Vital Signs - Health First
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MARCH 2018
Vital Signs
Provider News and Updates
SUMMER 2019
Pharmacy
Binge Eating Disorder
Binge eating disorder can be a challenge to diagnose and treat. The evaluation
ISSUE HIGHLIGHTS: of binge eating disorder includes a thorough history and physical to include
attitude toward body weight and shape, self-esteem and evaluation for other
Binge Eating Disorder
comorbid psychiatric disorders, such as depression or substance abuse. The
Provider Directory Updates standard and first-line therapy treatment consists of psychotherapy to include
cognitive behavioral therapy (CBT) or interpersonal therapy. Medication
Medical Record Requests: is considered a second-line therapy and may be used in conjunction with
HEDIS and Risk Adjustment psychotherapy.
Elements Five, Six and Seven In patients with binge eating disorder, it is recommended to use selective
of an Effective Compliance serotonin reuptake inhibitors (SSRIs) because of efficacy and tolerability. In
Program patients with binge eating disorder who do not respond to two courses of an
Clinical Documentation SSRI, then a trial of an either an antiepileptic (e.g., topiramate) or a medication
Integrity (CDI) Program typically used for attention deficit hyperactivity disorder [e.g., Vyvanse (generic
Updates name lisdexamfetamine)] is recommended. However, the potential for adverse
effects limits the utility of these two drugs; topiramate can cause cognitive
Out-of-Network (OON) Labs impairment, paresthesias and somnolence, whereas lisdexamfetamine can
cause anorexia, gastrointestinal distress, headaches, insomnia and sympathetic
How to Improve Patient
nervous system arousal (e.g., anxiety and dry mouth). In addition, central
Experience
nervous system stimulants such as lisdexamfetamine have a high potential for
Bogus Telemarketing: abuse or dependence.
Prescription Requests Target We wanted to include some clarification on the criteria for Vyvanse:
Floridians via Facsimile
Covered Use: All FDA-approved indications not otherwise excluded
Privacy Required Medical Information: Diagnosis of one of the following: A) ADHD
and tried and failed two alternative medications that are FDA approved for the
treatment of ADHD; or B) Moderate to severe binge eating disorder AND the
Health First Commercial Plans, patient is receiving psychological counseling AND the patient must have tried
Inc. is doing business under the and failed at least two antidepressant medications.
name of Health First Health Plans.
Age Restrictions: ADHD: Must be older than 6 years of age; BED: Must be 18
Health First Health Plans does not
years of age or older
discriminate on the basis of race,
color, national origin, disability, Prescriber Restrictions: BED: The medication must be prescribed by a
age, sex, gender identity, sexual psychiatrist or a psychiatric specialist.
orientation, or health status in Coverage Duration: 12 months
the administration of the plan,
Source:
including enrollment and benefit
UpToDate, “Binge eating disorder in adults: Overview of Treatment”
determinations.
Credentialing
Log in to our secure Provider Directory Updates
provider portal at Provider Directories are an important tool used by beneficiaries, and the
accuracy of the data is critical to helping beneficiaries make educated decisions
myHFHP.org/login about their Medicare Advantage (MA) plan choices and medical care. For that
05232019reason, the Centers for Medicare & Medicaid Services Contact us at HFHPmedrec@Health-First.org or Kelly
(CMS) continuously monitors the accuracy of Provider Small directly at 321.434.4625 to set up access to your
Directory data. EMR or our online file transfer system, or to schedule on-
site pickup.
CMS recently expressed concern about the lag time
between the effective date for provider terminations
and the notification date to the plan. Not only is the Compliance
gap an indicator to CMS about underlying issues, but,
most importantly, that the Provider Directories are not Elements Five, Six and Seven of an Effective
accurate and that the members are not receiving timely Compliance Program
communications related to their care. In Chapter 21 of the Medicare Managed Care Manual,
the Centers for Medicare & Medicaid Services (CMS)
It is important that providers and office staff practice requires each Medicare Advantage Organization (MAO) to
and enforce the CMS policy related to the accuracy of adopt and implement an effective compliance program.
Provider Directories. At the time your office is made aware As a MAO, Health First Health Plans has a compliance
of a change, including the termination of a provider, program that includes measures to prevent, detect and
please notify the plan immediately by contacting the correct Part C or D program noncompliance as well as
Credentialing Office at HFHPcredentialing@HF.org or fraud, waste and abuse.
321.434.4348.
Chapter 21 identifies seven elements, listed below, that
provide an outline for each compliance program:
Medical Record Requests
Elements of an Effective Compliance Program
Medical Record Requests:
HEDIS and Risk Adjustment Element 1 Written Policies, Procedures and Standards
In an effort to streamline the records retrieval process for of Conduct
our providers, HFHP has implemented an internal record Element 2 Compliance Officer, Compliance
retrieval team. HFHP Record Acquisition Coordinators Committee and High-Level Oversight
will be dispatched to handle all Brevard County requests, Element 3 Effective Training and Education
allowing our team to build relationships with our
Element 4 Effective Lines of Communication
providers and offer contact continuity. Our vendor partner,
CIOX, will continue to handle requests outside of Brevard. Element 5 Well-Publicized Disciplinary Standards
There are multiple record requests annually, each Element 6 Effective System for Routine Monitoring,
affecting a different area of regulatory need and health Auditing and Identification of Compliance
plan performance, including: Medicare Advantage Risks
Risk Adjustment program beginning each August, the Element 7 Procedures and System for Prompt
Affordable Care Act (ACA) Risk Adjustment in February, Response to Compliance Issues
and HEDIS Season record requests and RADV regulatory
audits, which occur twice annually. We have worked In our Fall and Winter Newsletters, Health First Health
to streamline our request, combining them whenever Plans, Compliance gave an in-depth look at elements one
possible, such as the recent combination of the ACA through four. In this newsletter, we will provide an in-
Risk Adjustment Requests with HEDIS requests. The depth look at elements five, six and seven.
combination, along with the implementation of an The fifth element of an effective compliance
internal team, will contribute to reducing disruption in program is Well-Publicized Disciplinary Standards.
your patient care. We appreciate your cooperation while Health First Health Plans has complied with this element
we gather records to reflect the great care we know you by:
are providing to your patients and our members. ¡ Having a Code of Ethics and Business Conduct
To make participation easier, we have several options to HF.org/about_us/code_of_ethics.pdf; and
submit charts: ¡ Having policies and procedures relating to identifying
1. Direct EMR/EHR access and reporting potential noncompliance or unethical
2. Online file transfer behavior, as well as policies and procedures to resolve
3. On-Site pick-up noncompliance and to effectively enforce the standards
4. Secure email at HFHPmedrec@Health-First.org if unethical behavior is determined.
5. Fax — 321.339.1941 The sixth element of an effective compliance
6. Mail — Health First Health Plans program is an Effective System for Routine
ATT: Medical Records Retrieval Monitoring, Auditing and Identification of
6450 U.S. HWY 1 Compliance Risks. Health First Health Plans has complied
Rockledge, FL 3295with this element by: the CDI Program into your daily workflows. The most
¡ Conducting an annual Risk Assessment; common request was for less paper. In response, the 2019
¡ Routinely monitoring or auditing internal functions of Program will be rolled out with a web-based platform for
the Health Plan; and ease of submissions, tracking and reporting from all sides.
¡ Routinely monitoring or auditing external functions We are hopeful that this new platform will help with day-
performed by vendors. to-day task of keeping up with your member’s care gaps
and documentation opportunities. We will see you soon.
The seventh element of an effective compliance
program is Procedures and System for Prompt Again, thank you for all of your participation and efforts
Response to Compliance Issues. Health First Health to better our members’ care, and we look forward to
Plans has complied with this element by: continued success in 2019.
¡ Having policies, procedures and a system to receive,
Any questions or issues, please feel free to contact us at
record and promptly respond to compliance questions
1.877.238.9046 or ClinDoc@Health-First.org.
or reports of suspected noncompliance. Team members,
providers and vendors can send compliance questions or
concerns to: HFHPComplianceTeam@Health-First.org. Out-of-Network (OON) Labs
As a partner in Health First’s pursuit of being fully Managing patient referrals according to the unique rules
compliant with all state, federal and regulatory of multiple payers is a challenging but necessary service.
requirements, it is suggested that your organization: When plan rules are not followed, this can result in
¡ Create and implement a code of ethics unnecessary costs and stress to members and can increase
¡ Create and implement policies and procedures which the overall cost of care. When a provider refers a member
identify or establish standards to a laboratory that does not participate with Health First,
¡ Encourage participation in compliance and then the member could be responsible for the entire cost of
enforce those standards communicated in your code of the service, or, if out-of-network benefits are available,
ethics and policies and procedures incur unnecessary additional expenses.
¡ Implement a system for routine identification and Alignment with referral requirements, including the use
monitoring of compliance risks of network providers and obtaining authorization when
¡ Investigate potential compliance problems when they needed, will ensure effective healthcare delivery and the
are identified and correct such problems promptly and highest member satisfaction. Please contact us if you have
thoroughly to reduce the potential for reoccurrence questions about plan rules or participating laboratories.
These are just three of the seven elements, feel free to
read the Fall and Winter Newsletters or contact the Health Patient Experience — CAHPS
First Compliance Department to gain more information
about the other four elements or about implementing How to Improve Patient Experience
your own compliance program. Reach them at Good communications can improve health outcomes and
HFHPComplianceTeam@Health-First.org. member experiences, which lead to higher CAHPS scores
for Providers and the Health Plan.
Risk Adjustment Begin by adopting a Customer-First approach:
Acknowledge, Listen and Consult, Take Ownership,
Clinical Documentation Integrity (CDI) Manage Expectations, and Follow Through
Program Updates
The 2018 CDI Program is wrapping up soon, and we
In your front office:
¡ Acknowledge your customer
would like to extend a huge thank you to all of the
¡ Answer the phone promptly and politely using a
providers, office staff and leaders who were involved in
consistent greeting
submissions; we had a tremendous response this year.
¡ Example: “Thank you for calling Happy Hills
In total, we received 5,406 CDI Records to close HEDIS
Medical Office. My name is Katie. How may I help
care gaps, with a 64% compliance rate, and for Risk
you?”
Adjustment, there were 16,380 total records received,
¡ Make eye contact and greet customers promptly,
with 70% compliance. Final reviews are complete — our
even if you have other tasks to complete prior to
auditors have worked diligently to complete them — and
helping them
you should have received your final bonus for compliant
¡ Take Ownership and Manage Expectations
submissions around the end of April or the beginning of
¡ Outreach to customers in advance of their
May.
appointment if a significant delay occurs
We are excited to be rolling out the 2019 Program. We ¡ Advise of the estimated wait time
received a ton of helpful feedback from providers, staff ¡ Communicate updates and delays to customers
and others in order to improve processes and help fit waiting longer than advised¡ Offer drinks or snacks, if possible Special Investigation Unit
¡ Manage-up the provider to improve patient trust and
perception Bogus Telemarketing: Prescription Requests
¡ Example: “Dr. Murphy will be with you shortly. Target Floridians via Facsimile
You’ll find him to be very sensitive about properly Facsimile prescription requests, sometimes referred to as
addressing any pain you may experience during pharmacy telemarketing schemes, have been very active
the procedure.” lately in the Central Florida area, hitting our provider
¡ Consult and Follow Through offices. Over the last two years, we have seen potentially
¡ Ask the patient about their scheduling preferences fraudulent faxed prescription requests for excessive
¡ Be considerate when leaving voice message about diabetic supplies and high-cost, compounded pain creams
our need to change an appointment date/time; offer for our members. As the Health Plan has implemented
tentative new appointment but ask patient to call policy changes and pre-authorizations for drugs involved
back to confirm, if convenient in the initial stages of this scheme, we have seen a shift of
¡ Appointment reminders — ask for your patient’s faxed prescription requests for other drugs.
preference: call, text or email
¡ Schedule a follow-up during check-out These pre-printed prescription forms will be faxed to the
member’s physicians’ offices in hopes that the office is far
In your exam room: too busy to review, and the provider signs the request.
¡ Manage Expectations The member’s plan is billed excessive amounts for these
¡ Make a positive statement about the provider or drugs and, in some cases, the member never receives any
clinical staff to improve patient trust and perception of the medications.
(Example: “I see you have an appointment with Dr.
Fleming. She’s an excellent doctor; her patients rave Physician offices can help in the fight against this scheme.
about her all the time. You are in good hands.”) Careful review of faxed prescription requests is essential.
¡ Advise of estimated wait time and check back with Be on the lookout for any prescription requests that
the patient regularly include:
¡ Set timeline for follow-up regarding test results ¡ Pre-printed prescription requests that are organized by
¡ Listen and Consult categories;
¡ Listen to the patient’s perspective; acknowledge and ¡ Pre-checked boxes for all drugs listed on request
validate the reason for the patient’s visit without regards for patient’s medical needs;
¡ Sit at eye-level with the patient while ¡ Excessive quantity of drugs and refill amounts; and
communicating; sitting improves the patient’s ¡ No pharmacy name or callback information will be
perception of the time you have spent with them listed on the prescription request
¡ Discuss any test results or other healthcare providers
who have treated the patient recently For more information about this scheme or to submit a
¡ Discuss the patient’s prescribed medications and any referral, contact Health First Health Plans’ Fraud, Waste
barriers or challenges to maintaining their health and Abuse divisions at SIUCompliance@Health-First.org
¡ Describe recommended treatment plan in layman’s or 321.434.3409.
terms, including explanation of procedure, screening,
test or surgery Privacy
¡ Follow Through
¡ Maintain communication between PCPs and Dozens of Chicago hospital staff fired for
Specialists improperly viewing Jussie Smollett’s records
¡ Communicate with referring physician about Dozens of nurses and other staff members at
treatment plan and scheduled appointments, Northwestern Memorial Hospital in Chicago were
keeping them involved in patient care, especially reportedly fired for improperly reviewing the medical
for complex cases records of actor Jussie Smollett, CBS 2 Chicago reports.
¡ Send a “thank you” note to referring physicians Three things to know:
¡ Provide quick and timely feedback to patient 1. Sources told CBS 2 Chicago the workers, including
regarding test results, follow-up with the lab if some nurses and other hospital staff, were terminated
results are not delivered in a timely manner earlier this year after gaining access to the actor’s
Please contact our Stars and Accreditation team at medical chart.
HFHPStars@HF.org with any questions or to share best 2. One nurse told CBS 2 Chicago she was fired after her
practices. shift Feb. 26 and escorted off of hospital property. She
told the publication she never accessed Mr. Smollett’s
records and had simply scrolled past them whilelooking for another patient’s name. The nurse said she was not asked any questions about the alleged incident before she was fired and was denied the chance to explain. 3. The nurse told the television station she plans to appeal the hospital’s decision and that several other staffers were similarly fired for simply scrolling past Mr. Smollett’s records. As a Health First associate, your access to patient’s records must be within your scope of work. Snooping is never acceptable and can result in corrective action, up to termination. For more information on Health First’s HIPAA program or to schedule a Privacy training for your department, please contact informationprivacy@HF.org.
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