1 Right Choices Program A combined MCO Presentation HP IHCP Provider Seminar October 20, 2010 Indianapolis Marriott East An independent licensee of the Blue Cross and Blue Shield Association RCPP0001 (09/10)

2 Right Choices Program Presented by Kelly Henderson, PharmD, RPh Director of Clinical Programs MDwise, Inc.

3 Overview  History  Program Overview Identification of member Primary Care Physician- Medical Home  Program Specifics  Review of waivers  Care Management as a tool  Claims submission requirements

4 History of Program  HealthCare Excel (HCE) began SURS unit that developed original Restricted Card Program for IN  RBMC MCOs were first allowed to participate in 2005 via a HHW pilot program Right Choices Program is Different -- experiences gained in the pilot and availability of managed care resources

5 What is the Right Choices Program?  The Right Choices Program (RCP) is a program that identifies members appropriate for assignment and subsequent “lock-in” to: one Primary Care Physician (PCP) one pharmacy and one hospital  “Lock-in” periods start at 5 years and a member is evaluated as early as 2 years to see if they are ready to be released.

6 Member Identification Process  members are considered candidates for restriction if they continue to misuse their benefits despite efforts on the part of RCP Administrator and its provider(s) to educate and assist the member in modifying misuse patterns.  The RCP Administrator considers multiple factors in enrolling a member into this program. They include, but are not limited to: Emergency Room utilization Medical records review Pharmacy utilization member compliance history outcomes of member interventions care management activities referrals from providers referrals from other internal and external sources

7 Primary Care—Medical Home  Right Choices Program reinforces the concept of the “Medical Home”. The member can no longer receive medical care and fill prescriptions outside of the medical home without the Primary Care Provider (PCP) being made aware and involved. Pharmacists are strongly discouraged from allowing Medicaid Right Choice members to pay cash for medications.  In some cases, depending on the prescription, this action may be interpreted as the pharmacist’s willingness to “aid or abet an addiction” or knowingly support diversion of a controlled substance Non-emergent use of the ER is not a covered service  Payment is the responsibility of the member ER must have member complete a waiver—CMS requirement ER should educate member about proper utilization of services

8 Getting a Member Approved for RCP  Incoming referrals or claim data support further review of member’s utilization pattern  Care manager (CM) alerted of referral or data  Care manager begins working with the member and/or providers and “builds a case” if necessary by documenting utilization patterns and attempts made by the care manager and/or providers to intervene or guide the members utilization choices  member resists interventions, PCP and CM agree to pursue RCP as an additional care management tool  Case file is forwarded to clinician for review and consideration for placement into RCP Program

9 Getting a Member Approved--continued  Clinician reviewer considers the case file in its entirety. In addition, they rule out clinical issues that may explain overutilization: Pseudoaddiction Catastrophic chronic illness Unidentified psych diagnosis PCP already primary prescriber

10 Notification to Providers  Once a member is active in the program, the PCP, lock-in hospital and lock-in pharmacy are notified in writing and given clear instructions.  In addition, the Member’s eligibility is flagged for ALL IHCP providers. So that ALL providers will be aware of the restriction and not render non- emergent services without first obtaining a member waiver to accept financial responsibility for services rendered.

11 The RCP Medical Home  The PCP is responsible for coordinating all aspects of the RCP members’ care.  RCP Administrator will support PCP and help PCP oversee Care manager- present throughout the entire enrollment in the program Care manager-must receive written referrals from PCP if RCP member is to be seen by another provider  RCP Administrator will process written referrals so that corresponding claims are recognized and accepted for payment by HP

12 Written Referrals  Referrals are encouraged to be kept to a minimum. Too many referrals allow for members to see multiple providers at will and potentially circumvent the RCP program Residency programs are NOT considered ideal for RCP members  Referral requirements: The PCP must write the referral on the PCP’s letterhead or prescription pad (provider NPI, phone, address, specialty, rationale) The PCP must date and sign the referral (electronic signature is ok) The referral must include the member’s name and member id The referral must include the specialist’s first and last name The PCP should list the period for which the referral is valid. If no time period is specified on the referral, the referral will be applied for the duration of the restriction. It is preferred that a reason for the referral also be communicated for care management support  Note: It is important to remember that HP/RCP Administrator does not reimburse providers for services unless these guidelines are followed because these services are non-covered.

13 Appropriate ER utilization  Important to reinforce that the ER is not an ideal “Medical Home” AND that ER is often sought when a members PCP “won’t give them what they want”  Check eligibility in ER and RCP enrollment Status, communicate to ER staff (also use INSPECT)  Emergent claims will be reimbursed by HP without authorization from the Right Choice Program member’s PCP.  It is important that ERs follow this procedure in order for inappropriate ER use to be deterred and for the Right Choice Program to have its best outcomes.

14 Financial Responsibility of RCP Member  The Right Choice Program member is responsible for payment of services if the member chooses to receive services from providers for whom they are not authorized to receive service.  Prior to rendering the service, the provider must inform the Right Choice Program member orally and in writing that the service is non-covered. The member may elect to request a written referral from their PCP OR sign a waiver and accept financial responsibility for the services rendered.  Note: For more information on billing IHCP members, refer to Chapter 4, Section 5.

15 RCP Support  The member’s assigned care manager is responsible for communication monitoring managing a member’s care plan coordinates all aspects of the member’s restrictions  monitoring emergency room use  pharmacy utilization patterns  collaborating with the member’s assigned pharmacy and PCP  updating the care plan as necessary  coordinating behavioral health care plans  continuity of care.  At regular intervals, member compliance is monitored reviewing treatment plans utilization of services care coordination conferences between the member, and the member’s care manager. The member’s PCP and Pharmacist will also be involved from time to time in care conferences.

16 RCP Support  At the end of a member’s RCP enrollment period, a decision to remove the member from the RCP may be made based on member compliance with the program and their treatment plan. The PCP, lock-in pharmacist, and Care Manager review the case and make recommendations for continuation or release from the program  If a Right Choice Program PCP encounters any issues that may affect the care of a RCP member, the PCP is STRONGLY encouraged to contact the member’s care manager in efforts to coordinate a meaningful intervention. URGENT Care Conferences can be arranged.  RCP Administrators supports its PCPs participating in the Right Choices Program. Please involve us if you need additional assistance in dealing with a member. Providers should contact the member’s care manager with questions regarding that member’s participation in the RCP.

17 Thank You  From the MCEs