December 2016
General News
Providers’ help needed to address opioid ‘epidemic’
As most are well aware, there is a crisis with opioid prescribing, which is viewed by the United States Surgeon General as an “opioid epidemic.” Medica encourages its network providers to agree to follow the Surgeon General’s recommendations in order to help address this problem. He sent out the following letter about this:
UNITED STATES SURGEON GENERAL
Vivek H. Murthy, M.D., M.B.A
August 2016
Dear Colleague,
I am asking for your help to solve an urgent health crisis facing America: the opioid epidemic. Everywhere I travel, I see communities devastated by opioid overdoses. I meet families too ashamed to seek treatment for addiction. And I will never forget my own patient whose opioid use disorder began with a course of morphine after a routine procedure.
It is important to recognize that we arrived at this place on a path paved with good intentions. Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely. This coincided with heavy marketing of opioids to doctors. Many of us were even taught __ incorrectly __ that opioids are not addictive when prescribed for legitimate pain.
The results have been devastating. Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly __ almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed. Now, nearly 2 million people in America have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C.
I know solving this problem will not be easy. We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic. As cynical as times may seem, the public still looks to our profession for hope during difficult moments. This is one of those times.
That is why I am asking you to pledge your commitment to turn the tide on the opioid crisis. Please take the pledge. Together, we will build a national movement of clinicians to do three things:
First, we will educate ourselves to treat pain safely and effectively. A good place to start is … the CDC Opioid Prescribing Guideline. Second, we will screen our patients for opioid use disorder and provide or connect them with evidence-based treatment. Third, we can shape how the rest of the country sees addiction by talking about and treating it as a chronic illness, not a moral failing.
Years from now, I want us to look back and know that, in the face of a crisis that threatened our nation, it was our profession that stepped up and led the way. I know we can succeed because health care is more than an occupation to us. It is a calling rooted in empathy, science, and service to humanity. These values unite us. They remain our greatest strength.
Thank you for your leadership.
Medica also wishes to thank providers for their help in addressing this epidemic.
State online database helps monitor controlled substances
As previously published, Medica recently expanded its Restricted Recipient Program to include new parameters for Medica members in commercial group and individual and family business (IFB) plans.
Before prescribing a controlled substance, providers should check an online resource called the Minnesota Prescription Monitoring Program (PMP) as a best practice. This online database identifies patients who may be restricted due to overuse of controlled-substance prescriptions. Patients are included on the PMP site regardless of their health insurance, or even if they don’t have insurance, as long as they’ve filled a prescription for a controlled substance.
Set up by the state of Minnesota to help track controlled medications, the PMP website requires that prescribers or their registered nurses (RNs) be in active practice in order to set up an online account. Learn more and access PMP.
Prescription monitoring should help providers combat the opioid epidemic, too (see above). PMP ultimately provides one more tool to ensure patient safety.
(Update to “Restricted Recipient criteria to expand for commercial, IFB” article in August 2016 edition of Medica Connections.)
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Clinical News
Effective February 1, 2017:
Medica to implement new coverage policies
The following benefit determinations will be effective beginning with February 1, 2017, dates of service. These new policies will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Radioembolization for hepatic tumors
Medica has reviewed radioembolization for hepatic tumors and has determined that this procedure will be covered for the treatment of:
- unresectable primary hepatocellular carcinoma
- unresectable metastatic liver tumors from primary colorectal cancer
- unresectable metastatic liver tumors from neuroendocrine tumors
- unresectable primary hepatocellular carcinoma as a bridge to transplantation
For the treatment of all other indications, radioembolization for hepatic tumors is considered investigative and therefore will not be covered.
Radioembolization is a treatment for unresectable hepatic (liver) tumors that is used as an alternative means to deliver radiation. A physician inserts a catheter at the femoral artery into the hepatic artery and injects the microscopic beads (glass or resin) that contain the radioactive element. The microscopic beads become lodged in the blood vessels surrounding the tumor thereby delivering high doses of radiation directly to the tumors. This is less toxic to the adjacent, healthy tissue than radiation delivered by other means. After approximately two weeks, the radiation dissipates, but the beads remain in the liver permanently. The goal of the procedure is to irradiate and destroy tumors while sparing normal liver tissue.
CLEAR Institute scoliosis treatment protocols
Medica has reviewed the CLEAR Institute scoliosis treatment protocols and has made the following determinations:
- CLEAR Institute scoliosis protocols, including rehabilitation therapies and/or exercises performed in the clinic or home setting, are investigative and therefore will not be covered.
- The scoliosis traction chair, including use in the clinic or home setting, is investigative and therefore will not be covered.
The CLEAR Institute treatment protocol includes a combination of scoliosis-specific physical therapy exercises, chiropractic adjustments, and balance training exercises purported to decrease or eliminate scoliosis curvature and/or deformity. The protocol does not involve standard bracing or corrective surgery. Interventions offered include a combination of the following:
- spinal mobility exercises/therapy, including chiropractic adjustments
- spinal traction, including cervical traction
- vibration therapy, incuding whole body vibration platform therapy
- massage therapy
- Eckard flexion/distraction table therapy
- scoliosis traction chair (e.g., VibeForHealth)
The complete text of the new coverage policies that apply to the determinations above will be available online or on hard copy:
- See Medica’s coverage policies as of February 1, 2017; 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 February 1, 2017:
Medica to make coverage policy changes
The following benefit determinations will be effective beginning with February 1, 2017, dates of service. These new policies will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Allogeneic morphogenic protein
Medica has reviewed allogeneic morphogenic protein (e.g., OsteoAMP™) and has determined that this procedure is investigative and therefore will not be covered.
OsteoAMP is comprised of cadaver-derived bone to which is bound naturally occurring proteins found in bone marrow and associated with promotion of bone formation. Two of these components are bone morphogenic protein (BMP)-2 and BMP-7. OsteoAMP is available in various forms, including a compressible sponge, putty for mixing with bone marrow or blood, and granules for incorporation with bone chips.
Genetic and pharmacogenetic testing
Medica has reviewed genetic and pharmacogenetic testing and has determined that multigene panels will be covered when all other applicable coverage criteria are met. In addition, tests ordered by a board-certified geneticist or genetic counselor not employed by or contracted with the commercial laboratory performing the testing will be covered when medical records document a detailed family history/pedigree and pre-test genetic counseling, unless Medica has previously determined that the test is investigative.
Genetic tests are laboratory tests performed on a sample of blood, saliva, hair, skin, or other tissue that identify changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person’s chance of developing or passing on a genetic disorder.
The complete text of the new coverage policies that apply to the determinations above will be available online or on hard copy:
Effective February 1, 2017:
Medica to revise IFB UM policy for behavioral health services
Medica has recently reviewed behavioral health services for individual and family business (IFB) members and has expanded and clarified the list of services for which notification and prior authorization will be required, beginning with February 1, 2017, dates of service.
First, notification will be required for all inpatient mental health, inpatient substance abuse or detoxification. This will apply to both in-network and out-of-network providers.
Second, prior authorization will be required for the following services, both in-network and out-of-network:
- mental health and substance abuse intensive outpatient, with or without lodging, such as day treatment and partial program, up to 19 hours per week
- mental health and substance abuse inpatient partial program, 20 hours or more per week
- mental health and substance abuse residential treatment
- intensive outpatient day treatment or partial program for treatment of autism
By instituting prior authorization, Medica aims to support members and providers in making evidence-based decisions about appropriate, medically necessary care. As a reminder, Medica requires that providers obtain prior authorization before rendering services. If any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability.
The revised utilization management (UM) policy that applies to the determination above will be available online or on hard copy:
- See Medica’s UM policies as of February 1, 2017; or
- Call the Medica Provider Literature Request Line for printed copies of documents.
Effective February 1, 2017:
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 February 1, 2017, unless otherwise noted.
UM policies — Revised
These versions will replace all previous versions.
| Name |
Policy number |
| Behavioral Health Services - Individual and Family Business (IFB) |
III-BEH.01 |
| Cervical Spine Surgeries (effective 11/16/16; see details) |
III-SUR.37 |
| Electric Tumor Treatment Fields (Optune System) (effective 11/16/16; see details) |
III-DEV.27 |
| Lumbar Spine Surgeries (effective 11/16/16; see details) |
III-SUR.34 |
Coverage policies — New
| Name |
| CLEAR Institute Scoliosis Treatment Protocols |
| Radioembolization for Hepatic Tumors |
Coverage policies — Revised
These versions will replace all previous versions.
| Name |
| Chemiluminescent Testing (ViziLite®) for Oral Cancer Screening |
| Genetic and Pharmacogenetic Testing |
| Hair Analysis in the Clinical Setting |
| Recombinant Human Bone Morphogenic Protein-2 (rhBMP-2)/InFUSE and Allogeneic Morphogenic Protein (e.g. OsteoAMP™) (formerly Bone Morphogenic Protein (BMP) for Spine and Orthopedic Applications) |
| Transcatheter Closure of Cardiac Defects |
These documents will be available online or on hard copy:
Reminder:
Prior authorization to be required for MSHO members
As published last month, prior authorization for several procedures will be required for Medica’s Minnesota Senior Health Options (MSHO) enrollees, in the Medica DUAL Solution® product, effective with January 1, 2017, dates of service. Here are the upcoming utilization management (UM) policies that will be updated to reflect this prior authorization requirement for MSHO:
- Blepharoplasty, Blepharoptosis Repair and Brow Lift.
- Cervical Spine Surgeries
- Inpatient Rehabilitation Facility (Acute Rehabilitation)
- Long-Term Acute Care Hospital (LTACH)
- Lumbar Spine Surgeries
- Positron Emission Tomography (PET) Scan
- Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT)
- Varicose Vein and Venous Insufficiency Treatments
- Wheelchairs, Scooters and Accessories
These UM policies will be available online or on hard copy:
As a reminder, providers should follow these Medica policies only when no National Care Determination/Local Care Determination (NCD/LCD) exists. If an NCD or LCD exists, it should be followed and would be available at cms.gov.
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Pharmacy News
Real-time approval for specialty-drug prior authorizations
As previously published, providers can expect a quicker response time when requesting prior authorizations online from Magellan Rx. Prior authorization is needed for select specialty drugs that are administered by providers and billed under the medical benefit (i.e., medical benefit drugs).
Rather than faxing a prior authorization request, using the online portal takes less time, even allowing approvals in real time. Going online provides a streamlined process that offers convenient access to a secure self-service website. This online option allows providers to submit prior authorization requests, track requests currently in progress, and view existing authorizations. Use the Magellan Rx tool.
More details on prior authorization for medical benefit drugs are available at medica.com, including a link to drug policies on the Magellan Rx website. See more under “Medical Benefit Applies.”
Effective February 1, 2017:
Medica to update drug coverage policies
Medica will soon update the following drug coverage policies, effective with February 1, 2017, dates of service.
Drug coverage policies — Revised
These versions will replace all previous versions.
| Name |
| Antineoplaston Therapy and Sodium Phenylbutyrate |
| Botulinum Toxin (BTX) Treatment of Non-Cosmetic Indications |
| Herpes Zoster Vaccine (Zostavax®) |
| Human Papillomavirus (HPV) Vaccine |
| Intravitreal Vascular Endothelial Growth Factor (VEGF) Inhibitor Antibody Treatment for Neovascular Ocular Indications |
These updated drug coverage policies will be available online or on hard copy:
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Administrative News
Provider College administrative training topic for December
The Medica Provider College offers educational sessions on various administrative topics. The following class is available by webinar for all Medica network providers, at no charge.
Training class topic
"Pharmacy Benefit Manager Changes" (class code: PBM)
There are two additional dates for this training, which was also offered in October. This webinar will give providers more detail around Medica’s switch to CVS Caremark as its new pharmacy benefit manager (PBM). It will include an overview of the transition timeline from September 2016 through January 2017 and what activities are occurring during that time, such as provider and member outreach. This training will also outline pharmacy program changes such as prior authorization and billing parameters related to the new PBM, new drug lists coming on January 1, 2017, and contact information for CVS Caremark so providers can request medication exceptions and appeals, when needed. The class will also cover the resources available to make this transition as seamless and efficient as possible for both providers and their Medica patients.
Class schedule
| Class code |
Topic |
Date |
Time |
Notes |
| PBM-WD1 |
PBM Changes |
Dec. 6 |
3-4 pm |
Class code with “WD” means offered via webinar in December |
| PBM-WD2 |
PBM Changes |
Dec. 20 |
8:30-9:30 am |
Class code with “WD” means offered via webinar in December |
For webinar trainings, login information and class materials are e-mailed close to the class date. To ensure that training materials are received prior to a class, providers should sign up as soon as possible.
The time reflected above allows for questions and group discussion. Session times may vary based on the number of participants and depth of group involvement.
The registration deadline is one week prior to the class date. Register online for a session above.
Recorded webinar online
Can’t attend a webinar at the times above? Well, good news. The “PBM Changes” training will be recorded and posted online for providers to access any time. See it soon on the Provider College webpage at medica.com.
Effective October 1, 2016:
Medica revises reimbursement policies
Medica has updated the reimbursement policies indicated below, effective with October 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) |
| Bilateral Procedures (updated code list) |
| Global Days (updated code lists) |
| Injection and Infusion Services (updated code list) |
| Laboratory Services (updated code list) |
| Nonphysician Health Care Codes (updated code list) |
| Professional and Technical Components (updated code lists) |
| Same Day Same Service (updated code list) |
| Time Span Codes (updated code list) |
This revised policy is available online or on hard copy:
Effective February 1, 2017:
Requirements for inpatient interim billing to be updated
Effective on or after February 1, 2017, dates of processing, Medica’s requirements for inpatient hospital interim billing will be updated to include the following:
- The Admission date is to be reported on each claim (first, continuing, and last) and will be the same on each claim.
- The Statement Covers Period (From-Through) will vary and reflect only the dates of services performed during the respective billing period. Interim bills are not to include charges billed on an earlier claim since the “From” date on the bill must be the day after the “Through” date on the earlier bill.
The complete list of requirements, as well as the UB-04 data elements necessary to correctly bill interim claims, are included in the Medica Provider Administrative Manual. Refer to Claim Submission Requirements for Facilities, where “Inpatient Hospital Interim Billing” information is located under “Submission Info.”
Effective February 1, 2017:
Medica to revise reimbursement policy
Medica will soon update the reimbursement policy indicated below, effective on or after February 1, 2017, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Services incidental to admission
Medica’s Services Incidental to Admission policy addresses the billing and reimbursement of outpatient hospital services rendered prior to an inpatient admission. This policy will be revised to more closely align with the Centers for Medicare and Medicaid Services (CMS) 3-Day Payment Window policy, which addresses outpatient hospital services provided on either the date of inpatient admission or during the three calendar days preceding the date of admission.
According to Medica’s revised policy, the following outpatient services will be considered incidental to admission. Therefore, they should not be separately billed but should be included on the claim for the inpatient hospitalization:
- all outpatient services provided by the same hospital on the date of admission
- all outpatient diagnostic services provided by the same hospital during the 3 calendar days preceding the date of admission
- all outpatient non-diagnostic (e.g. therapeutic) services provided by the same hospital during the 3 calendar days preceding the date of admission (excluding ambulance and maintenance renal dialysis services). All non-diagnostic/therapeutic services provided by the same hospital during the 3 calendar days preceding the date of admission are deemed related to the reason for admission unless the hospital attests that the services are clinically unrelated by submitting condition code 51 (“Attestation of unrelated outpatient nondiagnostic services”) on facility claims.
This policy will apply to all Medica commercial, individual and family business (IFB) and Minnesota Health Care Programs (MHCP) products. It will not apply to critical access hospitals (CAHs), rural health clinics (RHCs) or federally qualified health centers (FQHCs).
Note: Pre-admission services will be subject to post-payment audits and potential retraction of inappropriate payments.
This new policy will be available online or on hard copy:
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SelectCare/LaborCare News
Reminder:
Aetna terminates its SelectCare TPA contract, eff. Jan. 1
As previously published, Aetna has given notice that it is terminating its third-party administrator (TPA) contract for the Medica SelectCareSM network, effective at the start of next year. This will affect a majority of current SelectCare members effective beginning with January 1, 2017, dates of service. Starting next year, SelectCare network providers will need to contact Aetna directly for all inquiries about these enrollees, including claims, appeals, rate disputes and reconsiderations.
For more Aetna information about claims and appeals, providers can:
- Refer to Aetna’s website.
- Contact Aetna at 1-888-632-3862. (If unable to get a resolution, escalate issues to an Aetna supervisor.)
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (November 2016). Highlights that may be of interest to LaborCare® network providers include:
- Update to prior authorization for functional endoscopic sinus surgery (FESS)
- Enhanced applications for eligibility and claims on UHC Link online tool
- Revision to Multiple Procedure Payment Reduction for Diagnostic Imaging Policy — scheduled for January 2017
- Revision to Maximum Frequency per Day Policy and Bilateral Procedures Policy — scheduled for January 2017
View the November 2016 UHC provider bulletin.
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