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Doctor's Note
Dear Colleagues,
This issue contains a number of articles to help you and your team stay informed about the many approaches we are taking to improve our collaboration with you. A few examples are:
1) Detailed medical policy updates
2) Tips for using our Provider Portal
3) Communication of changes in viscosupplementation injection coverage (for example, knee injections)
As always, it is our goal to provide you with the resources and support you need to care for your patients who are also our members. We aim to make your work with us intuitive and seamless. If you have any questions, you can contact me at 608-977-8981 or
Michael.Ostrov@wpsic.com.
Best of health,
Michael Ostrov, M.D., M.S.
Chief Medical Officer
Aspirus Arise Health Plan
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Doctor's Note
As we continue to develop our health plan at Aspirus Arise, there are a number of areas where we clinicians can work hand-and-hand with our insurance partners to improve the care we provide for our patients. Specifically, we now have access to additional data which we are utilizing to identify individuals for our population health management programs. This data is also helping us create actionable workflows to ensure we are providing appropriate levels of care for our patients and shape the long-term growth strategy for Aspirus.
Because of our partnership, our population health management programs, provided by the Health Resource Team and Primary Center Medical Home coordinators, are receiving referrals from a number of avenues including from utilization managers (who evaluate prior-authorizations), claims information, and electronic medical record data. This referral process will be continually refined, but in just a few months it has successfully identified patients who are now receiving extra services that we hope will improve their quality of life. To refer a patient for complex care management you can enter Epic order 3000558. To refer a patient for chronic disease management you can enter Medical Home referral code 235515 and then select Disease Management.
Referrals to both programs can also be made by phone at
715-843-1061 or through email at
CDMHRT-AspirusInc-Intake@aspirus.org
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In addition to our population health efforts, our team is working to share information that will assist us in providing appropriate levels of care for our patients. In the past, Aspirus received a number of different sources of insurance data-many of which were outdated, not accurate, or unusable. Through our work with Aspirus Arise, we have been able to effectively work with insurance data. I am hopeful our work with Aspirus Arise will help improve care for all of our patients in the near future.
Additionally, we have been working together on a process to ensure that Aspirus Arise grows membership commensurate with our ability to provide access to care. While this will remain an area of ongoing collaboration, it is important that Aspirus Arise activities align with the overall Aspirus growth strategy.
I am encouraged by the results we've seen thus far working with Aspirus Arise and I am excited about the future opportunities we have, which I'm hopeful will come to fruition through continued collaboration.
Sincerely,
Renee Smith MD
Interim Executive Director and Chief Medical Officer
Aspirus Network Inc.
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Affirmative Statement on Incentives
Utilization Management (UM) decision-making is based only on appropriateness of care and service and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in under utilization.
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Enroll Today for Electronic Funds Transfer
Improve efficiency and go green with our Electronic Funds Transfer (EFT) direct deposit service. When you use EFT, you no longer have to wait for paper checks to be delivered through the mail. Instead, your payment is deposited right into your checking or savings account. This environmentally responsible electronic process uses less paper.
Your Electronic Remittance Advice will be your office's notification of the payment that will be posted to your account. Notification of your payment into your account will come from your bank. Please contact your bank for their notification procedures.
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Quarterly Medical Policy Updates
The Medical Policy Committee met this quarter and approved the medical policies due for annual review.
Click here
to view the revisions to medical policies.
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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Viscosupplementation Injection Now Considered Unproven
Effective July 1, 2017, all forms and brands of hyaluronan and derivatives used as viscosupplements will be considered unproven to affect health outcomes in the treatment of osteoarthritis and other related joint conditions and therefore not covered.
The accumulated scientific evidence has failed to support the efficacy of the treatment or improved outcomes for osteoarthritis.
Years ago, viscosupplementation was proposed for the treatment of osteoarthritis of the knee, showing promise in delaying the need for-or even presenting an alternative to-total knee replacement. It became a common treatment. However, in recent years,
the scientific evidence no longer supports this treatment.
On May 18, 2013, the American Academy of Orthopaedic Surgeons (AAOS) published the Treatment of Osteoarthritis of the Knee Evidence-Based Guideline 2nd Edition, which included a Strong Level Recommendation against
using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.
View the statement online
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The evidence for continued use of hyaluronan v
iscosupplementation became a subject of controversy. Results of additional research and analyses continued to be published.
By February 2017, MCG, one of our primary evidence-based resources, changed its previous clinical indications to "Current Role Remains Uncertain."
New evidence that resulted in this change included several analyses published in 2015 and 2016, which concluded that there was little or no improvement in pain and function for patients with knee osteoarthritis treated with intra-articular hyaluronic acid, and there remained uncertainties about the clinical benefit of this treatment; further high-quality studies were recommended. Mention of the AAOS recommendation against viscosupplementation was also made.
In view of this recommendation and numerous other evidence-based sources, our Medical Policy Committee now considers hyaluronan viscosupplementation unproven to affect outcomes in the treatment of osteoarthritis and other related conditions for all joints and therefore not covered.
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Provider Portal Claim Center is Accessible 24/7
You can access the Claim Center in our Provider Portal 24/7. When you're logged in to the Provider Portal, you can perform a simple search using the Claim ID. The Advanced Search function, shown below, allows you to search by Member, with the additional parameters of Type (Medical or Hospital), service date (not to exceed 60 days), Member, and Provider.
When the search is complete, you will see the Claim ID, Service Dates, Member ID, Service Provider, and Status for the claim(s) you requested. For additional information, such as ANSI codes, click on the Claim ID number, shown in the red circle in the image below.
If no claims are found matching the search criteria, you will be directed to our EDI Department at 800-782-2680 for claims submitted electronically or to Customer Service at 800-765-4977 for paper claims inquiries.
To access the Provider Portal, click the "Log In" button at the top right corner of our home page. If you do not have an account, simply send an email to
register@wpsic.com
with your administrator name, email address, tax ID, practice name, and a list of all clinic locations, including physical addresses. If your office already has an account, new users may be added easily by the administrator.
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Provider Portal tips: Patient Inquiry
Our website includes a Provider Portal that allows you to create an on-line account giving you real time, twenty-four hour a day access to:
- Claim status
- Eligibility
- Copayments and deductibles
- Code Combination Simulation Tool
- Secured messaging with Customer Service
In this issue, the focus is on the benefits of using the Patient Inquiry feature. This function enables you to verify the following information without having to place a call to Customer Service:
- Benefits
- Eligibility
- Deductible/Coinsurance/Copay/Accumulation Limits
- Member Address
- Other Insurance Information
- Primary Care Practitioner (if applicable)
You simply need the member's name or member number, and date of birth, from his/her ID card to get started. Click on the patient's name for more detailed subscriber and policy details, as well as recent claim information.
For more information on the Provider Portal, please check out the
Welcome Providers
section of our website under the Resources Section.
If you're not already using our Provider Portal and would like to enroll, please
send an email to
register@wpsic.com
with the following information: Administrator name, email address, tax ID, practice name, and a list of all clinic locations (including addresses).
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Provider Portal Enhancements: One Sign-On; Three Insurance Entities
If you are currently using our Provider Portal, you are aware that your one account will provide information for WPS Health Insurance, Arise Health Plan, and Aspirus Arise members. As shown in the picture below, the Portal now clearly identifies which insurance entity applies to the member or claim in question.
Note:
Not all providers are contracted with all three insurance entities. Your current Agreement specifies the insurance entity that pertains to your office/facility.
Provider network for member in question
The Patient Inquiry Screens, as seen below, will now reflect the provider network(s) that are tied to the member's plan under the
Find a Patient Search Results page and
Patient Information Detail page.
Be sure to check the effective dates of the member's policy, as the provider network will remain on the screen even if the plan has terminated. Should a member change networks with no lapse in coverage, two rows will be reflected; one for the current network and one indicating the previous network with applicable dates. "No Network Found" will be indicated for policies that do not have networks, such as a dental plan.
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Diabetes Screening Data Being Reviewed to Encourage Coordination of Care Between Medical, Behavioral Providers
HEDIS (Healthcare Effectiveness Data and Information Set) has several measures of performance on specific dimensions of care and service. One of these measures looks at the percentage of members-ages 18-64, with schizophrenia or bipolar disorder, who are taking an antipsychotic medication-to identify if they were screened for diabetes within the calendar year. Even though this measure is specific to the Medicaid population, we will be reviewing data for the HMO/POS product lines to encourage continuity and coordination of care between medical care and behavioral health care.
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Four New HEDIS® 2017 Measurements Help Track Health Outcomes
The Healthcare Effectiveness and Data Information Set (HEDIS) is vital to Aspirus Arise Health Plan. HEDIS measures track a health plan's and physician's ability to manage health outcomes. Generally, strong HEDIS performance reflects enhanced quality of care. With proactive population management, physicians can monitor care to improve quality while reducing costs.
The new HEDIS technical specifications for 2017 include four new measures, changes to seven existing measures, and retirement of one measure. Here, we highlight the four new measures published by the National Committee on Quality Assurance (NCQA).
New Measures
Standardized health care-associated infection ratio:
This measure assesses publicly available data from CMS' Hospital Compare to provide a gauge of the potential infection exposure risk to members admitted to the health plan's network hospitals.
This patient safety measure reports standard infection ratios (SIR) for four different health care-associated infections (HAI):
- Central line-associated blood stream infections (CLABSI)
- Catheter-associated urinary tract infections (CAUTI)
- Methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA)
- Clostridium difficile intestinal infections (CDIFF)
Follow-up after emergency department visit for mental illness:
This measure assesses the percentage of emergency department visits for members age 6 and older with a principal diagnosis of mental illness, who had a follow-up visit for mental illness within seven days and 30 days of the emergency department visit.
Follow-up after emergency department visit for alcohol and other drug dependence:
This measure assesses the percentage of emergency department visits for members age 13 and older with a principal diagnosis of alcohol or other drug (AOD) dependence, who had a follow-up visit for AOD within seven days and 30 days of the emergency department visit.
Depression remission or response for adolescents and adults:
This measure assesses the percentage of members age 12 and older with a diagnosis of depression who had evidence of response or remission of their symptoms 5-7 months after an elevated PHQ-9 score (PHQ-9 is a recognized depression screening tool).
We thank you for giving our members the highest quality care possible. Working together to meet these benchmarks, we have the best chance of improving our members' health outcomes and, ultimately, their quality of life.
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Postpartum Depression Screening is Encouraged
According to the American College of Obstetricians and Gynecologists (ACOG), perinatal depression is one of the most common medical complications associated with pregnancy. The organization recommends women be screened at least one time for depression within the perinatal period.¹
This year, we will be looking at the percentage of our members who were screened for depression at their postpartum visits. We will be encouraging members to ask their practitioners about postpartum depression screening via our member newsletter. Included below are some recognized tools used for depression screening:
If a patient scores positive for depression, please consult with a behavioral health practitioner.
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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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