July 2017
General News
Reminder:
UnitedHealthcare to administer Premium program starting soon
Physicians included in the Premium Designation program this year will soon receive a mailing announcing their new designation as well as outlining Premium program changes for 2017. As noted last month, the most significant program change this year is that UnitedHealthcare will begin administering activities of the Premium program on Medica's behalf. All communications and resources will come from UnitedHealthcare starting next month (including a sample annual assessment letter). As a new program feature, physicians will also be able to delegate Premium program activities to one of their staff members, to handle such things as the review of patient-specific reports online.
This year's Premium designations will be displayed online in the fall, tentatively scheduled for September 2017. The Medica provider-search tool on medica.com will be updated to reflect the new designations.
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Clinical News
Effective August 21, 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. These policies will be effective August 21, 2017, unless otherwise noted.
Monthly updates to Medica's policies are available on an ongoing basis. Updates are posted on medica.com prior to their effective date. The medical policy changes effective August 21, 2017, are already posted, and upcoming changes effective September 18, 2017, will be posted in July 2017. Policy changes are expected to be effective as of these dates unless otherwise noted.
The medical policies themselves will be available online or on hard copy:
Promoting bone health with appropriate screening, treatment
Medica is committed to improving the health of its members through appropriate osteoporosis screening and treatment. Early detection and intervention are crucial for promoting bone health in post-menopausal women and in other women at risk for the disease. Preventive services such as bone mineral density (BMD) testing should be discussed during annual physical exams, along with interventions to promote bone health.
Osteoporosis is a bone disease that affects nearly 10 million individuals in the United States. An additional 43 million have low bone density and are at risk for developing the disease. Most of these individuals are women and many will not receive a diagnosis until they experience a fracture.
Fractures are costly to individuals, health care systems and insurers. Each year, 2 million fractures are attributed to osteoporosis. These fractures result in more than 432,000 hospital admissions, nearly 2.5 million outpatient visits and 180,000 nursing home admissions. These services cost an estimated $19 billion per year. In the next 10 years, this cost is expected to increase to more than $25 billion.
The U.S. Preventive Services Task Force (USPSTF) recommends osteoporosis screening for all women 65 years of age and older, as well as for women younger than 65 if their fracture risk is equal to that of a 65-year-old white woman without additional risk factors. Medica’s data shows this recommendation is not consistently followed, and data collected for the Healthcare Effectiveness Data and Information Set (HEDIS) shows significant variation in the care delivered to age-appropriate women who have sustained a fracture.
Medica's goal, which aligns with USPSTF guidelines, is to promote appropriate osteoporosis screening and treatment among age-appropriate members. This means that women who meet the USPSTF screening guideline should receive a baseline BMD test. In addition, at a minimum, age-appropriate women who sustain a fracture should be referred for a BMD test within six months of the fracture date if one has not been completed in the last two years. Pharmacologic interventions should also be considered in this population.
Addressing osteoporosis is especially important following a fracture. Older women who sustain a fracture and have not had a BMD test in the last two years should have a BMD test to inform treatment decisions. Treatment in this population should include exercise and a diet high in calcium and vitamin D.
Due by July 15, 2017:
Quality complaint reports required by State of Minnesota
Medica requires its Minnesota-based network providers to submit second-quarter 2017 quality-of-care complaint reports to Medica by July 15, 2017.
The State of Minnesota requires that providers report quality complaints received at the clinic to the enrollee's health plan. All Minnesota-based providers should submit a quarterly report form, even if no Medica members filed quality complaints in the quarter (in which case, providers should note “No complaints in quarter” on the form).
Providers can now send reports by e-mail to [email protected]. Otherwise, reports can still be sent by fax to 952-992-3880 or by mail to:
Medica Quality Improvement
Mail Route CP405
PO Box 9310
Minneapolis, MN 55440-9310
Report forms are available by:
Note: Providers submitting a report for multiple clinics should list all the clinics included in the report.
Providers who have questions about the complaint reporting process may:
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Pharmacy News
Effective July 1, 2017:
Cost-sharing process to change for specialty drug savings cards
Medica individual and family business (IFB) members who use a savings card for the purchase of their specialty drugs will see a change in the way drug manufacturer discounts get applied to the members plan. Starting July 1, 2017, only the amount that members actually pay for their specialty drug filled through Fairview Specialty Pharmacy, not the total cost of the drug, will apply to their plan's deductible and/or out-of-pocket maximum. The remaining amount paid through the savings card will not be applied to the deductible and/or out-of-pocket maximum. The drug discounts themselves will continue unchanged.
Medica is notifying members who have recently used a savings card but have not yet met their out-of-pocket maximum limit to let them know that a change will begin on July 1. However, Medica will not notify members who have used a discount card and have met their limit. No retroactive out-of-pocket changes or adjustments will be made.
See more about this change (under "Specialty Drug Program"). Details will also be available to IFB members at medica.com.
Effective September 1, 2017:
Upcoming changes to Medica Part D drug formulariess
Medica posts changes to its Part D drug formularies on medica.com prior to the effective date of change. The latest lists notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective September 1, 2017. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. These latest changes will be posted soon. View the latest Medicare Part D drug formulary changes.
Medica periodically makes changes to its Medicare Part D formularies: the Medica Prime Solution® Part D closed formulary (4-tier + specialty tier) and the Medica DUAL Solution® Part D closed formulary. The Medica Medicare Part D drug formularies are available online or on paper:
Medication request forms
A medication 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 submit an exception form or call CVS Caremark.
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Network News
Effective September 1, 2017:
Medica to implement commercial, PPO fee schedule updates
Effective September 1, 2017, Medica will implement standard fee schedule updates for commercial products in both its metro and regional service areas. The Medica SelectCare℠ and LaborCare® standard fee schedules will be updated at the same time — i.e., for the Medica preferred provider organizations (PPOs).
These updates will result in an overall estimated increase to physician reimbursement. As always, the effect on reimbursement will vary by specialty and the mix of services provided.
Various fees for services without an assigned Centers for Medicare and Medicaid Services (CMS) relative value unit (RVU) will also be updated. Examples of these services include labs, supplies/durable medical equipment (DME), injectable drugs, and immunizations. This non-RVU update will also have an impact on physician reimbursement that will vary based on specialty and mix of services provided.
Medica will apply CMS-based RVU methodology where applicable. The CMS Medicare physician RVU file (National/Carrier) is available online from CMS.
Providers who have questions may contact their Medica contract manager.
Effective October 1, 2017:
Medica to revise fee schedule for MHCP products
Effective with October 1, 2017, dates of service, Medica will implement a revised fee schedule for its enrollees in Minnesota Health Care Programs (MHCP). The revised Medica MHCP fee schedule will be based on the fee schedule used by the Minnesota Department of Human Services (DHS) to pay providers for services provided to its fee-for-service enrollees. The effect on reimbursement overall for specific clinics will vary by specialty and the mix of services provided.
Providers who have questions may contact their Medica contract manager.
Effective September 1, 2017:
Medica to update ancillary fee schedule for all products
Effective September 1, 2017, Medica will implement standard ancillary fee schedule (reference guide) updates for all Medica products. This fee update will have an impact on the following provider types: durable medical equipment (DME), home health care, home infusion therapy, public health, skilled nursing facility (SNF) and transportation.
The effect on reimbursement due to this fee schedule update will vary by provider type and the mix of products or services provided. Providers who have questions or would like a copy of their updated fee schedule may contact their Medica contract manager.
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Administrative News
Provider College administrative training topic for July
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
"Skilled Nursing Facilities and Care Coordination" (class code: SNFCC)
In this course, providers will learn about the Medica Care System’s updated benefit determination process as it relates to skilled nursing facilities (SNFs). Participants will review “trigger events,” skilled nursing guidelines, and skilled rehabilitation information, as well as updated communication forms required for the Medica Care System. Time will also be provided for questions and answers as part of this discussion.
Class schedule
| Class code |
Topic |
Date |
Time
|
Notes |
| SNFCC-WJul |
Skilled Nursing Facilities and Care Coordination |
July 25 |
10-11am |
Class code with “WJul” means offered via webinar in July |
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.
Registration
The registration deadline is one week prior to the class date. Register online for the session above.
Effective September 1, 2017:
Medica to implement new reimbursement policy
Medica will soon implement the new reimbursement policy indicated below, effective on or after September 1, 2017, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Inpatient hospital readmissions
Medica will align with the Centers for Medicare and Medicaid Services (CMS) and implement a new policy effective on or after September 1, 2017, dates of service, to address reimbursement of same-day readmissions to the same hospital (same provider number) billed on a UB-04 claim form or its electronic equivalent or its successor form.
According to Medica’s Inpatient Hospital Readmissions policy, readmission to the same hospital on the same day as discharge for the same, similar or related condition is considered to be a continuation of treatment. In such cases, the hospital must combine the initial and subsequent stays onto a single claim. Separately submitted claims will be denied.
If the reason for readmission does not relate in any way to the initial admission, separate claims for the initial and subsequent stay may be submitted. Condition code B4 (“Admission Unrelated to Discharge on Same Day”) must be included on the readmission claim in order for the readmission claim to be considered for reimbursement.
This new policy will apply to Medica commercial, individual and family business (IFB) and Minnesota Health Care Programs (MHCP) products. Medica may request medical records pertaining to initial and readmission stays.
Readmissions involving transfers or discharge against medical advice will be excluded from this policy.
This new policy will be available online or on hard copy:
Reminder:
Best practice on using taxonomy codes on claims
Medica encourages providers to use taxonomy codes on claims whenever these codes have an impact on claims processing. Doing so supports best practices for claims submission, as outlined by the Minnesota Administrative Uniformity Committee (AUC). Taxonomy codes reflect the 10-digit alpha/numeric codes that enable providers to identify their specialty at the claim level. When providers include the taxonomy codes, it results in more accurate and faster claims processing, so Medica can make payments to providers more quickly.
A good example of where this helps is urgent care, as these physicians often practice in both urgent care and another specialty.
Loops, segments and elements for taxonomy codes
Taxonomy codes should be submitted according to AUC best-practice guidelines:
- 837P: 2000A, PRV (Billing/Pay-To Provider) 2310B, PRV (Rendering Provider) 2420A, PRV (Rendering Provider)
- 837I: 2000A, PRV (Billing/Pay-To Provider) 2310A, PRV (Attending Provider)
See more details from the AUC about the submission of taxonomy codes.
Reminder:
Providers need to regularly update demographic data, per CMS
As previously published, Centers for Medicare and Medicaid Services (CMS) rules require additional information for Medica’s provider directories as well as regular updates to them. The new rules state, among other things, that provider directories be accurate and updated regularly, in compliance with CMS guidance. As a result, providers need to update their practitioner and site-level demographic data in Medica’s directories as soon as they know of a change to that data, and to regularly review their demographic information for accuracy. See more details.
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SelectCare/LaborCare News
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (June 2017). Highlights that may be of interest to LaborCare® network providers include:
- Premium Designation annual assessments mailing out to physicians — scheduled for July 2017
- Prior authorization no longer required for certain heart procedures — scheduled for July 2017
- New prior authorization requirement for cancer patients — scheduled for October 2017
- New prior authorization requirement for genetic and molecular testing — scheduled for October 2017
- Revision to Consultation Services Policy — scheduled for October 2017
View the June 2017 UHC provider bulletin.
Effective August 1, 2017:
Pipe Trades union terminates its contract as LaborCare TPA
Pipe Trades Services MN has given notice that it is terminating its third-party administrator (TPA) contract with LaborCare®. This change will be effective as of August 1, 2017. LaborCare will continue to process claims with dates of service prior to August 1 during a claims run-out period through December 31, 2017. Questions on claims, appeals or other issues for dates of service on or after August 1 should be directed to Pipe Trades. For information about claims and appeals, providers can refer to the Pipe Trades website or call 651-917-8058.
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