InsideCollaboration in Care: Value Based Purchasing Program ...............................................2

Phone Program .......................................................3

iCare Member Health Fair and Flu Clinic ................. 4 Clinical Practice Guidelines ...................................... 4 Provider Access Standards ...................................... 5 Prior Authorization Department Updates .................. 6

National Drug Code Units Required on Certain Claims ..................................................... 6

Attention all Free Standing and Provider-based Ambulances and Laboratories .................................. 7

Important Claims Information ................................... 7

Help Us Prevent Fraud, Waste and Abuse ............... 7iCare Compliance Program ...................................... 8Keep Us Informed About Changes ........................... 8Please Stay Informed ............................................... 8We Want to Hear From You! ..................................... 9

CareBulletinTHE LATEST NEWS AND INFORMATION FROM INDEPENDENT CARE HEALTH PLAN

FOR PROVIDERSFollow us

iCare Bulletin For Providers

www.icare-wi.org

September 2016

Potentially Avoidable Hospitalizations: Are They Really Avoidable?As providers of care for individuals with Medicaid and/or Medicare benefits, we all play a role in keep-ing the people we care for safe and as healthy and out of the hospital as much as possible. Individuals living with multiple chronic health conditions face a greater risk of hospitalization than those without chronic disease and are more likely to admit for conditions that are potentially preventable. This risk increases for dual eligible individuals of Medicare and Medicaid benefits who receive long-term ser-vices and supports, be they nursing home cares or community-based social services. At the end of the day, we know as providers many issues factor into whether a patient is admitted to a hospital, often a blend of socioeconomic barriers to care, patient preferences, challenges to the accessibility of ap-propriate outpatient care, lack of goal alignment between providers, hospitals and payers, and many others. In such a complex environment, can we as professionals accept accountability for the results of decisions that are (often) out of our individual control?

I had an epiphany about six years ago while in one of my first law classes. My professor, attempting to support the moral case for trans-parency and honesty in medical error to a group of skeptical physi-cians, nurses, and other health professionals, simply displayed a large chunk of Swiss cheese. James Reason’s highly acclaimed model of accidents (a.k.a., the “Swiss cheese model”) truly provides the frame-work for medical error, error that occurs largely because of multiple failures in organizational policy culminating in patient harm; i.e., errors causing harm are not usually the fault of only one person or process. Similarly, more than one deviation from the healthcare path leads to what could be an otherwise avoidable admission. In ethics, the social contract theory suggests morality rests on the premise that we accept rules of behavior when others in our community accept and follow the same rules. The classic example is stopping at a stop sign or red light. What else would compel us to stop if others didn’t agree to do so, as well? We rely on each other as a society to uphold the basic tenets of communal agreements and obligations.

As a society of healthcare providers, we too have an obligation to uphold, to protect our patients and the people who place their trust in our care and our expertise. We all have a role to play in preventing avoidable hospital admissions, be it to follow healthcare policies and procedures, to provide safe transitions of care, to actively seek new ways to educate patients and their families as needed, to actively

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Dr. Linda Ellis

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engage ourselves as providers to promote access to cares that if used would promote prevention of disease progression, or to consider all possible options for healthcare-related services when patients are not obvious candidates for hospital admis-sion. No panacea exists to prevent preventable admissions. Not one of us as an individual provider holds the key piece to this puzzle. By working together and each continuing our accountability to the health and wellbeing of our patients, I believe we can reduce preventable admissions and make a difference in health outcomes, especially for our most vulnerable Medi-care and Medicaid populations. Our health care community relies on our continued accountability in providing the best care possible for our shared patients; for those of us who have taken professional practice oaths, it is our ethical duty. As the Chief Medical Officer of iCare, I am committed to improving our efforts to reduce avoidable hospital admissions and thank each of you for your dedication to the same. Unfortunately, we all know more work needs to be done! I welcome your thoughts and suggestions for collaboration on this and other population health issues and look forward to hearing from you.

Warm regards,

Linda S. Ellis, MD, MJ, MA Chief Medical Officer

Collaboration in Care: Value Based Purchasing ProgramiCare Administrator Sandra Holmes visited the Progressive Commu-nity Health Center (CHC) in Milwaukee in early June to meet with their Chief Operating Officer Connie Debbink and Chief Medical Officer Dr. Allison Kos to go over iCare’s Value Based Purchasing (VBP) program. Attending the meeting with her was iCare Family Care Partnership Supervisor Juwania Keys, RN Care Management Supervisor Kristine Peterka, and joined by conference call, Director of Business Systems Emilie Polzin. The Value Based Purchasing Program is an ongoing out-reach program aimed toward facilitating collaboration between iCare and network providers in managing the health care needs of iCare members.

Holmes provided an overview of the iCare product lines and presented three VBP reports on member encounters with Pro-gressive CHC. The first two reports outlined the number of member encounters in 2015 with Progressive CHC, the practitioner seen by the member, listed the members’ care coordinator, and the date of the most recent encounter. A third report pro-vided details for emergency discharge (ED) and inpatient visits. In 2015 Progressive CHC experienced 124 inpatient stays and 25 readmissions within 30 days with iCare members. Holmes indicated that although the Centers for Medicaid and Medicare Services (CMS) target is six percent for readmissions, Progressive CHC’s range is comparable to other medical groups. Dr. Kos indicated that Progressive CHC primary care providers (PCP) would find it useful to receive communication from iCare Care Managers to assist in coordinating care with members.

The model of care and care coordination for Medicaid SSI and Medicare Advantage Special Needs Plan members, including the work of the specialty care management teams in post admission and post ED follow-up was described by Peterka. She pro-vided an overview of the care management case load, the risk assessment process and described the transition of care pilot program at St. Joseph Hospital. The pilot program entails implanting an iCare transition of care nurse at St. Joseph to meet with members, work with discharge planning staff, follow-up with the member after discharge and coordinate care with the PCP. Peterka went on to state, “We are really trying to ingrain in the nurses especially, that with that hospital discharge, trying to set up that initial appointment; making sure the PCP knows that they (the member) were at the hospital and that they have a discharge plan, and if they have one to pass it on.” Dr. Kos recommended that iCare nurses should share the appointment

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l-r: Juwania Keys, Kristine Peterka, Connie Debbink, Dr. Allison Kos, Sandra Holmes

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iCare Bulletin For ProvidersSeptember 2016

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date, hospital discharge summary and the medication list with the Progressive PCP after hospital discharge.

Keys described the model of care for the Family Care Partnership (FCP) program, including FCP team caseloads, the type of professionals on the inter-disciplinary team and their roles. She indicated that it is an intensive comprehensive case manage-ment program, where the FCP team is “getting involved with them right away, going out within 10 days of enrollment and making sure that whatever services they had prior to enrollment are continuing and . . . assessing them and getting future ser-vices implemented within those first 30 days, making sure we are addressing their health and safety needs . . . It’s really about the members and helping them meet their own long-term care and personal outcomes.” One change to the FCP program in transition of care is that the FCP nurses now visit members when they are in the hospital and the nurse practitioners see them when they transition to home within 3 days of discharge.

Holmes provided an overview of a report on member encounters at Progressive and the Healthcare Effectiveness Data and Information Set (HEDIS) completion measures for 2015. She indicated that comparisons of 2014 to 2015 completion rates showed that six measures had completion improvement and three measures were completed above target. There were four members who did not meet the Care of Older Adult Measures and Holmes wanted to know if there was a way to collaborate on hard-to-contact members. Dr. Kos indicated that sharing demographic data to help meet these measures would not be a problem. Holmes also went over Medicaid and BadgerCare Plus Pay for Performance measures (P4P), where Progressive CHS was at or above target on all measures.

So far this year, Holmes has had VBP program meetings with 18 Skilled Nursing Facilities (SNF), eight home health agencies and eight medical groups. Holmes indicated that in the next quarter, she is planning four more visits with SNFs and four HHA agencies. She also indicated that for the medical groups, iCare is working toward an incentive or bonus for completion of HEDIS measures. “The face-to-face meetings are an opportunity to share information about iCare’s mission, model of care management, the quality metrics and best practices that we have seen to complete the measures and improve the health care of our members. We have seen improvement in measure completion over time as a result of the program,” said Holmes.

Phone Program Provides Empowerment in Accessing ServicesiCare has partnered with enTouch Wireless to provide eligible Medicaid SSI members with a free smart phone and service through the Lifeline federal government pro-gram. Members who already have a Lifeline issued phone, that is not a smart phone, are provided with a free upgrade.

Lifeline is a government benefit program that provides discounts on monthly tele-phone service for eligible low-income consumers to help ensure they have the op-portunities and security that telephone service affords. This would include being able to connect to iCare, 911 services and community resources. enTouch Wireless repre-sents the Lifeline service in Wisconsin.

The program was started in July with a mailing to approximately 867 hard-to-con-tact members informing them of the new benefit provided by iCare. We chose this group of members for the first mailing to improve our ability to contact them in our care management efforts. A consistent obstacle for improving quality performance measures in managing the care of our members is the inability to contact them to let them know of preventive health incentives, remind them of doctor’s office visits or other care management techniques that could benefit their health. In September we expanded the program to all eligible members who are in the Wisconsin Medicaid program.

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FREEPHONE

iCare will provide a

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To obtain a phone, members are given the option to visit or call iCare, or contact enTouch by phone, website or by filling out an application. Eligible members who make an appointment and visit our offices in Milwaukee, Green Bay or Madison can sign up and obtain a phone on the same day. Those who choose to sign up by phone or go through enTouch will receive their phone within five days of being determined eligible.

Members who receive a free phone are given 250 minutes of monthly voice and text messages and 100 megabytes of monthly data usage. They have access to a national wireless network, free 411 calls, voicemail, the Internet, as well as the ability to send email. We have also given our members pre-programmed numbers to connect to iCare Customer Service, the Nurse Advice Line and access to a Community Resources phone line where they can call the Income Maintenance Consortia, Medicare Fee-for-Service Customer Serice, Automated Health Systems, ForwardHealth, MTM or the Where’s My Ride Line, and verify coverage eligibility without losing any of their minutes.

With the ability to connect to the Internet, receive emails and access community resources, members will have another means toward maintaining their independence and enhancing their quality of life. This initiative will also provide iCare with an ad-ditional option for contacting members to assist in their care management.

iCare Member Health Fair and Flu Clinic Coming SooniCare members will be able to obtain a flu shot, have their blood pressure checked, get tested for diabetes, have their medications reviewed with a pharmacist and get their body mass index measured at the Mem-ber Health Fair and Flu Shot Clinic being held on October 12-13, from 10 a.m. to 2 p.m. Members will also have the chance to sign up for a free smartphone, to meet with community health care partners, receive free give-away items and enter to win a raffle prize. Members should call iCare at 1-800-777-4376 to schedule an appointment for a flu shot.

Clinical Practice GuidelinesIndependent Care Health Plan is dedicated to enriching the quality of clinical care provided to our members by our staff and contracted providers. Clinical Practice Guidelines support clinical care providers in treating chronic disease, providing preventative care, and facilitating provider-member interactions.

All Clinical Practice Guidelines recommended by iCare are based on national medical association and health organization recommendations. Information provided in iCare’s policy applies to all clinical providers of care to iCare members and is reviewed annually and updated no less than every two years, or as national guidelines change. Updates to the Clinical Practice Guidelines in policy form are reviewed by iCare’s Credentials Review Committee at the quarterly meeting immediately proceeding any policy revision.

iCare’s Clinical Practice Guideline’s policy may be found on iCare’s website:

http://www.icare-wi.org/providers/guidelines.aspx

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iCare Bulletin For ProvidersSeptember 20164

Provider Access StandardsIndependent Care Health Plan has access standards that reflect contractual requirements as they relate to its contracted network providers. These standards are monitored to meet the anticipated needs of members and to define the procedure(s) used to monitor member access to primary care services, behavioral health services, and other member services.

Access Standards: Members have the right to be seen by a contracted network provid-er in a timely manner. Independent Care maintains an adequately sized network for all behavioral health, specialty, ancillary, and facil-ity based providers which are designed to allow maximum member access to specialized providers who can meet their complex and chronic health care needs. Members may be required to choose a Primary Care Provider depending on which line of business they are enrolled in.

Acute, Primary, Specialty Health Care Providers’ Access Guidelines:

• Preventive or routine asymptomatic appointments – No more than 30 calendar days• Routine, symptomatic, non-urgent office visits – No more than four calendar days• Urgent care – within 24 hours (same day if possible)• Emergent care – immediate

Behavioral and Mental Health Access Standards

• Routine office visit – No more than 30 calendar days• Post hospitalization follow up appointment- No more than 30 calendar days for a follow up mental health ap-

pointment with a mental health provider after an inpatient mental health stay• Urgent care – within 48 hours• Non-life-threatening-emergency – within six hours• Emergent care - immediately

Primary Dental Care Access guidelines for:

• Routine care – within 90 calendar days• Emergent care – emergency treatment is addressed within 24 hours after the request is received.

High Risk Prenatal Care Services Access Guidelines:

• A member must be seen within two weeks of the member’s request for an appointment; or• Within three weeks, if the request is for a specific HMO provider, who is accepting new patients.

Additional Guidelines Independent Care requires providers to have an after-hours access mechanism which provides coverage 24 hours-a-day, seven days-a-week. Office wait times for scheduled appointments should not exceed 30 minutes from the appointment time until the time seen by the health care provider.

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Prior Authorization Department Updates:Effective January 1st, 2016, ForwardHealth implemented changes to its coverage policy regarding testing for drugs of abuse. These requirements parallel the requirements for drugs of abuse testing in place for Medicare beneficiaries as established by the Centers for Medicare and Medicaid Services (CMS). In order to be compliant with both CMS’ and the State of Wisconsin’s benefit coverage policies, iCare has implemented a prior authorization requirement for all urine drug screens. While neither the State nor CMS requires prior authorizations for urine drug screens, both require documentation of medical necessity for the provision of benefits, including testing for drugs of abuse. iCare’s prior authorization process ensures medical necessity is met for all urine drug screen requests, promoting just and accurate access to healthcare resources. Medical necessity documentation for the completion of a urine drug screen request may include, but is not limited to, the following: relevant medical history, physical examination, risk assessment, treatment plans, and results of pertinent diagnostic tests or procedures. All requests must include a dated and signed member-specific order. As any other service requiring a prior authorization, iCare will not grant retro-authorizations for services rendered before the receipt of an approved prior authorization request. To view iCare’s prior authorization requirements click the following link: http://www.icare-wi.org/providers/authorization.aspx

New Prior Authorization Forms Are Here!! The Prior Authorization (PA) Department has updated the forms and streamlined the PA process. Please check iCare’s provider webpage at http://www.icare-wi.org/providers/authorization.aspx to access the new and improved PA request forms.

National Drug Code Units Required on Certain ClaimsThe Centers for Medicare and Medicaid Services (CMS) and the Wisconsin Department of Health Services (DHS) require that a National Drug Code (NDC) unit and number of units are provided on any claim line with a HCPCS code beginning with J or Q. The HCPCS J and Q codes include the majority of those drugs & biologics that should be reported with infusions, injections and supply codes. As of 8/1/2016 if a required NDC is not indicated on a claim submitted to iCare, or if the NDC indicated is invalid, the claim will be denied by iCare.

The links below you may find usefule in regards to NDC coding and requirements:

NDC/HCPCS Crosswalk – This is very helpful. You can use this to look-up the NDC codes:

https://www.dmepdac.com/crosswalk/index.html

DHS National Drug Codes Required on Claims for Physician-Administered Drugs:

https://www.forwardhealth.wi.gov/kw/pdf/2008-126.pdf

CMS National Drug Codes (NDCs):

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1234.pdf

www.icare-wi.org

iCare Bulletin For ProvidersSeptember 2016

Attention all Free Standing and Provider-Based Ambulances and LaboratoriesIndependent Care is experiencing an increase in reconsideration requests due to untimely submission of initial claims. As a reminder, iCare encourages providers to work with members to confirm enrollment information at the time of service. This will alleviate delays in claims submission and subsequent denials if claims are received after the timely filing deadline.

Important Claims Information

Claim Inquiries and Reconsideration Requests Independent Care strives to process claims in a timely and accurate manner. Quality is a top priority, however, should claim processing errors occur; our goal is to resolve the situation as quickly as possible. For claim status, iCare offers a provider portal that can be accessed by clicking here. Email netdev@icare-wi.org for more information. Customer Service is also available to assist you with your claim questions.

• By phone: Call Customer Service at 414-231-1029 • By Fax: 414-231-1094, Attention Operations

If you have a reconsideration request, you may submit the request in writing , clearly marked as a reconsideration, along with the claim number, member name and ID number, DOS and the reason for the reconsideration to:

Independent Care Health Plan P.O. Box 660346 Dallas, TX 75266-0346

Claim Appeals For information on how to submit a formal Claim Appeal, please see the Provider Reference Manual or check the iCare provider web page at http://www.icare-wi.org/providers/claimsprocessing.aspx.

Help Us Prevent Fraud, Waste and AbuseIndependent Care is committed to detecting, correcting, and preventing fraud, waste and abuse. Generally, fraud is the intentional submission of false information to a government program such as Medicare or Medicaid in order to get payment or a benefit. Waste is the over utilization of services, or other practices that result in unnecessary costs to a government program such as Medicare or Medicaid. Abuse involves payment for items or services when there is not a legal entitlement to that payment and the provider has not knowingly and or intentionally misrepresented facts to obtain payment. There are differences between fraud, waste, and abuse. Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and abuse may involve obtaining an improper payment, but does not require the same intent and knowledge.

If you suspect provider or member fraud, waste or abuse please report your concern online by clicking the “Report Fraud” link at the top of iCare’s home page, or send an email to compliance@icare-wi.org.

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iCare Bulletin For ProvidersSeptember 2016

iCare Compliance ProgramIndependent Care is committed to ethical behavior and full compliance with all laws and regulations that apply to our health care business. To demonstrate iCare’s commitment to the highest standards of integrity and business ethics, as well as compliance with all Medicare and Medicaid program requirements, we have implemented a formal compliance program. To learn more about iCare’s compliance program as well as any vendor compliance program requirements, please click on “Compliance Information” under the Provider Resource section of iCare’s website.

Keep Us Informed About ChangesThe following forms were updated to notify iCare of an address or affiliation change. We are asking providers that are not using the forms to use them immediately. The forms are located on the Provider home page at http://www.icare-wi.org/providers and can be accessed from the links below:

Change in Provider Address or Affiliation

• Provider Address or Demographic Change Notification• Provider Affiliation Change Notification

If you would prefer to send your changes in-mass on an electronic file, you can submit the file to netdev@icare-wi.org.

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iCare Bulletin For Providers

*Please Stay Informed*iCare has important information for providers at www.icare-wi.org/providers

Please see iCare’s Provider Reference Manual and Long Term Care Provider Reference Manual for important provider and member information.

Providers can find details on many topics such as:

• Clinical Practice Guidelines • Educational Webinars

• Reconsideration/Appeal Info • Prior Authorization Requirements

• Contract Changes • How to Submit a Claim

• Provider Alerts • Claims Processing Issues

September 2016

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We Want to Hear From You!Do you have news to share for future issues of the iCare Bulletin? If you have a patient or office success story, a procedural or administrative tip or other information that might be of interest to your fellow providers, please let us hear from you. Contact:

Derrick C. Lewis, Editordlewis@icare-wi.orginfo@icare-wi.org

The iCare Bulletin is published for providers of services to iCare members. For information about iCare, please call the following departments:

Customer Service: (414) 231-1029 - Customer Service Phone lines are at maximum usage from 11:30 a.m. to 1 p.m. For more prompt services, please call outside of this time, if possible. Customer Services hours are 8:00 a.m. to 5:00 p.m.

TTY: (800) 947-3529 or 7-1-1Voice: (800) 947-6644 or 7-1-1 Fax: (414) 231-1092Claims: (888) 333-6820Pharmacy Services: (414) 223-4847

E-mail: providerservices@icare-wi.org

Independent Care Health Plan1555 N. RiverCenter Dr. Suite 206, Milwaukee, WI 53212

414-223-4847

Mission StatementThe mission of iCare is to secure the wellness of persons with complex medical and behavioral conditions, respecting their dignity and the values of caring stakeholdersPurposeTo measurably improve the health of iCare members through personalized, sustained and integrated care coordination.VisioniCare is the national leader for advanced managed care programs that serve people with complex health and social needs.

www.icare-wi.org

iCare Bulletin For ProvidersSeptember 2016