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Doctor's Note
Dear Colleagues,
Thank you for your continued participation in our network. Highlights of this newsletter include updates to the Provider Manual, Members Rights and Responsibilities, the definition of a new patient for E&M billing purposes, significant improvements to the iExchange web portal, our Health Management program, Clinical Practice Guidelines updates, and a number of Medical Policy updates, including back pain and gender dysphoria treatments.
Best of health,
Michael Ostrov, M.D., M.S.
Chief Medical Officer
Aspirus Arise Health Plan
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Closing Gaps in Care and Creating the Perfect Patient Experience
Our success will be determined by our ability to adapt to an ever changing economy where you can order just about anything online and marketing is largely driven by viral social media campaigns. How can we, as caregivers, adapt to this new reality?
There will certainly be technological advancements that create new ways to access care, nonetheless it is important for us to focus on the interpersonal relationships we develop with our patients. Regardless how we communicate, our quality of care is tied directly to our ability to provide the perfect patient experience. As caregivers, we need to:
- Maximize direct provider engagement by moving clerical and computer tasks away from the provider
- Support the needs of the patients via an extended care team model
- Improve patient engagement and self-management skills by maximizing involvement of the total health care team
How can we adapt these principles in our daily operations? One way is to ensure we are aware of all issues a patient may be facing when he or she comes in for an appointment. When Amazon can deliver 1-click buy, 2-day delivery and an ice bucket challenge can raise $100 million, we must be capable of satisfying our patients' desire for on-demand services.
We understand it can be challenging to identify all issues that a patient may be facing, which is why our team at the Aspirus Network has been working with our partners at Aspirus Arise to identify gaps in care on a patient-by-patient basis. I am proud to report we have identified patients' unaddressed issues and we know when they're coming in for appointments. We do not want to create a new process, however we need to make you aware of these gaps immediately for patients who have appointments already scheduled. It may be a while before they come back in for another appointment. Additionally, we will be reaching out to members who have unaddressed issues and are not scheduled for an appointment. Moving forward, we'll continue to work with clinics and regional leadership to integrate this information into existing caregiver workflows. If we positively identify true gaps, provide this information in an efficient way, and action is taken, it will help increase the overall quality of care we can provide to our patients.
While our efforts are aimed at the perfect patient experience, there are also real financial implications for Aspirus Arise. Federal regulations are extremely financially punitive to health plans who fail to appropriately close gaps in care. These regulations were put in place to dissuade health plans from solely focusing on utilization reduction.
As we pass along this new information, please help us find ways to make it easily usable for you and your staff. The quality of on-demand care we can provide and our overall financial stability rely on you taking action to help us close these gaps.
Sincerely,
Dr. Renee Smith
Renee Smith MD
Interim Executive Director and Chief Medical Officer
Aspirus Network Inc.
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Clinical Practice Guidelines Can be a Valuable Resource for Providers
Clinical Practice Guidelines (CPGs) are resources designed to assist clinicians in
prevention, diagnosis, and treatment of specific conditions or diseases
. They are not intended to replace professional judgment or to establish a rigid protocol for patient management. These guidelines are developed through analysis of
nationally published evidence based clinical literature combined with expert consensus. They
present an opportunity to significantly reduce variation in the clinical setting and provide part of a framework necessary for measuring and improving the quality of care.
CPGs are not intended to determine plan benefits or utilization management authorization determinations. They may, however, be used as references in our Medical Policies and Care Management Programs.
The National Committee for Quality Assurance (NCQA), requires the adoption of Clinical Practice Guidelines that are also helpful in demonstrating the quality of care provided to our members. The Health Plan has chosen nationally recognized guidelines that
reflect the current literature and research about treatment protocols, and best practices, which we hope you will find useful in your practice.
Recent updates include the 2017 Standards of Medical Care in Diabetes from the American Diabetes Association and the July 2017 American Academy of Family Practice (AAFP) Summary of Recommendations for Clinical Preventive Services. Links are provided to regularly updated Center for Disease Control and Prevention (CDC) resources for immunization and the United States Preventative Services Task Force (USPSTF) recommendations.
A new addition to our list is the
CDC Get Smart
website. This site provides interactive information for patients (
Get Smart About Antibiotics),
and recommendations for providers from the CDC and National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion to support your efforts in wise antibiotic prescribing.
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How to Bill Telemedicine Services
Aspirus Arise follows industry standards relating to standard billing modifiers and coding. These guidelines are like those established in UB-04 and CMS's Medicare Database.
Some member certificates now include coverage for telemedicine services. We'd like to remind you to use modifier-95 when submitting claims for synchronous telemedicine.
Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.
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The season is upon us: fall, football, and flu vaccine. HEDIS (Healthcare Effectiveness Data and Information Set) national average rates for the 2016-17 flu season reflect 47.5%.
When providers are proactive and prescriptive about the vaccine, better results can be reached. If you're not already doing so, adopting a "While you're here, let's give you your flu vaccine" approach may help.
The time is now and flu vaccines are covered under member health plans!
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The Medical Policy Committee met this quarter and approved the medical policies due for annual review.
Please be sure all doctors, other clinical staff, and office staff are aware of these changes before submitting requests for coverage. We ask that you share these policy changes with providers who may be ordering or performing services and clinicians who may be referring patients for services.
Specific questions or comments regarding development of policy content may be directed to the Medical Policy Editor at
medical.policies@wpsic.com
or 800-333-5003, ext. 77196.
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Member Rights and Responsibilities
The Member Rights and Responsibilities listed below set the framework for cooperation among members, practitioners, and Aspirus Arise.
Member Rights
- To be treated with respect and recognition of their dignity and right to privacy.
- To a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
- To participate with practitioners in making decisions about their health care.
- To receive information about us, our services, our network of health care practitioners and providers, and their rights and responsibilities.
- To voice complaints or appeals about us or the care we provide.
- To make recommendations regarding the members' rights and responsibilities policies.
Member Responsibilities as a health plan member
- To supply information (to the extent possible) that we and our practitioners and providers need in order to provide care.
- To understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
- To follow the treatment plan and instructions for care that have been agreed on with their practitioners.
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Tip to Avoid Claim Denials with New Patients
American Medical Association (AMA) guidelines define a new patient as "one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care profession of the
exact
same specialty and subspecialty who belongs to the same group practice within the past three years." When advanced practice nurses and physician assistants are working with a physician, they are considered as working in the same subspecialties as the physician.
We've recently enhanced our claims editing software related to new and established patients. Our policies apply the AMA (American Medical Association) and E/M (Evaluation and Management) guidelines. Please keep this in mind should you receive a denial on a new patient visit claim.
If you have questions related to this policy, please refer to the guidelines and decision tree referenced in the 2017 CPT Professional Edition. Further questions can be directed to our Code Governance department at
CodeGovernance@wpsic.com
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Notify Aspirus Arise of Roster and Location Changes
Current members, potential members, and providers use our online provider directory, Find A Doctor, to verify whether a provider participates in our provider networks.
To keep the directory up to date, we count on you, our preferred providers, to notify us of roster and location changes in an accurate and timely manner. This allows us to market you to our members appropriately. It assists users looking for a primary care practitioner, as well as those who are referred to a specialist.
We recommend that you periodically check our
Find A Doctor
tool to ensure we have your demographics listed accurately. Items to check include:
- Name
- Gender
- Specialty
- Hospital affiliations
- Medical group affiliations
- Accepting new patients
- Languages spoken by the physician or clinical staff
- Office locations and phone numbers
If you find an error, please complete a Provider Change form to notify Aspirus Arise of any necessary revisions. Your help in maintaining our directory is very much appreciated.
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Some EDI Claim Functions Moving to a Third Party
In the fall of 2017, we will begin migrating some EDI claim process functions to a third party called Smart Data Solutions (SDS).
This change will not affect your connectivity with us or how you send files. You will also continue to receive acknowledgement files (TA1, 999, 277CA) in the same location as today. Due to enhancements to our validation edit process, you may receive multiple 277CAs for claims within a single file/transaction.
For questions on electronic claim file rejections and acknowledgements, please contact SDS at
stream.support@sdata.us
or 855-297-4436.
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Updates to Fax Numbers and Forms
We've made some updates and want to make you aware. Our Medical Management team is now known as "Integrated Care Management." The Medical Affairs Integrated Care Management team's fax number has been updated. Please use the following fax numbers from now on:
- WPS Employee Group members: 608-226-8016
- All other members: 608-327-6300
Additionally, we've updated the following form:
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iExchange® Makes Prior Authorizations Faster for Providers
What is iExchange?
iExchange is a web-based portal for providers to submit prior authorization requests to our Integrated Care Management team for review. The days of faxing in information, hoping it was received, and waiting with no update on the status of the review are over. iExchange allows you, as the provider, to submit an electronic request, upload supporting documentation, and then track the status of the review. Not only that, iExchange allows automatic approval of certain requests, which means you can receive authorization in seconds rather than days.
Benefits of iExchange
iExchange is centered around saving you time and making the prior authorization process easier on your team. Some of the benefits include:
- Automatic approval of specific requests
- Easy-to-use upload of supporting documentation
- Elimination of hand writing errors
- Elimination of fax problems
- Status tracking of requests
- Secure environment for protected health information (PHI) protection
We'd love to show you iExchange
Over the past several months, our team has been working on improving the functionality of iExchange to better meet your needs as a provider. The most important improvement is the dramatic increase in services that can be automatically approved. Our outreach is designed to educate and encourage the use of the iExchange portal for all prior authorizations submitted to us. The outreach team created a webinar and will be setting up sessions for clinics to attend online. We are offering in-person, hands-on education and support to providers and their teams.
How to register:
The use of iExchange is FREE and it's easy to sign up. Here is how to register as a new user:
- Go to AspirusArise.com
- Click on the Providers tab
- Click on the iExchange button
- Open up the Register for an Account tip-down section
- Fill out the brief form and select Submit
The Account Administrator will be notified in 10 business days of the approval and will receive the new iExchange Group ID and temporary password.
Our team can assist you with registration, questions, or technical issues by email at:
iexchange@wpsic.com
.
We strive to continuously improve our services to make iExchange easier to use and as efficient as possible for our providers. Our goal is to have 100% of all prior authorization requests submitted through iExchange by mid-2018. We ask for your assistance in helping us achieve this goal, all while making your life easier.
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Our Promise:
Make our high-quality health care services cost-effective
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Integrate your health care so that your personal needs and preferences are considered.
Improve the communities we serve.
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