February 2016
General News
Premium program to enhance quality, cost-efficiency metrics
Next updates to physician ratings delayed until 2017
The Medica Premium Designation Program, a collaboration with UnitedHealthcare, is currently undergoing updates, which include some changes to methodology. Premium designations are based on a review of physician performance against national quality and regional cost-efficiency standards. The most recent designation results were posted in April 2015. In an effort to increase the value of the program and in response to feedback from physicians, UnitedHealthcare is enhancing the program’s quality measures and cost-efficiency metrics to include:
- new national standard quality measures
- enhanced analytics
- refined population cost methodology
Due to the time required to implement these changes, updated Premium Designation results will not be available to physicians until January 2017 rather than January 2016. Current Premium designations will stay in place, and Medica will continue to accept reconsideration requests for these designations through July 2016. New assessments using the latest updates will be run in late 2016, and results will be mailed to physicians in January 2017. Display of these new results in provider directories is currently scheduled for April 2017. More details on changes to the new methodology will be available soon.
Effective January 1, 2016:
Medica offers new Medicare ‘Thrive’ plan as value option
Medica has rolled out a new “Thrive” option for its Medica Prime Solution® Medicare plan that lowers the monthly premium for members and has no copays for most services. New for 2016, this plan allows Medicare members to choose complete Medicare coverage without paying for “extras” they tend not to use. Thrive provides more value for less money. The Thrive plan is offered only to Minnesota residents.
Thrive medical benefits are similar to those of the Medica Prime Solution Enhanced plan, although the Thrive premium is 33 percent lower. Some of the extra features excluded from Thrive are:
- hearing exam and hearing-aid coverage
- routine eye exam and non-Medicare eyewear coverage
- Silver&Fit® fitness membership
- option to purchase dental coverage
Here’s a sample ID card for a member with the Thrive plan:
Due by March 1, 2016:
Annual ‘Disclosure of Ownership’ forms needed soon
Each year, providers must complete and submit an updated “Disclosure of Ownership Statement” in accordance with regulatory agency requirements. This year, providers should complete and return this disclosure form no later than March 1, 2016. It can be returned to Medica by e-mail.
As a reminder, providers who see patients covered under Medica products for government programs need to complete and return the Disclosure of Ownership Statement to Medica annually. This step is necessary for Medica to comply with contracts it holds with both the Centers for Medicare and Medicaid Services (CMS) and the Minnesota Department of Human Services (DHS).
Medica wishes to thank providers for their time and a prompt response to this obligation. More details about this compliance requirement are available in the Medica Provider Administrative Manual.
Effective April 1, 2016:
Billing for non-covered Medicare services using GY modifier
Beginning with April 1, 2016, dates of service, Medica will closely follow Centers for Medicare and Medicaid Services (CMS) guidelines regarding the GY modifier when processing Medica Prime Solution® Medicare claims. CMS states that the GY modifier (“Item or service statutorily excluded or does not meet the definition of any Medicare benefit”) must be used when providers want to indicate that an item or service is statutorily non-covered or is not a Medicare benefit.
Effective April 1, 2016, the GY modifier will only be allowed for services that are statutorily excluded for Medicare. Medica will deny claims for these services as member liability using denial reason code 0068 (“Your plan does not cover this expense”). For a code normally covered by Medicare but where a diagnosis for the procedure makes it a non-covered service, the code would be considered circumstantially non-covered, so therefore the GY modifier would not be appropriate. In such situations, Medica will deny the claim as provider liability using denial reason code 092 (“Incorrect modifier”). The provider would then need to correct the claim and re-submit it with the correct modifier for proper processing.
This upcoming change will not affect Medica Prime Solution member benefits that Medica covers above and beyond Medicare coverage. Medica will continue to process and pay claims for such benefits as it does today.
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Clinical News
Effective March 1, 2016:
Medica to make UM policy change
Medica will soon revise the following utilization management (UM) policy that requires prior authorization, effective beginning with March 1, 2016, dates of service. This change will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Genetic testing for susceptibility to hereditary breast and ovarian cancer
Medica recently reviewed genetic testing for susceptibility to breast and ovarian cancer and has made a determination concerning several new tests. This decision addresses testing for variants of the PALB2 and CHEK2 genes, as well as multi-gene next generation sequencing panels, including but not limited to the following: BRCAplus, BROCA Cancer Risk Panel, BreastNext Next-Gen Cancer Panel, BreastTrue High Risk Panel, Color Test, and PreOvar KRAS-Variant Test. Medica has determined that these tests are investigative and therefore will not be covered. BRCA1 and BRCA2 gene testing and testing for large rearrangements (BART) remain covered as long as prior authorization criteria are met.
Medica will implement an updated UM policy titled “Genetic Testing for Susceptibility to Hereditary Breast and/or Ovarian Cancer,” addressing genetic testing for susceptibility to breast and ovarian cancer. This policy will replace current Medica UM policy “Genetic Testing for Hereditary Breast and/or Ovarian Cancer (BRCA 1 and BRCA 2 Genes and BRACAnalysis® Rearrangement Test [BART]).”
Medica previously notified providers about this benefit change with a Provider Alert in late December 2015. The complete text of the policy that applies to the determination above will be available online or on hard copy:
- See Medica’s UM policies as of March 1, 2016; or
- Call the Medica Provider Literature Request Line for printed copies of documents, toll-free at 1-800-458-5512, option 1, then option 5, ext. 2-2355.
Effective April 1, 2016:
Medical policies and clinical guidelines to be updated
Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective April 1, 2016, unless otherwise noted.
UM policies — Revised
These versions replace all previous versions.
| Name |
Policy number |
| Genetic Testing for Susceptibility to Hereditary Breast and Ovarian Cancer (effective 3/1/16; formerly titled Genetic Testing For Hereditary Breast And/Or Ovarian Cancer (BRCA 1 And BRCA 2 Genes And Bracanalysis® Rearrangement Test [BART]) |
III-DIA.04 |
Coverage policies — Revised
These versions replace all previous versions.
| Name |
| Exhaled Breath Asthma and Other Inflammatory Pulmonary Conditions: Exhaled Nitric Oxide Breath Test and Exhaled Breath Condensate pH Measurement |
| Lipoprotein Subclass Testing for Screening, Evaluation, and Monitoring of Cardiovascular Disease |
| Lipoprotein-associated Phospholipase A2 (Lp-PLA2) Immunoassay for Prediction of Risk for Coronary Heart Disease or Ischemic Stroke (PLAC® Test) Lp-PLA2; PLAC Test |
| Quantitative Electroencephalogram (qEEG) and Referenced Electroencephalogram (rEEG) |
| Tissue-Engineered Skin Substitutes for Wound and Surgical Care |
| Total Ankle Replacement Surgery |
These documents will be available online or on hard copy:
Medica follows new screening guidelines for breast cancer
Medica follows the U.S. Preventive Services Task Force (USPSTF) guidelines regarding breast cancer screening recommendations, which the USPSTF updated in 2015. Currently the task force recommends the following:
- Routine screening should occur for average-risk women who are 50-74 years of age.
- Screenings should occur every other year rather than yearly.
- There is no evidence to support the use of 3-D mammography (tomosynthesis) as a screening modality.
- There is insufficient evidence to support the use of ultrasound, magnetic resonance imaging (MRI) or 3-D mammograms as adjunctive screening for women with dense breast tissue who otherwise have a negative screening mammogram.
See full details from the USPSTF. Medica supports the task force guidelines, but will continue to provide coverage for women 50 to 74 years of age who want to get an annual mammogram.
Partnering with patients to reduce bone-fragility fractures
Clinical care teams are in the best position today to provide patients who are 50 years of age and older with information to make healthy choices and mitigate the negative outcomes of decreased bone density. Today, many care teams have electronic health records and workflow capabilities making information readily available during the annual health care visit, about previous fractures, testing and treatments attempted for their patients. This ensures that the provider is prepared with the information needed to address bone health within the patient encounter.
Understanding the problem
Health plans can partner with providers who do not have the data readily available to identify pertinent information and who are willing to work together to eliminate barriers to testing and treatment. These partnerships can be leveraged to help patients understand what to expect with a fracture beyond the repair and rehabilitation of their first broken bone, including statistics on life-altering changes and the prevalence of the problem. Providers can help patients make informed choices about testing and treatment for this health condition based on the following numbers:
- Up to 50 percent of all women and 25 percent of all men over 50 years of age will sustain fragility fractures in their remaining lifetime.
- Nearly 25 percent of patients who suffer a hip fracture die within 12 months, while another 20 percent end up in a nursing home.
- The incidence of fragility fractures is over 2 million annually.
- Fragility is the most common cause of fractures among seniors, yet only 20 percent of patients receive best-practice care.
- Fragility fractures are costing the United States health system more than $19 billion.
Treating the condition
Testing and treatments for patients can include the following (unless they are contraindicated):
- nutrition counseling, such as calcium supplementation and vitamin D supplementation
- physical activity counseling, such as weight-bearing and muscle strengthening exercise or education on fall prevention
- lifestyle counseling, such as smoking cessation (if needed) or limiting excessive alcohol intake
- diagnostic testing, such as dual-energy X-ray absorptiometry (DXA) to test bone mineral density
- pharmacology, for the treatment of osteoporosis
- fracture liaison service teams, to address the osteoporosis treatment gap and prevent subsequent fractures for patients who sustain a fracture
These interventions are consistent with recommendations from the National Osteoporosis Foundation, the Centers for Medicare and Medicaid Services, The Joint Commission, the World Health Organization, and the American Medical Association.
The National Bone Health Alliance has also identified model programs for fracture liaison service care teams (offering educational webinars on them): Kaiser Permanente’s “Healthy Bones” program, which has led to an overall 38 percent reduction in the expected hip-fracture rate since 1998; and Geisinger Health System’s osteoporosis disease management program, which achieved $7.8 million in cost savings over 5 years. See more from the National Bone Health Alliance.
Other online resources for providers, patients and families include:
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Pharmacy News
Effective April 1, 2016:
Medica to update MHCP drug list
Medica has reviewed the following drug classes on the List of Preferred Drugs for Minnesota Health Care Programs (MHCP). Respective changes in coverage status will be effective April 1, 2016. These changes will only apply to the Medica MHCP drug formulary, which applies to the following products: Medica Choice CareSM (including Minnesota Senior Care Plus program, or MSC+), Medica MinnesotaCare, Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs.
| Drug class name |
Specific drugs affected |
New formulary position |
Current preferred alternatives |
Approved therapeutic indications |
| Nasal Steroids |
budesonide, flunisolide, Nasonex, Qnasl, triamcinolone |
Non-formulary |
fluticasone propionate |
Treatment of rhinitis |
| Ophthalmic Antihistamines |
Pataday, Patanol |
Non-formulary |
ketotifen (OTC), azelastine, epinastine |
Treatment of itchy eyes |
| Proton Pump Inhibitors |
esomeprazole, Vimovo |
Non-formulary |
omeprazole, pantoprazole, lansoprazole, rabeprazole |
Treatment of gastro-esophageal reflux disease and ulcers |
Medica drug formularies are available online or on paper:
Medication request forms
A uniform formulary exception request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:
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Network News
Third-quarter PCR checks to be mailed in January 2016
By the end of January 2016, Medica plans to mail to eligible providers the physician contingency reserve (PCR) payment for the third quarter of 2015. This represents a 100-percent return of the third-quarter 2015 PCR withhold, plus interest, for the Medica Prime Solution® Medicare product. Checks will cover PCR withheld for claims with dates of service of July 1, 2015, through September 30, 2015, and dates paid of July 1, 2015, through December 31, 2015.
Note: Medica began processing claims with a 2 percent payment reduction in April 2013 due to federal sequestration legislation. The 2 percent sequester reduction was in addition to the standard PCR withhold amount for Medica Prime Solution claims. This 2 percent cut will not be included in PCR returns.
Next payment for ACA MHCP rate increase to be mailed to PCPs
In the coming weeks, Medica plans to mail out the second Minnesota Health Care Programs (MHCP) enhanced lump-sum payment for eligible primary care practitioners (PCPs). This payment covered eligible services for which Medica processed a claim in calendar years 2013 and 2014.
Note: The Minnesota Department of Human Services (DHS) made adjustments to the payment amounts for 2013. This will be reflected in the net amounts payable to providers for 2014.
Enhanced rates are to be paid for certain MHCP primary care evaluation and management (E/M) and vaccine administration services provided in 2013 and 2014 by eligible PCPs. This was one result of the federal Affordable Care Act (ACA). The following services are eligible for the enhanced rates:
- primary care services (CPT codes 99201-99499); and
- vaccines for Children administration services (CPT codes 90460-90461 and 90471-90474)
For more details about these PCP enhanced payments, providers may:
(Update to "Payment for 2013 ACA MHCP rate increase mailed" article in the October 2014 edition of Medica Connections.)
Effective April 1, 2016:
Medica to update Medicare physician fee schedule
Beginning with April 1, 2016, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. This fee schedule change will reflect the April 2016 Centers for Medicare and Medicaid Services (CMS) update applicable to reimbursement for injectable drugs and immunizations. The reimbursement impact of this quarterly update will vary based on specialty and mix of services provided. Updates for durable medical equipment (DME) and orthotics and prosthetics (O&P) will not be implemented at this time.
Details on Medicare changes to drug fees are available online from CMS. Providers who have further questions may contact their Medica contract manager.
Note: CMS also recently published a revised relative value unit (RVU) file for calendar year 2016, effective January 1, 2016. Medica is updating its Medicare fee schedule to reflect these changes, retroactive to January 1. This update will then apply for Medica Medicare claims going forward after the update is complete.
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Administrative News
Providers can change advanced-practice specialty types
As of January 1, 2016, Medica has made a system update to now have individual specialty types designated for these advanced-practice practitioners providing specialty care in specialty clinics: certified nurse practitioners, certified nurse-midwives, and physician's assistants. If these providers do not see an updated specialty type in online provider directories like Provider Search or Find a Physician, they can submit a change by filling out the Minnesota Uniform Practitioner Change Form and sending it to Medica. Medica should be able to implement requested changes within 30 days.
The update for January 1 sought to better align advanced-practice practitioners with the specialty services they perform at their respective clinics. The system update improves the way advanced-practice practitioners are displayed in directories and aligns their reimbursement with the contracted services they provide. It also affects Medica member benefits, better aligning them with the specialty services being performed by these practitioners in accordance with their Medica provider contracts.
(Update to "After delay, advanced-practice specialty types to change" article in the December 2015 edition of Medica Connections.)
Effective April 1, 2016:
Overpayment detection program to expand to IFB claims
Medica will soon expand its existing enhanced overpayment detection and recovery program, launched in 2013, to include claims for its individual and family plan (IFB) members. This change in claims review is expected to begin April 1, 2016, and will apply for IFB members in Iowa and Nebraska as well.
Waste and error prevention and detection procedures — such as those of the enhanced Medica overpayment detection and recovery program — are required by the Centers for Medicare and Medicaid Services (CMS) as well as the Minnesota Department of Human Services (DHS) for contracted health plans such as Medica. Providers will continue to have the ability to appeal payment decisions by following the standard Medica appeal process.
Effective January 1, 2016:
Medica makes annual reimbursement policy code list updates
Medica has updated the reimbursement policies indicated below, effective with January 1, 2016, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Add-On Code (updated code list) |
| Ambulance (updated code list) |
| Anesthesia (updated code lists) |
| Assistant Surgeon (updated code list) |
| Bilateral Procedures (updated code list) |
| Bundled Services (updated code list) |
| Care Plan Oversight (updated code list) |
| Co-Surgeon/Team Surgeon (updated code lists) |
| Contrast and Radiopharmaceutical Materials (updated code list) |
| From-To Date (updated code list) |
| Global Days (updated code lists) |
| Injection and Infusion Services (updated code list) |
| Laboratory Services (updated policy and code lists) |
| Maximum Frequency per Day (Units) (updated unit values) |
| Microsurgery (updated code list) |
| Moderate Sedation (updated code list) |
| Multiple Procedures (updated code list) |
| One or More Sessions (updated code list) |
| Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction (updated code list) |
| Professional and Technical Components (updated code lists) |
| Services and Modifiers Not Reimbursable to Health Care Professionals (updated code lists) |
| Supply (updated code lists) |
| Time Span Codes (updated code list) |
These revised policies are available online or on hard copy:
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PPO News
Latest UHC provider bulletins available online
UnitedHealthcare (UHC) has published the latest editions of its Network Bulletin (December 2015 and January 2016). Highlights that may be of interest to LaborCare® network providers include:
- Multiple procedure payment reduction policy updates for endoscopy and the technical component of diagnostic cardiovascular and ophthalmology procedures — delayed until March 2016
- New Replacement Codes Policy — scheduled for March 2016
- Telemedicine and Procedure to Modifier policies to be revised — scheduled for first quarter 2016
- New select musculoskeletal and pain management procedures — scheduled for April 2016
- Supply Policy to be revised — scheduled for May 2016
View the December 2015 UHC provider bulletin and January 2016 UHC bulletin.
Effective January 1, 2016:
UHC requires fewer copays for Wisconsin Medicaid services
As of January 1, 2016, UnitedHealthcare (UHC) BadgerCare Plus members no longer need to pay copays on many covered services. This means Medica SelectCareSM providers in western Wisconsin no longer need to collect payment on such services from their BadgerCare Plus patients prior to providing treatment. This change applies for all covered medical services. Members continue to have copays due for vision services and other services covered by the State of Wisconsin such as chiropractic, pharmacy and dental services. To learn more about copay details, providers can call UHC at 1-877-651-6677. Copay changes will also be included in the UHC Community Plan Provider Manual.
UnitedHealthcare Community Plan helps administer BadgerCare Plus coverage for the state of Wisconsin’s Medicaid members. UHC has taken several steps to notify affected members of the change to copays, and appreciates providers’ assistance in making this a seamless transition. The removal of copays should assist in helping these patients live healthier lives by allowing easier access to treatment. If UHC BadgerCare Plus patients have questions about their benefits, they can call UHC at 1-800-504-9660.
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