From the Desk of Dr. Imad Mansoor, Chief Medical Officer
August, 2010
High Tech Imaging Authorization through AIM:
American Imaging Management (AIM) administers radiology preauthorization requirements through the Order Entry program. Many Health Plans, including Priority Health, HAP and BCBSM require AIM prior authorization for certain high tech imaging. (Priority Health offers an $8-per-order incentive for each successful submission completed online. BCN performs their own review of high tech imaging referrals and does not use the AIM prior authorization program.)
“Privileging” refers to physicians who are allowed to perform in-office diagnostic imaging exams appropriate to their specialty. Physicians who are not privileged should refer patients to a freestanding imaging center or hospital or to a specialist.
AIM’s Order Entry program for prior authorization can be accessed through the AIM website, www.americanimaging.net/services/OrderEntry or through each Health Plan’s website. Links to these websites are available at www.opns.org . Additional information can be found on the AIM website and will also be published in the OPNS NEWS third edition in September, 2010.
July 2010
OPNS current GENERIC DISPENSING RATES
OPNS BCN GDR through 04/30/2010 = 81 %
Compared to our Regional Average at = 82 %
OPNS BCBSM PGIP GDR 12/31/2009 = 66.1 % (adults)
= 67.9 % (pediatric, ages 0-17)
Compared to the All Group Average of 69.3 % and Control Group Average of 66.7 % for adults and the All Group Average of 67.8 % and Control Group Average of 69.3 % for pediatrics
ARE YOU DOING YOUR PART TO HELP IMPROVE THESE STATISTICS? Remember there are quality generic versions for many brand name drugs and more are becoming available each year. Where possible please help curb high co-pays and out of pocket expenses for your patients and also save health care dollars by prescribing generic medications whenever appropriate.
May 2010
Not only is obesity the second leading cause of preventable deaths in the United States in adults, the rapidly increasing prevalence of obesity in children has become one of the most challenging dilemmas facing pediatricians. Yet surveys indicate that many physicians do not routinely assess BMI during office visits or initiate weight management programs with their patients.
Beginning with HEDIS 2009, health plans nationally began measuring the rate at which health plan members:
- Ages 18-74 years who had an outpatient visit, had their BMI documented during the measurement year or prior year.
- Ages 3-17 years had had an outpatient visit with a primary care physician or OB/GYN and who had the following documented:
Evidence of BMI percentile documentation
Counseling for nutrition
Counseling fo physical Activity.
The only exception is pregnancy.
Visit Michigan Quality Improvement Consortium (MQIC) web site at http://www.mqic./com/guid.htm for a current Copy of clinical practice guidelines for management of adult and childhood obesity adopted by all Michigan Health Plans. Offices can also access FREE educational materials on obesity on the National Institutes for Healths website at http://.nhlbi.nih.gov/healh/public/heart/obesity/wecan/
Information extracted from Great Lakes Health Plan April 2010 newsletter: The Compass
April 2010
The number of physician practices implementing e-Rx continues to grow. Below are some important reminders.
- The definition of “e-Prescribing” is a prescription electronically generated from end-to-end.
- Not all scripts are eligible for submission using e-Prescribing software. Eligible scripts are those that are nationally recognized as having the ability to be submitted through e-Prescribing systems.
Although scripts for controlled substances are currently not eligible for e-Prescribing, recent notification from the Drug Enforcement Agency (DEA) indicates that following Congressional review, these regulations will be revised, allowing for electronic prescription of controlled substances in the near future. The complete document re: these revisions is available at www.regulations.gov.
In 2012, CMS will reduce Medicare payments to physicians who are not e-Prescribing.
All Medicare claims for e-Prescribing are required to use code G8553.
The 2010 Priority Health Partners in Performance incentive program is offering supplemental rewards for e-Prescribing. (See pages 51-52 of the 2010 PIP Manual by following the Health Plan News link on the OPNS home page)
OPNS offers training and support in the use of DrFirst. Favorable contract rates are available through OPNS. Please contact the office at 248-682-0088 Ext. 122 or 118 for more information
February 2010
Physician offices, please make note of this recent communication in regards to the disposal of out dated pharmaceuticals.
Health Care Law Alert
February 8, 2010
Rx for Trouble: Health Care Facilities Pay Fines for Flushing Drugs Down the Drain
In January 2010, New York Attorney General (AG) Andrew Cuomo announced settlements with two critical-access hospitals and three nursing homes, as part of an ongoing investigation of health care facilities that dump unused pharmaceuticals down their drains. The agreements call for the facilities to pay civil penalties for past violations, reimburse the state for the investigation, and implement pharmaceutical "take-back" programs for area households.
Health facilities, NY settle over drug-flushing
By MARCUS FRANKLIN, The Associated Press 4:11 PM Tuesday, January 12, 2010
January 2010
The new year provides an opportunity for physicians to review current office practices and address those that can be revised to improve both efficiency and quality of patient care. One area of focus to consider is the identification of performance measures required to fulfill quality improvement initiatives.
Through the collaboration of member physicians, health plan administrators and quality improvement experts, the Michigan Quality Improvement Consortium (MQIC) has established a standardized set of clinical practice guidelines and performance goals.
OPNS physicians are encouraged to review and implement the MQIC guidelines into their practice. Please visit www.mqic.com for additional information about this organization as well as a list of participating organizations and a complete set of the MQIC guidelines.
December 2009
OPNS Needs You – Every Prescription Counts!
You may not be able to help the Detroit Lions, but you can help OPNS.
Despite talented players in peak physical condition that have memorized the playbook, know their role and have the desire to win, somehow the Lions just fail to execute – and the losses count up.
The OPNS team continues to lose in the field of high cost prescription drug use. Please help our organization to reduce drug costs by keeping in mind the following:
Not all generics cost the same – remember to compare costs.
Lipitor, Nexium and Effexor SR are examples of high cost drugs heavily prescribed within the OPNS Network. Remember to consider the use of generic drugs that can be used in place of these and other costly brand drugs when appropriate.
Your colleagues are counting on you. Even one or two changes in prescriptions will make a positive difference.
October 2009
Patient Data Submission Deadlines - 2009
For Inclusion in 2009 incentive rewards programs, these health plans have announced the following DEADLINES for submission of Unmet Measures patient data:
BCN: All data for inclusion in the 2009
PRP (Physician Recognition Program) and the final Pay As You Go
payouts must be submitted to Health e-Blue by
January 15, 2010
Priority Health Plan: All data for the 2009 PIP (Partners in Performance) incentive program must be entered into Priority's Patient Profile data base by
February 26, 2010
Great Lakes Health Plan: Services credited for 2009 rewards incentives must be provided by
December 31, 2009 and billed for or forwarded to Christine
Hillman at: Fax 248-331-4519
in a timely manner.
Health Plan of Michigan: All data for 2009 rewards incentives must be billed for or submitted to
HPM Quality Services: Fax 313-202-0006 by
February 28, 2010
BCBSM (PGIP): All patient data is received via ongoing claims submissions and
MCIR.
Offices are reminded to bill for all services provided, whether you are paid for them or not, so health plans are able to capture data for quality reporting and incentive purposes.September 2009
Physician offices are eligible for additional reimbursement for “After Hours” services.
Guidelines and procedure codes are listed below.
99050: Services provided in the office at times other than during regularly scheduled business hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.
99051: Services provided in the office during regularly scheduled evening, weekend or holiday office hours, in addition to basic service.
BCN: “After Hours” - Appointments scheduled before 9:00 AM and after 5:00 PM (M-F), weekends and holidays.
99050 and 99051can be billed along with basic service codes and are eligible for additional payment.
BCBSM: “After Hours” - Appointments scheduled before 8:00 AM and after 5:00 PM (M-F), weekends and holidays.
99050 and 99051can be billed along with basic service codes and are eligible for additional payment.
Coverage depends on the group – not all contracts cover this service. Reference The Record: October 2008, p. 2; August 2008, p. 7; May 2008, p. 22 for further details or contact your provider consultant.
Priority: “After Hours” - Appointments scheduled before 8:00 AM and after 5:00 PM (M-F), weekends and holidays. 99050 and 99051can be billed along with basic service codes and are eligible for additional payment.
HAP: “After Hours” - Appointments scheduled between 6:00 PM and 10:00 PM (M-F), weekends and holidays.
Only procedure code 99051 can be billed along with basic service codes and is eligible for additional payment. Procedure code 99050 is not payable.
August 2009
A reminder that when comprehensive Well Child Visits are done simultaneously with a Sick Visit and documentation supports both services, the following rules apply to the plans listed:
BCBSM – Permits only one code billed for one date of service. Benefit plan determines whether Well Child visit is a covered service.
BCN – Bill for only one of the visits, preferably the Well Child Visit. BCN does not permit billing of both, but will pay for the Well Child Visit and will give credit to physician towards P4P bonuses.
GLHP - Bill for both visits, adding a Modifier 25 code to the sick visit code. This will credit the practice for a Well Child Visit and will give credit to physician towards P4P bonuses.
Health Plan of MI - Bill for both visits, adding a Modifier 25 code to the sick visit code. This will credit the practice for a Well Child Visit and will give credit to physician towards P4P bonuses.
Molina - Bill for both visits, adding a Modifier 25 code to the sick visit code.
Priority Health - Bill both as long as separately identifiable services. Modifier 25 will need to be appended to the problem oriented services (sick visit).
July 2009
Please be aware that health plans often monitor office coding practices. Correct coding, supported by sufficient chart documentation, is key to avoiding penalty.
June 2009
Important Well Child Visit Coding Information
OPNS is working hard on improving quality in the area of “Well Child” visits. We believe that our physicians are providing these services, but that they are not being captured by the plans because of coding oversight. By oversight, we mean that often a physician will perform a comprehensive exam when the patient is in for a sick child visit, especially if the child has not been in for a while, but will only code the sick visit code. Many plans are encouraging physicians to submit codes for both services on the same day. This insures that the plan captures the data in their claims system and the physician’s quality score is reflected more accurately. Outlined on page 5 are the coding rules by plan for “Well Child” visits.
When comprehensive Well Child Visits are done simultaneously with a Sick Visit and documentation supports both services, the following rules apply to the plans listed:
BCBSM – Permits only one code billed for one date of service. Benefit plan determines whether Well Child visit is a covered service.
BCN – Bill for only one of the visits, preferably the Well Child Visit. BCN does not permit billing of both, but will pay for the Well Child Visit and will give credit to physician towards P4P bonuses.
GLHP - Bill for both visits, adding a Modifier 25 code to the sick visit code. This will credit the practice for a Well Child Visit and will give credit to physician towards P4P bonuses.
HAP - Bill preferably the Well Child Visit. HAP does not permit billing of both, but will pay for the Well Child Visit and will give credit to physician towards P4P bonuses.
Health Plan of MI - Bill for both visits, adding a Modifier 25 code to the sick visit code. This will credit the practice for a Well Child Visit and will give credit to physician towards P4P bonuses.
Health Plus - Bill both as long as separately identifiable services. Modifier 25 will need to be appended to the problem oriented services (sick visit).
Molina - Bill for both visits, adding a Modifier 25 code to the sick visit code.
Priority Health - Bill both as long as separately identifiable services. Modifier 25 will need to be appended to the problem oriented services (sick visit).
May 2009
Generic Dispensing Rate continues to be an important issue these days.
OPNS hopes that the reports we send our physicians are of value in helping to make informed decisions on whether to change a patient from brand name to generic.
- BCN
- Current overall GDR is 77%
- The Regional Average is 79%
- BCBSM - PGIP
- Data from July 1, 2008 – December 31, 2008 overall GDR is 61%
- The Control Group shows 63%
- Priority
- Data from March 2009 overall GDR is 76.17%
- The Regional Average is 77.20%
We applaud all of our Network Physicians in their ongoing awareness regarding the importance of generic prescribing.