadline
Completed Comprehensive Visit Forms must be returned within 60 days from the date of service.

Thank you for your partnership as we continue this important program in 2023!