ANNOUNCEMENTS

Introducing MAHP's New Chief Operating Officer

Nicole Oishi

Chief Operating Officer

MAHP

Medical Associates Health Plans (MAHP) announces the arrival of Nicole Oishi as its new Chief Operating Officer. In this role, she will provide strategic leadership to strengthen operations and guide initiatives to drive organizational growth.

"We are excited to welcome Nicole to our team," said Zach Keeling, Chief Executive Officer of Medical Associates. “Her leadership and experience will help us build on the strong foundation we’ve created and continue delivering the excellent service our Health Plans is known for.”

Oishi brings more than 30 years of diverse healthcare experience, including over 15 years in executive leadership roles. Her background includes managing large multi-site physician groups, holding key positions at Regence/Cambia (a Blue Cross Blue Shield Health Plan operating in WA, UT, OR, and ID), and overseeing healthcare purchasing for the State of Washington. She also led operations and clinical programs at multiple healthcare startups, including Collective Medical (now PointClickCare), Matrix Medical Network, and Asserta Health (now Frontier Health). Most recently, Oishi provided operational and clinical expertise to regional health plans and clinical companies, serving self-funded and fully insured employers, individual and small group plans, as well as Medicare Advantage and Medicare Supplement members.

“I am thrilled to be part of Medical Associates,” said Oishi. “I started my career as a nurse and I have spent the last 30+ years working across the healthcare continuum, to make healthcare better for the patients and members I served. Being able to join an organization that delivers a comprehensive and integrated care model, where the health plan and providers work together as partners, is incredibly exciting.”

Welcome Central Plains Physician Health Plan Providers

Medical Associates is excited to partner with local providers and facilities in the Hutchinson, Kansas area to create Central Plains Physicians Health Plan. More information regarding the products offered in this area can be found on the provider page of www.centralplainshealthplan.com.

Announcing Heartland Health Plan

MAHP has rebranded its individual commercial networks into a single, comprehensive network, now known as Heartland Health Plan. This new network includes a wide range of healthcare practitioners and facilities across Iowa. Participating facilities include MercyOne hospitals and affiliates surrounding Mason City, Cedar Falls, Waterloo, Clinton, the Quad Cities, and Des Moines, as well as Mercy Medical Center Cedar Rapids and affiliates. The care model remains the same with care directed locally when possible. As a result of this change, you may notice fewer provider directories in the quarterly provider directory validation. Click here to view maps of Heartland Health Plan's provider network.

As members transition to Heartland Health Plan from MercyOne North Iowa Health Plan, Mercyone Cedar Valley Health Plan, Quad Cities Community Health Plan, Mercy Cedar Rapids Health Plan, or Central Iowa Health Plans they will be issued new ID cards. Their current cards will remain active until they are issued new ones.

A sample ID card for Heartland Health Plan is below: 

New Vendor for Payments

We are excited to announce a new partnership with ECHO Health to provide electronic payments and remittances. We are anticipating transitioning to ECHO Health in Spring 2025. Please keep an eye out for more information.

QUALITY IMPROVEMENT

Key Quality Measures for this Year’s HEDIS Audit

As we step into a new year, staying informed about the latest developments in healthcare quality and performance is essential. In this edition, we explore the Healthcare Effectiveness Data and Information Set (HEDIS®) measures of healthcare quality, emphasizing our commitment to delivering exceptional care to our valued patients.

What is HEDIS?

HEDIS, developed by the National Committee for Quality Assurance (NCQA), is a set of performance measures used to assess the quality of care and services provided by healthcare organizations. It serves as a benchmark for evaluating and comparing healthcare plans across the nation.

Key HEDIS Measure Areas

1. Prevention and Screening:

• Ensure your patients are up-to-date on essential vaccinations.
• Encourage screenings for conditions such as cancer and diabetes to detect potential issues early.

2. Chronic Disease Management:

• Support the management and improvement of chronic conditions like hypertension and diabetes.
• Emphasize patient education to enhance self-management.

3. Behavioral Health:

• Improve access to behavioral health services and ensure follow-up care within seven days of emergency or hospital care.
• Promote screenings and interventions for substance use disorders.

4. Health Equity and Patient Experience:

• Address Social Determinants of Health (SDoH) areas of housing, transportation, safety, and food insecurity that contribute to health disparities and inequities.
• Collect patient feedback to drive continuous improvement in care experiences.

Our Commitment to Excellence

At MAHP, we are dedicated to surpassing the expectations set by HEDIS measures. These measures play a vital role in demonstrating the quality of care we provide and in driving optimal health outcomes for our community.

How Providers Can Contribute

• Accurate Documentation: Ensure thorough and precise documentation of patient encounters.
• Patient Engagement: Encourage patients to take an active role in their care plans.
• Continued Education: Stay informed about the latest guidelines and best practices in your field.

Over the next few months, our Quality Improvement team will be reaching out to ensure we obtain the most accurate patient information to reflect the quality of care you provide. The most efficient way to gather this information is by allowing access to the EMR during our hybrid auditing period, which remains open through May 1. Please consider this option when we contact you.

Thank you for your unwavering dedication to healthcare excellence.

Documentation and Coding Guidance: CVA or Stroke

A cerebrovascular accident (CVA), or stroke, is a medical emergency. There are two types: ischemic and hemorrhagic. An ischemic stroke is the more common type (ICD-10-CM Code Category I63) and is usually caused by a blood clot that blocks or plugs a blood vessel in the brain. A hemorrhagic stroke is the less common type (ICD-10-CM Code Categories I60-I62) and occurs when a blood vessel ruptures and bleeds into the brain. The documentation resource below focuses on the more common ischemic stroke.

An ischemic stroke should only be documented and coded as an acute CVA (any code starting with I63) at the onset or initial encounter, when the condition is first diagnosed, typically in an emergency or hospital setting. It is rare for this to occur in an outpatient office setting; therefore, it would be inaccurate to document “CVA” or “stroke” and submit an ICD-10-CM code for an acute CVA when a patient is seen for a follow-up outpatient visit.

During a follow-up outpatient visit, the provider should instead document and code any neurological deficits the patient is exhibiting as a result of the CVA. These neurological deficits, known as “sequelae” in coding, may include hemiplegia or hemiparesis, monoplegia, facial droop, cognitive deficits, or expressive aphasia. ICD-10-CM codes for sequelae of cerebral infarction begin with I69 and include additional digits for specificity. Examples include:

• I69.311: Memory deficit following cerebral infarction
• I69.320: Aphasia following cerebral infarction
• I69.331: Monoplegia of upper limb following cerebral infarction affecting right dominant side

If the patient’s neurological deficits resulting from the CVA have resolved, then “history of CVA” should be documented, and code Z86.73 (personal history of CVA and cerebral infarction without residual deficits) should be assigned.

If you would like additional information on documentation improvement, you may contact Kari Pace, MAHP Clinical Documentation Improvement, at (563) 584-4849.

Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY2025-Chapter 9: Diseases of the Circulatory System (I00-I99).

CREDENTIALING

Reporting Reminders

Please update CAQH regularly with new insurance information, locations, and any other changes. Accurate information ensures that provider directories remain up to date, helping members find the care they need.

Additionally, please self-report any malpractice cases or disciplinary actions to mahpcredentialing@mahealthcare.com.

HEALTHCARE SERVICES

GLP-1 Prescription Guidance

Kate Kurt, PharmD

Clinical Pharmacist

MAHP

We’ve seen a staggering increase in prior authorization (PA) requests—both new and renewal requests—in the past few weeks. To streamline approvals and reduce delays, please keep the following guidance in mind when prescribing GLP-1 medications.

Key Considerations for Prescribing GLP-1s

• Ensure correct prescribing: All MAHP Plans (Medical Associates Health Plans, Health Choices, Central Plains Physicians Health Plan, and Live360 Health Plan) strictly adhere to FDA-approved indications for each medication. If treating type 2 diabetes, prescribe only GLP-1s approved for this condition.
• Use brand names: This minimizes confusion at the pharmacy and during the PA process.
• Not approved for pre-diabetes: GLP-1s are not FDA-approved for pre-diabetes and are generally not covered for this use.

As a reminder, MAHP Plans do NOT cover medications used for weight loss.

GLP-1 requests require complete and accurate supporting clinical documentation. To help authorization staff review these requests with accuracy, the following information should be included in every encounter with these patients:

• A1c values for patients who are utilizing these medications for treatment of type 2 diabetes
• Cardiovascular diagnosis (see next section for detailed items required)

Wegovy was recently approved by the FDA for use in reducing risk of major adverse cardiovascular events in patients 45 years of age and older with a BMI ≥27 mg/k2. Wegovy is the only GLP-1 approved for this indication.

• If you are requesting use of Wegovy for cardiovascular risk reduction, you must include the following information in your clinical documentation for the PA to be submitted:
• Documentation of established cardiovascular disease (with date of onset) from one of the following:
• Prior myocardial infarction (MI)
• Prior stroke (transient ischemic attack, ischemic, or hemorrhagic stroke)
• Peripheral arterial disease (i.e., intermittent claudication with ankle-brachial index < 0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease)
• Documentation that the medication is being used in combination with a program supporting a reduced calorie diet of at least 500 kcal/day and patient can be active for at least 150 minutes/week
• Documentation that the A1c <6.5% in the past 12 months
• Documentation that the patient does not have
• Type 1 or type 2 diabetes
• NY Heart Association functional class IV heart failure

GLP-1 FDA-Approved Indications for Use

Zepbound’s recent approval for use in Sleep Apnea has not yet been assessed related to coverage on the MAHP Plans. Review of this new indication will occur over the next few months and any updates to coverage will be shared later this summer. We anticipate very specific criteria for coverage if this is added to the formulary.

RESOURCES