presented by moda health · 2020. 7. 9. · eastern oregon membership. 92,245 9,878 commercial...
TRANSCRIPT
Presented by Moda Health
2016 Provider Workshop
• Moda Networks
• OEBB & PEBB Plan Changes
• Credentialing
• Primary Care Support
• Prior Authorizations updates
• Ensuring Accurate Claims
• Risk Adjustment
• Contacting Moda Health
Agenda
Moda Networks
266,403
42,269 46,763
Commercial Medicare Medicaid - EOCCO
Total membership
10,165
3,971
Commercial Medicare
Northern Coast membership
8,191
1,328
Commercial Medicare
Southern Coast membership
22,478
4,527
Commercial Medicare
Southern Valley membership
19,108
3,745
46,763
Commercial Medicare Medicaid - EOCCO
Eastern Oregon membership
92,245
9,878
Commercial Medicare
Portland Metro membership
4,194
827
Commercial Medicare
The Gorge membership
21,943
2,660
Commercial Medicare
Central Oregon membership
37,891
4,649
Commercial Medicare
Willamette Valley membership
32,935
6,776
Commercial Medicare
West Central Valley membership
Affinity(Individual plans)
Connexus(Large and small group
employer plans)
Beacon(Individual plans)
Summit(Large and small group
employer plans)
Synergy (Large and small group
employer plans)
EOCCO(Medicaid)
Medicare Advantage
2017 Network overview
2017 Individual Network lineup
BeaconSelect Western Oregon
counties
AffinityEastern Oregon
counties
Clackamas, Clatsop, Columbia, Coos, Curry, Hood River, Jackson, Josephine, Marion,
Multnomah, Polk, Wasco, Washington and Yamhill
counties
Baker, Grant, Gilliam, Harney, Lake, Malheur,
Morrow, Sherman, Umatilla, Union, Wallowa
and Wheeler counties
Effective January 1, 2017
What is different?• Smaller geography• Clinically integrated network, which includes nine health system
partners and their referring providers• Simplified plan design options (1 bronze, 3 silver and 3 gold)• PCP selection is required
Beacon Network
Beacon Network
1. Adventist Health
2. Asante
3. Bay Area Hospital
4. Columbia Memorial Hospital
5. Mid-Columbia Medical Center
6. Oregon Health & Science University (OHSU)
7. Salem Health
8. Tuality Healthcare
9. Willamette Valley Medical Center
1
2
3
4
5
6
7
8
9
2
Effective January 1, 2017
What is different?• Replaces Beacon Network in Eastern Oregon• Mirrors EOCCO & Summit Network geography• PCP selection is required
Affinity Network
1. Blue Mountain Hospital District
2. CHI St. Anthony Hospital
3. Good Shepherd
4. Grande Ronde Hospital
5. Harney District Hospital
6. Lake Health District
7. Morrow County Health District
8. Saint Alphonsus – Baker City
9. Saint Alphonsus – Ontario
10. Wallowa Memorial Hospital
Affinity Network
1
2
4
5
6
7
8
103
9
2017 Employer group network lineup
Connexus
Statewide
SummitEastern Oregon counties
SynergyWestern Oregon counties
Small group
Connexus
Statewide
SynergyWestern Oregon counties
SummitEastern Oregon counties
Large group
Partnership between Moda Health and Providers to achieve Triple Aim goals
Synergy/Summit networks
Key tenets
Population health management Provider/payer business model characterized by partnership Sharing risk, data and best practices PCPCH support
Better health
Better care
Better value
1. Adventist Health
2. Asante
3. Bay Area Hospital
4. Columbia Memorial Hospital
5. Legacy Health
6. Mercy Medical Center
7. Mid-Columbia Medical Center
8. Oregon Health & Science University (OHSU)
9. PeaceHealth
10. Salem Health
11. Samaritan Health Services
12. Santiam Hospital
13. Silverton Hospital
14. Sky Lakes Medical Center
15. St. Charles Health System
16. Tillamook Regional Medical Center
17. Tuality Healthcare
Synergy Network
15
6
78
9
1
2
2
3
4
10
11
14
15
1111 15
15
1716
13
12
1. Blue Mountain Hospital District
2. CHI St. Anthony Hospital
3. Good Shepherd
4. Grande Ronde Hospital
5. Harney District Hospital
6. Lake Health District
7. Morrow County Health District
8. Saint Alphonsus – Baker City
9. Saint Alphonsus – Ontario
10. Wallowa Memorial Hospital
Summit Network
1
2
4
5
6
7
8
103
9
Rose City Network
• Discontinued as of 12/31/16
Community Care Network
• Discontinued as of 12/31/16
Discontinued networks
OEBB Plan changes
• Travel network is changing to First Health Network effective October 1, 2016
• Synergy Network expanded into Crook, Deschutes, Douglas and Jefferson counties
• As a reminder, Synergy/Summit members must choose a Moda Medical Home for primary care and preventive services
OEBB Medical plan changes
Plan options have been consolidated and renamed
OEBB Vision plan changes
Opal$600 benefit
max
Pearl$400 benefit
max
Quartz$250 benefit
max
PEBB Plan changes
• Marion County (through the YMCA)
http://theyonline.org/programs-services/ymcas-diabetes-prevention-program
• Polk County (through the YMCA)
http://theyonline.org/programs-services/ymcas-diabetes-prevention-program
• All Eastern Oregon counties (through CCNO)
http://www.ccno.org/index.cfm?fuseaction=dep_intro&dept_id=11
Diabetes Prevention
Program
PEBB Plan changes
PEBB is expanding Synergy into the following counties for 1/1/17:
• Hood River
• Jackson
• Josephine
• Klamath
• Deschutes
• Jefferson
• Crook
• Douglas
• Coos
• Curry
PEBB Plan changes
Credentialing
• Effective 4/25/2016, credentialing applications for Moda are processed through Medversant
• To use ProviderSource™, simply go to modahealth.providersource.com and follow the steps to submit your information
• For general credentialing questions, you may continue to contact Moda Health Credentialing Department directly at 855-801-2993, or modahealth.com/medical/credentialing/overview
Medversant technologies
Credentialing is now an online process via Medversant
Technologies ProviderSource™
platform
modahealth.com/medical/credentialing/overview
Credentialing
Moda Primary Care Support
What is Passport to Health?
Innovative healthcare program
Provides support with health conditions
Program varies based on employer
group
Targets high-risk members
Email [email protected] to learn more
Who has a Passport to Health Program?
Program name Employer group Engagement level
Healthy Foundations City of Portland High
Passport to HealthSalem Health
PCC Structurals High
Comprehensive Coordinated Care (C3)
Program
OEBBPEBB
Moderate
Passport to Health engagement
Online tools Health style assessment
Patient-centered primary care home
integration
Access to a health advocate
Concierge clinical services
Face-to-face community-based
care team
2017 OHA Patient-Centered Primary Care Home revisions
• The Oregon Health Authority’s Patient-Centered Primary Care Home program works with stakeholders across Oregon to set standards for what high-quality, patient-centered primary care looks like.
• New criteria effective January 2017
• PCPCH Medical Home tiering expanded to 5 levels
• Further differentiates advanced Medical Home practices
• Payment structure for additional tiers will be communicated to participating Synergy, Summit, and EOCCO certified Medical Home providers
• *More information can be found at www.oregon.gov/oha/pcpch/Pages/index.aspx
Primary care transformation
• Moda Health and EOCCO were each selected as a payer partner in the Comprehensive Primary Care Plus Program (CPC+).
• Comprehensive Primary Care Plus (CPC+) is a national advanced primary care Medical Home model that aims to strengthen primary care through:• Multi-payer payment reform• Care delivery transformation
• Multi-payer payment redesign will give practices greater financial resources and flexibility to make investments to achieve better care, smarter spending and healthier people. Key tenets include: • Care management fee• Quality incentive• Alternate payment model for advanced practices, beginning in 2018
• Details related to Moda and EOCCO’s CPC+ program will be communicated to participating practices as soon as the CMS practice selection process is complete.
• Program is effective January 1, 2017
CPC+
Prior authorization updates
• MagellanRx reviews injectable medication prior authorization requests performed in an outpatient facility, a patient’s home, or in a physician’s office
• To register with MagellanRx and submit prior authorization requests or re-authorizations, please visit www.magellanrx.com
More information on the MagellanRX injectable medication program can be found at www.modahealth.com/medical/injectables/
MagellanRx
Moda has partnered with MagellanRx to assist
in medical pharmacy management through
the provider administered injectable
medication program
Cinqair
Empliciti
Kanuma
Onivyde
Darzalex
Nucala
Portrazza
Bendeka
• Applies to all fully insured Commercial membership
• Select ASO, Medicare Advantage, PERS Medicare and non-Medicare membership
We will expand this initiative to cover and include specialty and injectable medications in the future
Tecentriq
Effective October 1, 2016, Moda is expanding its claim check program for injectable and/or infusion medications:
MagellanRx updates
Ensuring accurate claims
PIP examines and flags potential claims daily prior to payment
Captures license status and provider records
This program is designed to review healthcare claims that may represent questionable or abusive billing practices
Provider Integrity Program (PIP)
TruClaim
• TruClaim is a rigorous daily audit to detect and avoid claims billed inaccurately
Clinical editing
Applies clinical logic edits if a claim is billed inaccurately. For example: a modifier is missing, wrong modifier was attached or primary code if the provider only bills with an add-on code
Effective September 1, 2015:
Complete NDC information is required on all professionally administered medication claims billed to Moda for the Oregon Health Plan (Medicaid), Medicare and Commercial Members.
National Drug Codes (NDC) Policy
Required:
Professional office services
Not required:
Home care setting services
Outpatient services
Inpatient services
Effective with dates of service January 1, 2017, two major CMS/DMAP diagnosis coding requirements will be applied to all Commercial claims
ICD-10 Diagnosis requirements
Diagnosis codes must be complete, valid and have all required digits/characters
• This requirement applies to all diagnosis codes billed in any position on all claims in all settings from all provider types
Certain diagnosis codes are not eligible to be reported in the principle diagnosis field
on facility claims
• These include, but are not limited to, manifestation diagnosis codes
• CMS/DMAP identifies the specific diagnosis codes that are unacceptable as a principle diagnosis
Risk adjustment
Risk adjustment is the process that CMS uses to reimburse Medicare Advantage and Affordable Care Act plans
• Payment is based on predicted patient health status and plan membership demographics
• Payment is prospectively risk-adjusted based on burden of disease
• Accurate coding ensures that Moda receives the appropriate level of payment for the risk of its membership
What is risk adjustment?
Medical record documentation dictates which
ICD-10 (diagnosis) code is assigned
Chronic
ICD-10-CM diagnoses map to HCCs (Hierarchical
Condition Categories)
The HCC category assigned
corresponds to a risk score
Accurate data is gathered from the thorough and accurate annual reporting of provider’s face-to-face visits with patients
How is risk adjustment determined?
Documentation/coding examples
Documentation within Annual Exam: Amputated R second toe
• ICD-10: Z89.421 – Acquired absence of other right toe
• MA HCC: 189
• ACA HCC: 254
Documentation within HPI: Patient not bothered by her colostomy
• ICD-10: Z93.3 – Colostomy status
• MA HCC: 188
• ACA HCC: 253
Documentation within A/P: CKD, stage 4 (or severe)
• ICD-10: N18.4 – Chronic kidney disease, stage 4
• MA HCC: 137
• ACA HCC: 188
Contact information
Provider Relations Consultants
Medical Provider Configuration (demographic updates)[email protected]
Medical Provider Relations or Contracts [email protected]
Moda Customer ServicePhone 503-243-3962Email [email protected]
Prior AuthorizationsPhone 503-243-4496 Toll-free 800-258-2037
CredentialingPhone 855-801-2993Email [email protected]
Need to contact us?
