The Point | ISSUE 1 | 2024

CMS requires us to regularly contact network providers to confirm the accuracy of our directory information. Up-to-date information helps our members find new providers when they need care and helps claims get processed in a more timely and accurate way. To maintain appropriate continuity of care for our members, provide 30 days advance notice of any changes to your provider/practice information, including when providers leave your organization.

Two Ways to Update:

Use these convenient online tools to keep your NPI-related practice/provider information accurate:

1. Provider DataPoint: Use our web-based provider data management tool to submit real-time changes:

• Change practice information, including name, phone, fax, address, billing information, NPI, and the like
• Add/delete a location for your already-contracted practice/group
• Change provider information, including name, specialty, and panel status; add a language, and more
• Add a provider who needs credentialing to your practice
• Terminate a provider from your practice/group
• Check the status of a previously submitted data change-request

Visit: Provider DataPoint Tool. If you have questions, see the instructions on our website or speak to a Provider Representative.

2. National Plan and Provider Enumeration System (NPPES): CMS now allows providers to use NPPES to certify NPI data. Find information and FAQs about NPPES as a reliable source for provider directory data at NPPES Information. Questions about NPPES? Contact Jeremy Willard at [email protected].

Tips for Practice Administrators

• Set a monthly tickler reminder to check provider/practice information in Provider DataPoint.
• We no longer accept NPI-related updates/changes and credentialing applications via email or fax. They must be submitted online via Provider DataPoint.
• Radiologists, anesthesiologists, and midlevel providers such as nurse practitioners and physician assistants who do not practice as PCPs do not require credentialing.
• For more information on Provider Demographic Updates, please review this section in our Provider Manual: Provider Demographic Updates

Continuity of Care—New CMS 90-Day Rule

The 2024 Medicare Advantage Final Rule requires coordinated care plans to provide a 90-day transition period when an enrollee currently undergoing an active course of treatment switches to a new Medicare Advantage plan. This includes new members enrolled in Martin’s Point Generations Advantage plans or a current Generations Advantage member switching to a different Generations Advantage plan.

During this transition period, the new plan is prohibited from requiring prior authorization for an active course of treatment that started prior to the member joining the new plan. This requirement can be found at 42 CFR § 422.212(b)(8).

An active course of treatment is one in which a patient is actively seeing the provider and following the course of treatment. If a patient switches to or joins Martin’s Point Generations Advantage during an active course of treatment, the plan can’t subject the patient to additional prior authorization for that service for a period of up to 90 days.

The rule does not prohibit concurrent or retrospective reviews of active treatment. Per CMS, “A plan may conduct concurrent reviews as necessary, as long as the review does not interfere with an active course of treatment.”

After the 90-day transition period, the plan may reassess medical necessity and apply out-of-network limits in accordance with plan benefits and other relevant (and appropriate) requirements. For example, if the active course of treatment included visits with an out-of-network provider, after 90 days, the plan may direct care to in-network providers and apply prior authorization requirements.

Understanding Behavioral Health Quality Measures

Martin’s Point has partnered with Dr. Dylan McKenney, Medical Director for the MaineHealth ACO Behavioral Health Care Program, to provide education regarding behavioral health quality measures for 2024. The Behavioral Health Care Program manages the behavioral health network and performs behavioral health utilization management for Martin’s Point Health Care.

Dylan McKenney, MD is certified with the American Board of Psychiatry and Neurology in both General Psychiatry and Child and Adolescent Psychiatry. Dr. McKenney has practiced in a hospital setting for nearly 10 years and has a wealth of experience in treating a broad range of acute mental health problems.

In 2024, Martin’s Point Health Care will monitor the five HEDIS^® measures below to determine the quality of care our beneficiaries receive from our network providers.  If a measure falls below the benchmark of the 75th percentile of National Commercial Quality Compass2 rates, an analysis will be performed to identify opportunities and steer possible outreach to providers or beneficiaries to determine barriers and provide education

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics:

• HEDIS Measure: 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. (Martin’s Point monitors the full measure as stated.)

Medications like risperidone, aripiprazole and lurasidone are commonly called antipsychotics despite their use for a variety of indications. They are more commonly used to stabilize mood and to augment the treatment of depression with SSRIs and SNRIs. In many cases, these compounds are prescribed to youths who may present with challenges in emotion regulation like oppositional behavior problems or self-injury. In such off-label uses, psychosocial interventions like individual therapy, parent training, or other family-based interventions are the established first line of treatment. They are the only types of medical interventions that bring long-term improvement. While the use of these medications in such conditions may be clinically appropriate, their use should always be paired with interventions that help youths learn strategies to self-regulate. This measure of behavioral health care quality tracks psychosocial interventions to ensure that we deliver effective, evidence-based treatment that addresses the causes of symptoms rather than simply suppressing symptoms with this powerful class of medication.

Metabolic Monitoring for Children and Adolescents on Antipsychotics:

• HEDIS Measure: The percentage of children and adolescents 1 – 17 years of age who had two or more antipsychotic prescriptions and had metabolic testing. (Martin’s Point monitors the percentage of children and adolescents on antipsychotics who received blood glucose and cholesterol testing.)

This important quality measure is directed at preventing the onset of metabolic problems in youths being treated with this commonly prescribed class of medication. Best practices in the treatment of youths with atypical antipsychotic medications involve monitoring lipids and hemoglobin A1c along with tracking BMI closely during treatment. Monitoring of prolactin is also indicated in cases of gynecomastia or galactorrhea that emerge during treatment.

Follow-Up Care for Children Prescribed ADHD Medication:

• HEDIS Measure: The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 300-day (10 month) period, one of which was within 30 days of when the first ADHD medication was dispensed. (Martin’s Point monitors the Continuation and Maintenance (C&M) Phase: the percentage of children 6-12 years of age with a prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the initiation phase ended.)

Stimulant treatment has become a first-line intervention in the management of ADHD in children and teenagers. This highly effective intervention has been shown to promote academic growth and to protect against adolescent development of antisocial behaviors as children progress into adolescence. A child with ADHD may improve significantly with regard to the core characteristics of ADHD. As a result, parents and caregivers may see less need to seek ongoing care and monitoring. Nonetheless, close follow-up is important to help identify potentially serious adverse reactions such as weight loss and growth restriction, as well as to monitor for comorbidities that may emerge during treatment. This measure encourages us to monitor children treated for ADHD during the initiation and maintenance phases of treatment.

Depression Screening and Follow-Up for Adolescents and Adults:

• HEDIS Measure: The percentage of members 12 years of age and older who were screened for clinical depression using a standardized instrument and, if screened positive, received follow-up care. (Martin’s Point monitors the following:)
• Depression Screening: the percentage of members who were screened for clinical depression using a standard instrument.
• Follow-Up on Positive Screen: the percentage of members who received follow-up care within 30 days of a positive depression screen finding.

Rising rates of depressive illnesses among adolescents and adults have been seen yearly, since at least 2012 progressively. This measure tracks both detection of depression and follow-up. Diagnosing depression early is essential as is intervening early in the course of illness. This measure is reinforced by using a specific screening tool, the PHQ-9.

Utilization of PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults:

• HEDIS Measure: The percentage of members 12 years of age and older with a diagnosis of major depression or dysthymia, who had an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter. (Martin’s Point monitors the full measure as stated.)

The PHQ-9 is a screening instrument that measures subjective self-report of symptoms over a 2-week period. While the PHQ-9 is often used to screen for depression, it is also a validated instrument for monitoring symptomatic changes over time. This tool lends itself well to monitoring of treatment with medications, psychotherapy, and any other interventions. The use of the PHQ-9 has been identified as an important marker of behavioral health care quality as it highlights the presence of symptoms that may not otherwise be observed during medical encounters.

¹The Healthcare Effectiveness Data and Information Set (HEDIS^®) is one of health care’s most widely used performance improvement tools in the managed care industry. HEDIS^® is developed and maintained by the National Committee for Quality Assurance (NCQA). https://www.ncqa.org/hedis/

²Quality Compass^® is a tool used to examine quality improvement and benchmark plan performance. Quality Compass is developed and maintained by the National Committee for Quality Assurance (NCQA). https://www.ncqa.org/programs/data-and-information-technology/data-purchase-and-licensing/quality-compass/

Martin’s Point Health Care 2024 Clinical Practice Guidelines

Martin’s Point Health Care adopts guidelines for the prevention and treatment of illness and disease from nationally recognized government organizations and medical specialty societies including the Veterans Administration (VA)/Department of Defense (DoD) guidelines. VA/DoD Guidelines.

Clinical practice guidelines provide practitioners with a “best practice,” evidence-based resource and form the basis for our efforts to monitor the delivery of health care and outcomes. Clinical practice guidelines are used in developing health and disease management programs as well as quality interventions. We review and revise these guidelines annually or more frequently if needed and seek input from community providers who have appropriate knowledge specific to the guidelines to ensure that we are using the most current, evidence-based guidelines from nationally recognized sources.

The 2024 clinical guidelines can be found here: Standard of Practice Guidelines.

Deprescribing in Medication Management

Deprescribing is the supervised dose reduction or discontinuation of medications that may no longer provide a benefit to a patient or may cause harm, and is an important tool in good prescribing practices. As more medications are added to a patient’s treatment regimen, it can lead to an increased risk for medication-related problems (including risks for falls, side effects, and hospitalizations).

When appropriate, optimizing a medication regimen through deprescribing potentially inappropriate medications (PIMs) can have multiple benefits for a patient, including: decreasing medication burden/complications and side effect risks, improving quality of life, and lowering patient drug costs.

Examples in medication regimens which may be appropriate for deprescribing include:

• Long term use of PPIs
• Beers List medications in patients over 65 years of age
• Medications with no indication
• Duplicative therapies
• Medications with unlikely benefit
• Medications with drug or disease interactions

Our goal at Martin’s Point is to support the best care for our members and patients. As part of our medication safety initiatives, we continually review ways to impact adverse drug reactions and treatment failures. Periodically throughout the year, you may receive alerts if your patient is taking a potentially inappropriate medication which may be a candidate for deprescribing.

Recommended resources for providers:

• Deprescribing.org
• NSW Therapeutic Advisory Group
• AGS 2023 Beers Criteria

Resources:

• Deprescribing.org
• Deprescribing Guidelines (PDF)
• Medication Safety Toolkit (PDF)

Following HEDIS^® KED Measure Requirements for the Benefit of All

As of 2024, the HEDIS measure for kidney evaluation in patients with diabetes (KED) is officially a CMS Medicare Star measure, elevating its significance as an industry-standard best practice. Performing annual kidney health evaluations based on HEDIS quality guidelines benefits all stakeholders in our health care system—patients, providers, and payers. First and foremost, for patients, it promotes early detection and treatment of chronic kidney disease for best outcomes. Adhering to HEDIS guidelines gives providers the confidence they are following clinical best practices in caring for their patients while earning any related quality-driven incentive payments they may qualify for from payers. Capturing documentation that the measure criteria have been satisfied allows Medicare plans to demonstrate to CMS that their networks are providing the highest standard of care to beneficiaries while boosting their own quality ratings.

The benefits to providers and payers hinge on accurate and complete documentation of provided services, obtained through claims, data feeds, and submission of nonstandard supplemental data. Here is information to help providers satisfy the HEDIS KED measure and obtain applicable payment for doing so:

KED Measure Requirement: Patients identified as having diabetes between the ages of 18-85 receive both recommended kidney evaluation tests annually—an estimated glomerular filtration rate (eGFR) (reflecting kidney function) and a urine albumin creatinine ratio (uACR) (reflecting kidney damage).

Historically, some providers have experienced difficulties with performance against this measure—due to some reported challenges with both obtaining urine samples for the uACR during the visit and incorrect coding. We encourage informing patients that a urine sample will be collected at their visit on their reminder calls and providing a urine cup upon check-in.

The following codes reflect those required to satisfy the HEDIS measure. Please ensure correct coding for all services your patient receives.

NCQA Diabetes Measure Has Changed

Hemoglobin A1c Control for Patients with Diabetes (HBD) is now Glycemic Status Assessment for Patients with Diabetes (GSD)

Starting this year, the NCQA’s previous HBD measure is now updated to GSD with the addition of an in-range glucose management indicator (GMI) being able to close the gap. A GMI is a measure converting the mean glucose from a continuous glucose monitor into an approximate A1c. A1c values are still able to also close this blood sugar control measure’s gap as both A1c and GMI are identified as types of glycemic assessments. Like its predecessor HBD, GSD gap closure is still based on the last reading of the year (whether that’s GMI or A1c).

Like HBD, the measure has two parts:

• Glycemic Status <8.0%
• Glycemic Status >9.0%

An additional positive change regarding this measure is that the NCQA has decided that prescription medication alone no longer qualifies someone to be in the denominator. What does this mean? Historically, a prescription for insulin or antihyperglycemic medication identified someone as having diabetes which isn’t always true. For example, a patient who was taking Ozempic for weight loss or Jardiance for heart disease with no history of diabetes historically still counted. Going forward, a member with a prescription for these medications must also have at least one diagnosis of diabetes during the measurement year or prior year.

Maternal Flu and Tdap Vaccines Protect Moms and Babies

At Martin’s Point Health Care, we monitor the care that our members receive to assure they are getting the quality care they deserve. One of the quality measures we monitor is the HEDIS^® Prenatal Immunization Status (PRS-E). The measure assesses the percentage of deliveries in a year in which women had received influenza and tetanus, diphtheria toxoids, and acellular pertussis (Tdap) vaccinations.

As the most valued and trusted source of health information for pregnant women, it’s important that ob-gyns, midwives, and other health care professionals recommend maternal vaccines to their patients.

Flu Vaccine:

• Maternal flu vaccine is the best way to protect pregnant persons and their babies from the flu and prevent possible flu-associated pregnancy complications. Maternal flu vaccine helps protect babies from flu for several months after birth. This is important because babies under 6 months of age are too young to get a flu vaccine themselves. Flu vaccination is safe to administer during any trimester.

Tdap Vaccine:

• Maternal Tdap vaccination helps protect newborns who are at the greatest risk for developing pertussis and its life-threatening complications. Tdap vaccine is recommended during every pregnancy, between 27 and 36 weeks gestation (preferably earlier in this period). When given during pregnancy, Tdap vaccine boosts antibodies in the mother, which are transferred to her developing baby. Early third trimester administration optimizes neonatal antibody levels.

It is safe to give the flu vaccine and Tdap vaccine to pregnant patients during the same appointment.

Source: Pregnancy and Vaccination: Why Maternal Vaccines Are Important | CDC

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 below:

• Sexually active persons with a cervix age 25 or younger: 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 screening as a Quality Incentive measure in our 2024 Primary Care Performance Payment Model. Providers who participate in our Primary Care Performance Payment Model are eligible for a $25 payment during the 2024 calendar year for each screening performed on persons with a cervix between the ages of 16-24 years who are identified as sexually active.

Resource: Centers for Disease Control Detailed Fact Sheet. 04/11/2023.

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

SUPD Measure description: The percentage of individuals ages 40 to 75 years who were dispensed a medication for diabetes that receive a statin medication (higher rate indicates better performance).

The Pharmacy Quality Alliance (PQA) has updated the exclusions for the Medicare SUPD quality measure. Previously, only members enrolled in hospice or who have end-stage renal disease (ESRD) were excluded. The new added exclusions include: rhabdomyolysis and myopathy, cirrhosis, pre-diabetes, pregnancy, lactation or fertility and/or polycystic ovary syndrome (PCOS).

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

Patient Experience: Thank You for Your Part and Lessons Learned through Surveys

Last fall, Martin’s Point Health Care received our 2024 CMS Star Ratings for our Generations Advantage plans (Medicare Advantage) and our 2023 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 2023 and reflecting the experience our members had with us and their providers through 2022, constitute an important part of these CMS and NCQA ratings.

Thanks to You: First, we want to thank you for the quality of care you provide to our health plan members. Due to your hard work, our HMO contract achieved an average of four and a half stars in the ‘Member Experience with Health Plan’ element of the Medicare Star Ratings and our PPO contract received four stars. 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.

Lessons Learned and Thoughts for Improvement: Although we are very proud of the experience we offer our members, some ratings, including health care quality and getting needed care, did decline from the previous year. Since the CAHPS survey is anonymous, we performed an unblinded patient experience survey this winter to better understand our results. That survey’s most noteworthy trends were challenges with getting in with a specialist or radiology and having to call providers to get results as they hadn’t been provided to the patient. We want to share these findings with you as we believe that member education and expectation setting may decrease some of these negative responses. Education that our members may benefit from are:

• Reasonable timeframe expectations for specialist appointment based on their condition
• How members can expect to receive lab results (portal, phone call, mail)

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 best care possible. Thank you for doing your part!

Tramadol Prescribing for US Family Health Plan Members

Opioid prescription limits and policies vary by state, particularly with tramadol, as some states we service do not include tramadol in these limits. In an opioid-utilization analysis of our US Family Health Plan members, tramadol was identified as the top medication prescribed for extended-day supplies (15 days of prescription opioid within a 30-day period or 31 days of prescription opioid in a 62-day period). In most cases, these prescriptions were filled infrequently (for example, a patient who fills just one 30 or 90-day supply of tramadol per year).

NCQA implements a “Risk of Continued Opioid Use” measure, intended to identify patients at an increased risk for opioid overuse and misuse. The following factors are cited as to the importance of this measure:

• “Literature suggests that long-term opioid use often begins with the treatment of acute pain, and a relationship exists between early prescribing patterns and long-term use of opioids.”
• “Continued opioid use for noncancer pain is associated with increased risk of opioid use disorder, opioid-related overdose, hospitalization, and opioid overdose-related mortality.”
• “Studies find a consistent link between increasing days’ supply of the first prescription with probability of continued opioid use, and the rate of opioid use at 1 year post-initial prescription increases substantially for patients with 31 or more days of opioid therapy.”

We are committed to partnering with you to improve the quality of care and health outcomes for your patients. In an effort to decrease potential excess supply your patient has on hand, we respectfully encourage you to assess utilization before writing each prescription. Please check the prescription drug monitoring program and ask your patient how often they are taking their tramadol. Please update the prescription to a lower quantity and day supply or discuss discontinuing if possible. To assist in this effort, you may receive calls or faxes from us requesting you update the prescription based on our utilization review.

Resource: NCQA Risk of Continued Opioid Use Measure.

Save Time with Digital Authorization Management

Martin’s Point offers digital authorization management and US Family Health Plan referral submission 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
• Referrals for US Family Health Plan members (learn more here)

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, register for access here.

NOTE: ProAuth is not used for behavioral health, advanced imaging services, and certain drugs and radiation services (see below).

• 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 (Non-cardiac CT, MR, PET) and nuclear medicine authorizations for Generations Advantage members services go through our partners at eviCore at 1-888-693-3211.
• Specialty drug, oncology drugs, and radiation services for Generations Advantage members go through Optum’s authorization portal.

Introducing our New Community Health Worker Team!

Our Certified Community Health Workers focus on community-based preventive services and resources, supporting, educating, and advocating for members who may be experiencing barriers to getting the health care they need. They provide these key services:

• Health education and promotion
• Help navigating health care services and acting as a liaison between members and their providers
• Connecting members to community resources, e.g., transportation, interpreters, financial, etc.
• Enhancing continuity of care, improving patient engagement, and achieving better health outcomes

Prevention is Job #1: What to Expect If You Get a Call

The first efforts of this new team will be to reach out to members who may be overdue for important preventive care—like mammograms and colorectal cancer screenings. If you receive a call from one of our Community Health Workers, the purpose of their call is to learn how they can connect with your office staff to help facilitate assistance in getting the care our members need.

Our Community Health Worker team looks forward to building a relationship with you through this critical work—and getting great results in supporting our members’ best health and well-being!

Alternative to Change Healthcare Claims Submission

We understand the importance of streamlined claims submission processes for your practice, which is why we want to ensure you have the necessary information regarding our clearinghouse options. In addition to Change Healthcare, Martin’s Point is able to receive/pay claims from many major clearinghouses using Office Ally. We recommend that you verify with your current clearinghouse to confirm its ability to connect to Office Ally. You may call Office Ally at 1-360-975-7000 (Martin’s Point Payor ID: MPHC1).