2018 IHCP 1st Quarter Workshop

2018 IHCP 1st Quarter Workshop
MDwise Updates Spring 2018 HHW-HIPP0541(2/18) “Hi, my name is ______________________ and I am the MDwise Provider Relations Representative for Region _____.” “I ask that you hold all questions until the end of the presentation. If they are for all MCE’s please table these questions until the roundtable at the end of the workshop.” *Next Slide*

Meet you Provider Relations Team Quality Review ER Utilization
Agenda Meet you Provider Relations Team Quality Review ER Utilization Tips for Claims Adjudication Contact Information Resources Questions “Today we will meet the MDwise PR team and talk about the recent region updates, review MDwise Quality standards and what they can do for you and your office. We will go over appropriate ER utilization and how to educate your members on when to properly use the ER. I will also give some tips on claims adjudication and how to have your claims questions answered. And finally I will provide some additional resources and MDwise contact information before we have a short question and answer session.” *Next Slide*

MDwise Provider Relations
1 Region Provider Representative 1 Paulette Means 2 Garrett Walker 3 Charmaine Campbell 4 Jamaal Wade 5 Whitney Burnes 6 Tonya Trout 7 Chris Woodring 8 Sean O’Brien 2 3 5 4 6 “Recently we shifted a few of our Provider Relations Representatives. Region one is now covered by Paulette Means. Garrett Walker has shifted to Region 2 in northeast Indiana. Charmaine Campbell continues to cover region 3, Jamaal Wade is now the dedicated representative for central Indiana’s region 4, Whitney Burnes is in region 5, Tonya Trout has region 6, Chris Woodring-Bryant is in region 7 and Sean O’Brien is the dedicated Rep for region 8.” *Next Slide* 8 7

MDwise Provider Relations
Territory PR Representative Phone Region 1 Paulette Means Region 2 Garrett Walker Region 3 Charmaine Campbell Region 4 Jamaal Wade Region 5 Whitney Burnes Region 6 Tonya Trout Region 7 Chris Woodring Region 8 Sean O’Brien DME, Home Health Michelle Phillips Behavioral Health Nichole Young “Here we have the phone and contact information for our Provider Relations representatives, including the specialty Reps. Michelle Phillips is the provider representative for out Home Health, Hospice and DME providers and Nichole Young is dedicated to Behavioral Health. Mdwise no longer has a dedicated Hospital rep, as mentioned in previous presentations. Hospitals are now covered by their respective provider reps.” “Now that we know our PR Rep and how to contact them, lets get started on the first quarter updates.” *Next Slide*

What is Quality? Quality
Quality is comprised of HEDIS measures and NCQA guidelines HEDIS – Healthcare Effectiveness Data and Information Set National Committee for Quality Assurance (NCQA) uses these performance measures for commercial insurance, Medicare, and Medicaid HEDIS is the most used set of performance measures in the Managed Care industry, developed and maintained by NCQA Administrative data is calculated by a claim or an encounter submitted to the health plan Annual State mandated quality improvement initiative required of all Health plans “Our first update is more of a review, but a very important review. Quality is an essential topic for MDwise providers. We want to make sure you have all of the information available on how to meet and exceed the MDwise quality standards as set by HEDIS and NCQA.” “So what is quality to MDwise? Quality is comprised of HEDIS measures and NCQA guidelines. These procedures are used by MDwise providers to guarantee that our members are receiving the best care possible for the most qualified providers. Information is collected based on claims submitted and reported back to MDwise to make sure guidelines are being met. If there are areas that could use some additional attention, MDwise has dedicated teams to assist.” *Next Slide*

MDwise Quality Improvement (QI) program
Designed to lead to improvements in the delivery of health care and services, inclusive of both physical and behavioral health, to its members, as well as in all health plan functional areas MDwise conducts an annual CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey to determine member satisfaction with the plan and network providers MDwise is focused on providing services to members that are culturally and linguistically appropriate MDwise quality improvement initiatives strive to achieve significant improvement over time in identified clinical care and non-clinical care/service areas “MDwise establishes and maintains the MDwise Quality Improvement (QI) program, which is designed to lead to improvements in the delivery of health care and services, inclusive of both physical and behavioral health, to its members, as well as in all health plan functional areas. The annual MDwise QI work plan prioritizes and defines health and clinical care and service activities to be monitored and evaluated in the calendar year. The QI work plan is specific to the MDwise member population, monitoring activities and interventions for improving both health outcomes and the delivery of health care services across the continuum of services available to MDwise members. With the QI program, MDwise can make sure members are receiving the best care and work with providers to achieve maximum member satisfaction.” *Next Slide*

Quality Did you know: MDwise has dedicated teams who educate on HEDIS, NCQA, and OMPP standards through office visits MDwise Quality and Network Improvement Teams These teams are here to maximize the opportunity for MDwise, Inc. to recoup as much of the State withhold on quality as possible in the targeted Pay for Outcomes (P4O) measures “Part of the QI program is provider education through dedicated MDwise departments. The MDwise Quality and Network Improvement teams are available to come to your office and educate you and the rest of the staff on NCQA and HEDIS standards and how you can benefit from meeting these measures.” *Next Slide*

How We Promote Quality Care:
Provider and staff education Network Improvement Program (NIP) Team Billing and process audits Member education and incentives Provider Incentives Care Management services for members “Now what does this education do for you as a provider? With this education, you can utilize your quality reports to see where your office stands in the P4O criteria and what you need to do to educate your members on necessary health practices. By having your members follow these practices, your office becomes eligible for incentives, like P4O.” *Next Slide*

Opportunities for Quality Improvement
Maximize every member interaction to provide preventive and well-care Proactive Outreach: Staff who does scheduling can identify members that need services to schedule in a timely fashion Ensure proper billing for services rendered Be sure that the documentation is complete Implement alerts to reflect the non–compliant members in the quality measures if EMRs (electronic medical records) are used “Educating your office and its members is important, but so is making the most of your time. The front office can get very busy, especially this time of year with sick visits. Having your front office staff evaluate if an acute visit can be turned into a well-visit can mean covering two types of appointments with one visit. Also, checking if the member is scheduled for their next well- or preventive care visit can help your office reach the appropriate amount of visits needed for the P4O incentives.” “So, what is P4O and how do I know if I am eligible to earn the incentive?” *Next Slide*

Quality What is P4O? A reward through FSSA for providers who meet the standards of high quality preventive care What determines if I am eligible for P4O? FSSA established benchmarks that are set on an annual basis Standards defined in health plan contract Measures are typically nationally recognized HEDIS measures developed by NCQA for use in health plan accreditation Performance of network providers is tracked based on submitted claims “P4O, or Payment for Outcome, is a reward through FSSA for providers who meet the standards of high quality preventive care. Performance of network providers is tracked through claims received. Eligible services include Well Child visits for members 0-15 months, 3-6 years, and years. They also include adult preventive or new office visits.” “P4O payments are based on the percent of members who take advantage of these services. There are three tiers that you can fall into for payment. To know what tier your office is currently in and how to get to the next tier, MDwise provides reports of the percent of members using the services and how many more members need to take advantage to get you to the next level.” *Next Slide*

Quality “These reports are available on the MDwise Portal. To access the portal, go to mdwise.org, click on the For Providers tab, and under Quick Links on the right, go to myMDwise Provider Login.” *Next Slide*

Quality “The login page will appear for you to sign in. If you do not have a portal account, you can also request an account on this page by clicking the request a new account link, highlighted on the screen. You can also request to have your password reset if you forget.” *Next Slide*

Online Quality Reports
Quality reports, members in need of services, and provider panels available online and updated monthly “Once you have logged in the MDwise Portal, you can request a report under the Quality Reports tab. Any reports that you previously requested will be available in the archive folder under Progress Reports. If you have any issues requesting a report, accessing archived reports or accessing the MDwise Portal, call ” “Utilizing quality reports, assessing member appointments to maximize efficiency and educating your office are all great ways to benefit from the QI program. Another important part of having high quality as a provider is making sure members know how to utilize your office. This take us into our next topic…” *Next Slide*

ER Utilization An emergency medical condition is defined in IC as a medical condition manifesting itself by acute symptoms, including severe pain, could reasonably expect the absence of immediate medical attention to result in: Serious jeopardy to the health of: the individual in the case of a pregnant woman, the woman or her unborn child Serious impairment to bodily functions Serious dysfunction of any bodily organ or part “ER Utilization. For example, encouraging members to schedule an appointment for an acute issue instead of utilizing the ER. ER overutilization can cause a member to incur possible additional costs from copays and puts the risk on you as an emergency provider of not being paid.” “An emergency medical condition is defined by Indiana Code as a medical condition manifesting itself by acute symptoms, resulting in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. “ “We do not want to discourage members from visiting the ER, only divert them to a more appropriate provider.” *Next Slide*

Instead of the emergency room, encourage members to utilize:
ER Utilization Instead of the emergency room, encourage members to utilize: Assigned PMP Urgent Care Walk-In Clinics After Hours Offices Find A Doctor Select the Hoosier Healthwise or HIP Search by provider type “For instance, members can schedule a sick visit with their provider, go to an urgent care or walk-in clinic, or an after hours office. Members can search for the nearest provider of this type by using the Find A Doctor link on our website. The member will choose their program, Hoosier Healthwise or HIP, then search by provider type. They can get a listing of available providers in their area to see instead of depending on the ER.” “If you have members who are unsure if they should go to the ER…”

ER Utilization Reminder: If a member has an urgent health need or is unsure if it is an emergency, they are always encouraged to call: Assigned PMP MDwise NURSEon-call 24-hour nurse hotline If you feel a member may be inappropriately using the emergency room for primary care services, please inform MDwise by calling or contact your Provider Relations Representative “…they are always encouraged to call their PMP or the MDwise NURSEon-call, our 24-hour nurse hotline. MDwise providers are encouraged to help educate their patients about the appropriate use of the emergency room. If you become aware of a member that is inappropriately using the emergency room for primary care services, please let us know and a MDwise Health Advocate will attempt to contact the member to educate them about appropriate emergency room use. Our Health Advocates are part of our Case Management/Disease Management department, or CM/DM for short.” *Next Slide*

Care Management/Disease Management
ER Utilization Care Management/Disease Management MDwise identifies care management as an integral part of medical management Care management involves the development and implementation of a coordinated, member-focused plan of care that meets the member’s needs and promotes optimal outcomes Care management objectives include: Developing and facilitating interventions that coordinate care across the continuum of health care services Decreasing fragmentation or duplication of services Promoting access or utilization of appropriate resources “Our CM/DM department is an integral part of MDwise. This team works one on one with our members, their providers and even their family members to make sure the member is on track with their health care plan and is taking full advantage of all the benefits MDwise has to offer.” “Another member benefit that the CM/DM department offers is the Right Choices Program, or RCP.” *Next Slide*

Outcomes of member interventions Referrals from providers
ER Utilization The Right Choices (RCP) program was created to safeguard against unnecessary or inappropriate use of Medicaid services by identifying members who use Indiana Health Coverage Programs (IHCP) services more extensively than their peers MDwise considers multiple factors in enrolling a member into this program. They include, but are not limited to: ER utilization Pharmacy utilization Member compliance Outcomes of member interventions Referrals from providers “The RCP program is ideal for members who do over utilize the ER or may have formed unhealthy dependencies to medication. With the RCP program, members are locked-in to one PMP, one Pharmacy and one Hospital for medical services. By limiting access to other providers, MDwise can ensure members receive the appropriate care while preventing incorrect utilization of services. If you know of a member who may benefit from the RCP program, please notify MDwise my referring the member to the CM/DM department.” *Next Slide*

ER Utilization “To refer a member, visit mdwise.org, go to the Providers page, and to the Manual and Overview link on the left. This will give you the option to review the Right Choices Program and to refer a member for this benefit.” “Now the RCP program is ideal for members who over utilize the ER as they have only one ER to visit and have services covered. With this in mind, there are a few things about emergency room visits to remember...” *Next Slide*

ER Utilization ER services do not require a PA but may require prudent layperson (PLP) review Certain ER codes are paid according to the ER auto-pay list found at MDwise.org To automatically initiate PLP review and receive possible additional payment, claims should be submitted with medical records “While ER services do not require an authorization, these services are subject to a PLP review standard of the emergency medical condition. The PLP review will confirm that the services rendered to the member were truly due to an emergency. To automatically initiate PLP review and receive possible additional payment, claims should be submitted with emergency and medical records. At any point in the review process if it is determined that it meets the prudent lay standard, the claim is approved for payment.” “Speaking of claims, our last update is on tips for successfully submitting claims” *Next Slide*

Provider Requirements Provider must:
Claims Tips Provider Requirements Provider must: Be registered and be actively eligible with the Indiana Health Coverage Program (IHCP) Be enrolled with the appropriate MDwise delivery system Obtain a prior authorization if the provider is out of network Complete all required elements on the appropriate claim form Submit claim to appropriate MDwise delivery system claims payer “For providers to submit claims to MDwise for payment, the provider must be registered and be actively eligible with the Indiana Health Coverage Program (IHCP), be enrolled with the appropriate MDwise delivery system, obtain a prior authorization if the provider is out of network, complete all required claim form elements, submit the claim to the proper delivery system. Also, if you are a non-participating provider who obtained a prior authorization for services, be sure to complete the non-participating form on our website and submit with your original claim submission to make sure payment can be made to your account.” *Next Slide*

Prior to rendering services:
Claims Tips Prior to rendering services: Verify their following eligibility information IHCP program Managed Care Entity (MCE) What delivery system they are assigned to Assigned PMP Confirm if the services to be rendered require PA and request a PA if appropriate Non-Urgent PA requests: 7 day turn around Urgent PA requests: 3 day turn around “After you fulfill all of the provider requirements, be sure to complete the following two steps prior to rendering services to the member: Verify they are eligible for services on the date of their appointment and confirm that the services to be rendered do or do not require a PA. If they require a PA, you must request an authorization and give the appropriate amount of time for authorization consideration and response. Remember non-urgent PA’s take up to 7 days, urgent 3 days and as we discussed earlier, emergency services do not require an authorization.” *Next Slide*

Claim Form Requirements
Claims Tips Claim Form Requirements IHCP outlines all required fields for the CMS 1500 and UB-04 claims forms in the Provider Modules Follow correct coding guidelines for claims submission Verify that the correct place of service codes are submitted Confirm appropriate modifiers are included Check for proper diagnosis code(s) Include the rendering provider NPI “MDwise follows IHCP for required fields on the claims forms. Please reference the Claim Submission and Processing module in the Provider Reference Materials. Also be sure you are suing correct ICD-10 codes with NCCI edits, verify that your place of service, modifiers and diagnosis codes are correct. The provider NPI is required on both types of claim form (box 24J on the 1500 and box 76 and 77 on the UB form). Finally, and most importantly, be sure you are submitting the claim to the correct payer.” *Next Slide*

Claims Tips Claim Form Submission Make sure you submit the claim to the correct payer Be sure claims are submitted timely: Contracted providers must submit claims to MDwise within 90 days of the date of rendering the service When MDwise is secondary, claim must be submitted within 90 days of the date on the primary EOB Claim must be submitted with a copy of the EOB “The next slide covers where to submit MDwise Excel claims. Being sure to submit your completed claims to the correct payer in a timely manner is the best claim tip. Contracted providers have 90 days from the date of service to submit claims unless MDwise is the secondary insurance. Then the provider has 90 days from the date of the primary insurance EOB. For secondary insurance claims, the primary EOB must be submitted.” *Next Slide*

Hoosier Healthwise Claims Tips Paper claims should be submitted to:
MDwise HHW Claims P.O. Box Corpus Christi, TX CMCS pays Hoosier Healthwise claims for: St. Vincent St. Catherine Select Health All Electronic Data Interchange (EDI) Change Health/Emdeon/Web MD Payer ID: 35191 Please note: Paper claims must be on red/white form with black ink “This slide covers where to submit Hoosier Healthwise Excel Claims. If you submit electronically, the EDI information is shown here as well. If you are submitting to a different delivery system, be sure to review our Quick contact guide for the correct address and EDI information. *Next Slide*

Healthy Indiana Plan Claims Tips Paper claims should be submitted to:
MDwise HIP Claims P.O. Box Corpus Christi, TX All electronic EDI Change Health/Emdeon/WebMD Payer ID: 31354 Please note: Paper claims must be on red/white form with black ink “Here we have the information for submitting Healthy Indiana Plan. Again, here we have the address and electronic submission information. Please note that all paper claims MUST be on a red and white form with black ink.” *Next Slide*

Claims Tips If you would like an update on your claim status, please complete the following steps: Check the Evolent Claims Portal Contact the MDwise Claims department – Notify your Provider Relations Representative if you see trending denials or have additional questions “If you have questions regarding the status of a claim, be sure your first action is checking the Evolent or MDwise portal. There may have been claim movement that you have not received an EOB on yet. If claim status can not be received from the portal, please call into our Claims Customer Service department for additional assistance. If after calling the claims department, you still have outstanding questions, then you should contact your Provider Relations Representative, but the claims portal and a call to the claims department should always be your first course of action.” *Next Slide*

Claims Tips If you would like to dispute a claim, please complete the following steps: Submit a dispute to the claims department Complete one Claim Dispute Form for each claim Claim Dispute Form Submit one Claim Dispute Form per to Completely fill out the form and include all supporting documentation in the Be sure you send the securely “If you receive a denial and disagree with this outcome, please submit a dispute to our MDwise Claims Department by using our . The link in this presentation is for the claims dispute form, which is also available on our website on the forms page of the Providers tab. One form should be used per claim dispute and only one dispute should be submitted per . Be sure to include all supporting documentation to avoid extending the timeframe for dispute research. If you disagree with the outcome of a dispute, the letter sent to you by the claims department has next steps that should be taken for resolution.” *Next Slide*

Items that do no constitute a dispute include:
Claims Tips Items that do no constitute a dispute include: Corrected Claims New Claims Medical Records Attachments, including but not limited to: Consent forms MSRP on IHCP website Invoices Recoupments “Just to review, there are certain things that do not constitute a dispute. These include corrected claims, new claims, submitting requests for medical records or attachments like consent forms, or recoupments. If you are unsure if you need to submit a dispute, again, contact the MDwise Claims Department and they can assist you.” *Next Slide*

Claims Quick Contact Guide Quick Contact Guide
Contact Information Claims Quick Contact Guide Quick Contact Guide Includes Delivery System claim submission information Provider Relations Contact List Contact List Includes Deliver System Provider Relations contact information MDwise Excel PR Territory Map Provider Relations Territory Map “Here are additional resources for contacting the appropriate department for any of your MDwise questions. The claims quick contact guide includes submission information for all delivery system claims including dental and pharmacy claims. The provider relations contact list also gives delivery system contact information for all provider relations representatives. Finally we have our updated territory map that we went over in the beginning of the presentation, along with additional Rep contact information.” *Next Slide*

MDwise Provider Manuals MDwise Provider Page MDwise Customer Service
Resources MDwise Provider Manuals MDwise Provider Page MDwise Customer Service IHCP Provider Modules Indianamedicaid.com “Finally, there are many resources for tips and general claims submission information for you to utilize both on the MDwise website and on the IHCP website.” *Next Slide*

Questions “Are there any questions?”

2018 IHCP 1st Quarter Workshop

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2018 IHCP 1st Quarter Workshop

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