The Point Issue 2 2023

For more of The Point Provider Newsletter

IN THIS EDITION:

IMPORTANT NOTICE: Specialty referrals must be submitted to the US Family Health Plan Effective 10/1/2023.

Advancing Health Equity: CDC Resources for Provider

Authorization Request Process Changes October 1

Want Timely Claim Payments and More New Patients?

Martin’s Point Service Standards

Where to Get Help

Help Improve Health Outcomes for Seniors

Transition of Care: A Critical Time to Document Four Key Steps

Accurate uACR Coding Key to Closing Gaps for New KED/Diabetes Star Measure

Use of Imaging in Low Back Pain (LBP)

Optimizing COPD Pharmacotherapy after Inpatient Discharge

Staying Ahead of Osteoporosis-Related Fractures

Just for Kids: Adolescents and Childhood Immunizations

IMPORTANT NOTICE: Specialty referrals must be submitted to the US Family Health Plan Effective 10/1/2023

Due to new TRICARE® reporting requirements, referrals to other providers/specialists must be submitted directly to the health plan. In-network, medically necessary referrals with supporting documentation will initially be verified through claims. Claim submission without a documented referring physician or failure to produce a referral order upon request may result in a higher cost share for your patient/our member. Out-of-network, medically necessary referrals must be submitted through our online portal, ProAuth.

For a list of in-network providers/facilities, check our online directory or call 1-888-732-7364. For the most up-to-date information about these changes and what services require a referral, please visit our USFHP Referral Program FAQs on our website.

Advancing Health Equity: CDC Resources for Providers

As health care providers, we witness firsthand the impacts that social, environmental, behavioral, and other factors have on our patients’ health. Disparities in all of these areas often result in increased incidence and severity of chronic and acute conditions for vulnerable populations.

To help providers think about and improve health equity for those we serve, the CDC developed A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. We invite you to explore this guide and visit the Health Equity section on the CDC website for resources and tips to incorporate in your practice.

Authorization Request Process Changes October 1

Effective October 1, 2023, all authorization requests that would normally be sent directly to Martin’s Point Health Care must be submitted through the ProAuth online referral and authorization portal.

No need to wait

Authorization requests can be sent through the ProAuth portal right now, with the benefits of real-time submission, status tracking, and auto-authorization responses. To learn how to use ProAuth for authorization requests, go to https://martinspoint.org/For-Providers/Tools/ProAuth-Documentation or contact Provider Inquiry at 1-888-339-7982.

The process for direct authorization requests to vendors BHCP, EviCore, and Optum has not changed.

• BOTH PLANS: For mental health/substance abuse services for Generations Advantage plan members, call BHCP at 1-800-708-4532. For US Family Health Plan members, call BHCP at 1-888-812-7335.
• GENERATIONS ADVANTAGE PLAN ONLY: Imaging services—call eviCore at 1-888-693-3211 or use eviCore’s self-service web portal at https://www.evicore.com/resources/healthplan/martins-point.
• GENERATIONS ADVANTAGE PLAN ONLY: Specialty drug, oncology drugs, and radiation services at participating locations are managed by Optum, which you can access through the Martin’s Point provider portal.

Want Timely Claim Payments and More New Patients?

Keep your provider directory current. We make it easy.

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.

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: https://www.martinspoint.org/For-Providers/Tools/Update-Your-Info. 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 https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/index. 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 practioners and physician assistants who do not practice as PCPs do not require credentialing.

Please provide 30 days advance notice of changes to your provider/practice information. 

Martin’s Point Service Standards

We would like to remind you that Martin’s Point provider agreements support patient service standards consistent with TRICARE, CMS, commercial, and state regulations. This means patients should be scheduled according to the applicable standards below. 

Where to Get Help

Get mental health support 24 hours a day, 7 days a week

If you or someone you know is in emotional distress—help is available no matter what time of day or night. The Suicide and Crisis Lifeline is there to assist with a range of support—for those in crisis and/or considering suicide or self-harm to those who need help with the mental health challenges that come with substance abuse, economic worries, relationships, sexual identity, getting over abuse, mental or physical illness, loneliness, and more. To get help right away:

• Call the Suicide and Crisis Lifeline at 988.
• Veteran’s Crisis Line: call 988 then press 1.
• Call 1-800-273-TALK (1-800-273-8255).
• Text HOME to 741741 to access the Crisis Text Line.

Behavioral Health Care Management Program

A Martin’s Point care manager can also help address ongoing behavioral health needs. If you would like to speak to a Martin’s Point behavioral health care manager about our free care management program, call 1-877-659-2403.

Learn more about ways to support the mental health of adults and children on our Mental Health page.

Help Improve Health Outcomes for Seniors: Discuss Fall Prevention, Activity, and Incontinence Management

In an effort to improve health outcomes for Medicare beneficiaries, CMS has highlighted three areas that can have a significant effect on the health of seniors: preventing falls, promoting physical activity, and managing incontinence. As part of CMS's annual Health Outcome Survey (HOS), a sample of Medicare Advantage plan members are asked if they have discussed these important issues with their providers in the past year.

The Medicare Advantage Star measures that derive from the HOS results include:

• Fall Prevention: The percent of beneficiaries with a problem falling, walking, or balancing, who discussed this with their doctor and received a recommendation on fall prevention during the year.
• Physical Activity: The percent of members over age 65 who discussed exercise with their doctor and were advised to start, increase, or maintain physical activity during the year.
• Incontinence Management: The percent of beneficiaries with a urine leakage problem in the past six months who discussed treatment options with a provider. If you have any questions or feedback about the new online provider directory or ProAuth, please call Provider Inquiry at 1-888-339-7982.

We rely heavily on our network providers to have these discussions with their patients to drive better health outcomes and succeed with these measures. As a health plan, we also remind our members to discuss these topics with their doctors.

Did you know? Our Generations Advantage plans offer extra benefits that support members with these concerns:

• Physical Activity: Our Wellness Wallet reimburses for a wide range of gear, fees, and services to help keep members active indoors and out (including golf fees, bikes, gym fees, and much more).
• Fall Prevention: Members for whom we have a documented history of falls/hip fractures are eligible for reimbursement on eligible bathroom safety equipment up to $200 and up to $50 per year to attend an eligible fall prevention class. 
• Incontinence Supplies: Members receive a quarterly stipend to use toward CVS OTC health care items.

Transition of Care: A Critical Time to Document Four Key Steps

Patients are often most vulnerable when transitioning from hospital care to outpatient settings. Upon discharge, they could have a new diagnosis, a new treatment plan, or a change in their ability to manage their health. It’s imperative that health care organizations—including hospitals, primary care, and health plans—provide the necessary support and interventions during transitions to ensure positive patient outcomes.

This October, the Transitions of Care (TRC) measure will become part of the Medicare Star Rating process. The TRC measure has four components, including Medication Reconciliation Post-Discharge, which is already part of Star Ratings:

1. Notification of inpatient admission. Documentation of receipt of notification on day of admission or within 2 days of the admission in primary care doctor’s record (3 days total). Note: Advising a patient to go to the emergency department is not considered notification of an inpatient admission.     
2. Receipt of discharge information. Documentation of receipt of discharge instructions on day of discharge or within 2 days after the discharge in primary care doctor’s record (3 days total).
3. Patient engagement after inpatient discharge. A visit in office, via telephone, or virtual check in, through transitional care management services or performed at the patient’s home, within 30 days of discharge. Note: This visit must include the same diagnosis code as discharge.
4. Medication reconciliation. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days). This can be performed by a prescribing practitioner, physician assistant, registered nurse, or clinical pharmacist.

Of all Medicare Star Ratings, providers have especially high influence on steps 2 and 4: patient engagement and medication reconciliation. We urge you to provide and documents these extra supports to your patients during this vulnerable period after an inpatient stay.

Accurate uACR Coding Key to Closing Gaps for New KED/Diabetes Star Measure

According to CMS, the HEDIS measure, kidney evaluation in patients with diabetes (KED), will be a part of Medicare Advantage Star Ratings, starting with measurement year 2024. KED reflects the percentage of 18- to 85-year-old members with diabetes who undergo annual kidney health evaluation, including estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (uACR).

With kidney disease on the rise in patients with diabetes, the goal is to identify kidney disease early to prevent further damage and complications to promote the best possible outcomes. 

In 2022, we significantly improved our rate of compliance with this standard over the previous year, building from 18.9% to 44.9%. Still, we continue to identify great variation in rates among providers and health care sites. From our analysis, the problem seems to lie with inconsistencies in CPT/ICD coding of the uACR. Below is a list of codes to accurately capture the combination(s) of testing you are performing. We appreciate your efforts to use the correct codes to help close the KED care gap.

Use of Imaging in Low Back Pain (LBP)

One way Martin’s Point monitors quality of care is by tracking claims received for imaging within six weeks of a diagnosis of acute back pain.

Low back pain (LBP) is extremely common—roughly 75% of all adults will experience LBP in their lifetime. Often, these patients just need conservative treatment and time to improve. Imaging is often not necessary.

Guidelines for imaging patients with LBP have been adopted and published by the American College of Radiology, the National Institute for Health and Clinical Excellence, and the American College of Family Practice, among many others.^1,2 All stress the following principle:

Routine imaging of patients with acute LBP should not be undertaken within the first six weeks of presentation, unless there are signs and symptoms of severe or progressive neurological deficit, cancer, cauda equina syndrome, infection, or fracture. Early advanced imaging studies are indicated for all of the above except fracture. Early plain film studies are indicated for fracture suspected after trauma or in the setting of osteoporosis, cancer, or chronic steroid use.

We encourage clinicians to reassure patients that, in 90-95% of cases, pain improves over time regardless of treatment, and to discuss the risks and benefits of imaging. A short conversation about the risks of radiation, expected time frames for recovery, and recommended treatments can go a long way to help inform shared treatment decisions.

Highlights from the American College of Physicians³ review of noninvasive treatments for acute, subacute, and chronic low back pain state the clinical outcomes they evaluated included:

• Reduction or elimination of low back pain
• Improvement in back-specific and overall function
• Improvement in health-related quality of life
• Reduction in work disability/return to work
• Global improvement
• Patient satisfaction

Sources:

¹American College of Radiology, Committee on Appropriateness Criteria, “Low Back Pain,” Originally published 1996, revised 2021. https://acsearch.acr.org/docs/69483/narrative/

²American Academy of Family Practice, “Imaging for Low Back Pain, Choosing Wisely,” 2023. 

https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/cw-back-pain.html
³American College of Physicians issues guideline for treating nonradicular low back pain | ACP Online.

Optimizing COPD Pharmacotherapy after Inpatient Discharge

Your qualifying patients may receive outreach from us as part of our COPD Transitions of Care program.

Martin’s Point Health Care has found that our health plan members with COPD are at risk for adverse outcomes when transitioning from the inpatient setting to home. Our COPD Transitions of Care program is designed to help mitigate this risk through targeted interventions, including using HEDIS recommendations for pharmacotherapy management of COPD exacerbation after discharge.

We wanted to remind you about this important program as you may be contacted by a Martin’s Point care manager, or health plan pharmacist regarding your patient’s treatment plan. Participating patients may also reach out to you with questions. We appreciate your support as we both provide services and resources to keep our members/your patients as healthy as possible.

Which patients qualify?
We use the following claims data to identify those who meet the HEDIS eligible-population criteria: Age 40 and older with COPD with an acute inpatient discharge or an emergency department (ED) encounter with a principal diagnosis of COPD.

What are we checking for?
Once identified, we review the member’s medical records to determine if they have received the HEDIS-recommended care, including the following.

• Been prescribed BOTH of the following:
  • a systemic corticosteroid and have filled the prescription within 14 days of discharge
  • a bronchodilator and have filled the prescription within 30 days of discharge

What do we do?
To try to reduce COPD complications which could lead to readmission, we call the member and provide the following:

• Medication-related education—to ensure understanding of the dosage, timing, importance of adherence
• Medication adherence assessment—offering formulary alternatives and referring to prescription-access programs to address inhaler costs
• Medication reconciliation
• Complete medication review—to ensure the member has a rescue inhaler on hand and to address high-risk medications, drug interactions, and any other potential gaps in therapy
• We look to make sure the member is on a maintenance inhaler. Per the 2023 GOLD Global Strategy for Prevention, Diagnosis and Management of COPD: maintenance therapy with a long-acting bronchodilator should be initiated as soon as possible before hospital discharge for management of exacerbations. The preferred choice is a combination product consisting of a long-acting beta-2 adrenergic agonist (LABA) and a long-acting muscarinic antagonist (LAMA).
• Care coordination
• Promotion of lifestyle changes

Results so far:
Since initiation of this program, we’ve seen improvements in prescribing practices and medication adherence for program participants in the case of both bronchodilators and, more significantly, for systemic corticosteroids.

Staying Ahead of Osteoporosis-Related Fractures

Closing gaps in care related to osteoporosis management in women who have had a fracture (OMW) can make a real difference in the health of affected patients. Challenged by consistently low Medicare Star Ratings for this measure, we are committed to improve our effort to drive better health outcomes and lower costs for our members and your patients in this area.

The OMW Star measurement reflects the incidence of women aged 67 to 85 years who have experienced a fracture and either had a bone density scan or were prescribed a drug to treat osteoporosis in the six months after the fracture. (Women who have had a bone density scan in the 24 months prior to the fall are not included.)

Why measurement matters

Fractures that result from osteoporosis can impact quality of life, as well as add unnecessary health care expense. One study in the American Journal of Managed Care found that health care costs following a fracture exceeded $30,000—and that there was a 20.9% cumulative rate of experiencing another fracture within four years.

Outreach that makes a difference

Martin’s Point started calling provider offices with members on the OMW gap list, asking providers to consider the appropriateness of a bone density scan. We also provided some of our accountable care organizations lists of their members in this target group. As of August, we have seen a 5% increase in our OMW rate compared to this time last year.

Martin’s point covers in-network bone density scans at no cost to members every 24 months if they have been identified as at risk for losing bone mass or osteoporosis.

What can providers do?

We understand pain and functionality are top priorities when a patient experiences a fracture. We also know that bone density screenings can take time to schedule. We encourage you to:

• Discuss bone density screening and appropriateness of osteoporosis medications with your patient at the next visit following a fracture.
• Consider ordering a bone density scan if the patient is an appropriate candidate and you won’t see the patient in the near future. The National Osteoporosis Foundation recommends assessment of bone mass density every two years, so there’s no need to wait until a fracture occurs to test.

Source:

Williams, S., Chastek, B., Sundquist, K., Barrera-Sierra, S., Leader, Deane, Weiss, R., Wang, Y., and Curtis, J. (2020) Economic burden of osteoporosis-related fractures among Medicare beneficiaries. Journal of the American Medical Association Internal Medicine, 180(11), 1489-1497.

Just for Kids:
Adolescents and Childhood Immunizations

Zeroing in on HPV for Adolescents
Every year, Martin’s Point reviews a sample of our adolescent members’ immunization records to see how many are keeping up with CDC guidelines. Regularly, we find the biggest gap with the human papillomavirus (HPV) vaccination.

HPV vaccination is important for both all adolescents, regardless of gender. The CDC estimates there will be over 36,500 new HPV-caused cancer diagnoses every year. And HPV vaccination could prevent more than 90% of these cancers from ever developing.

The CDC recommends HPV vaccination for all children 11 or 12 years of age, and encourages health care professionals to recommend HPV vaccination in the same way and on the same day they recommend other vaccines for adolescents.

Here’s a sample script: “Now that your child is 11, they need three vaccines to help protect against meningitis, HPV cancers, and whooping cough. We’ll give these shots during today’s visit. Do you have any questions about these vaccines?” The CDC also recommends reminding parents to make their child’s next appointment before leaving the office. Check out more CDC tips on talking with parents about vaccines.

Keeping Childhood Immunizations on Track
Yearly sampling of young member vaccination records shows that a significant number are not fully vaccinated before age two. Pediatric immunizations are essential for preventing disease, and must be administered according to recommended CDC timelines to prevent resurgence. Please help us support children’s health by doing all you can to make sure your youngest patients are getting the early and best protection. If you have any questions regarding this program, please contact Health Plan Quality at 1-866-484-2788.