Provider Network Newsletter
In This Issue
Why Coding is Key
Meet Melinda Wood
Tip to Speed Up Credentialing
Beacon Health Goes to Washington
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Issue: # 2June 2015
  
Greetings! 

It's hard to believe June is already here, kids are out of school for the summer and our social calendars are getting packed full of BBQs, hiking, and lots of outdoor fun!
  
Life at Beacon Health is always exciting and ever changing, much like the weather in Maine. We hope you have some wonderful plans to enjoy our beautiful state this summer with family and friends.
  
 If there's something we can help you with, please be sure to reach out to us. Please, consider us a resource.
  
Happy Summer,
  
The Beacon Health Provider Network Team

Acronyms of the Month

Because they're just a part of healthcare!

 

   

Can you decode the healthcare acronyms below?

  • ACO               _________________________________
  • TPA                _________________________________
  • NCQA            _________________________________
  • PHI                 _________________________________
  • CMMI             _________________________________

  Find the answers at the end of the newsletter.

Why Coding is Key to Getting Paid for

Providing High Quality Care

   

Proactively delivering consistent, personalized care not only makes good sense for our patients, it also keeps our doors open. So, how do 'risk scores' relate to providing excellent patient care?

 

No doubt, you've heard about practices beginning to look at their data from a 'risk' perspective. Many of our contracts with health plans and CMS are based on the 'risk score' of patients in that practice. It's called hierarchical condition code (HCC) by CMS and it's determined by patient admissions, procedures, and mostly by assigning diagnoses during yearly patient visits.

  

At Inland Hospital, Gavin Ducker, MD, lead physician for primary care, is helping his practices improve their scores using Geisinger Health Plan data. "When we looked at the reports, our risk scores seemed too low - we were well below the 1.0 average with an average score of 0.79." Dr. Ducker knew that many of Inland's patients were living with serious chronic illnesses, so the score didn't make sense to him.

 

Dr. Ducker and the other providers reviewed their patient lists from Geisinger and saw that the diagnoses usually did not include recent procedures or complications. They realized that because the providers often did not capture these in the EMR, their billing did not reflect the severity of their patients' conditions, and the health plan underestimated the risk score.

  

Inland now has a standing agenda item at their quarterly coding meeting with primary care practices. That's when the group reviews recent Geisinger and Anthem reports making sure patient diagnoses reflect their true condition. Similar work is also being done during Patient Centered Medical Home monthly meetings, as well as at practice operations meetings.

 

"I think that teaching is very important through this coding process and that the messages need to be very practical and not so academic," shares Dr. Ducker.

 

As part of the EMHS Practice Redesign initiative, Dr. Ducker has visited five practices and spends part of that time observing providers during patient visits. Accurate coding is frequently seen as an opportunity in their discussions. Fortunately, all Inland providers are trained in computerized provider order entry (CPOE), so they already have a basis for improving coding and reflecting the complexity of a patient in the chart.

 

Providers are looking at managing the EMR problem list more routinely. It takes time, but if successful, a provider's productivity actually goes up, and they get more credit for the work they do. In many cases, patient visits and their workday are becoming more manageable because each problem list on the first screen is more concise and helpful, since it's being well maintained.

 

In two years, Inland is seeing improvement; their average risk score is now 0.82. They have set their mid-term goal to be 1.0 or average, even though they realize that they should and can exceed that.

 

Improved coding benefits the patient, provider, and the practice a winning formula for any problem!

 

Introducing... Melinda Wood, Credentialing Specialist

 

     Melinda Wood is Beacon Health's credentialing specialist and our "go to" staff on payor credentialing, payor notifications, and data management for our more than 3,900 contracted EMHS Medical Plan network providers.

 

 Prior to joining Beacon Health, Melinda was the network and credentialing manager and database administrator/programmer for Maine Network for Health in Bangor, where she worked for more than a decade. 

 Before that, Melinda worked for nine years at Anthem and Machigonne Health Administrators in customer/provider service, claims, utilization management, and medical review. Melinda, has nearly two decades of managed care experience working with providers, hospitals, healthcare facilities, patients, and insurance payors. When not working tirelessly on network management,

Melinda is an active member of MeAMSS, the Maine chapter of the Association of Medical Staff Services.  She is also a 2014 graduate of the Bangor Region Leadership Institute (BRLI). 

Melinda lives in Bangor with her fiancÚ, two daughters and two dogs.  In her spare time, she loves to visit lighthouses and enjoys photography.

What Can I Do to Speed Up the Credentialing Process on My Providers?

 

Some Tips for More Timely Credentialing Request:

  • Complete all information on theProvider Data Form and submit it to Karen Eldridge (KEldridge@EMHS.org) with required documents. 
  • Complete a DEA waiver on any provider that does not have a DEA and submit it with the provider data form. 
  • Include board certification numbers for all nurse practitioners 
  • CAQH:
    • Reattest every 120 days and make sure that the practicing state is Maine
    • Explain all gaps over six months
    • Include all work history
    • Upload current documents such as DEA and malpractice insurance as soon as they expire

Beacon Health Goes to Washington...

Director of Care Coordination Testifies before Senate!

   

In May, the office of Senator Susan Collins (R) of Maine called and asked if Beacon Health would provide testimony before the Senate Committee on Aging.

 

 Beacon Health, one of the remaining 19 Pioneer CMS accountable care organizations (ACO) has been participating in a three day skilled nursing facility (SNF) waiver for the past three years. The pilot program is an attempt to see if patients and their families have better outcomes if they can receive the right care, at the right time, in the right place, and if medically stable, can avoid a three night hospital stay and go directly to a SNF.

 

The Beacon Health Pioneer ACO began in 2012 with just more than 9,000 Medicare beneficiaries. We are now in our fourth year of the five year program caring for nearly 29,000 Medicare beneficiaries.

 

"The three day SNF waiver program allowed us to expand our network and partner with more caregivers in order to truly make a difference in patients' lives. What the waiver does is allow our primary care teams to partner with caregivers across the care continuum," explains Tori Gaetani, RN, Beacon Health director care coordination.  

 

Beacon Health partnered with 15 SNFs including swing beds in four critical access hospitals across our state all which were required to have a quality rating of three or more stars under the CMS 5-Star Quality Rating System, as reported on the Nursing Home Compare website, and must commit to quality of care measures beyond the Nursing Home Compare reports. The SNFs also agreed to admit our patients 24/7 in order to allow for safe transitions no matter the time of day or night. This was not easy feat - it required a true spirit of collaboration between Beacon Health Pioener primary care practices, the qualified SNFs, and hospitals, creating a truly seamless transition across the care continuum for our patients and families. 

 

Pioneer patients can be referred directly from a primary care practice, emergency department, or after one or two day stay in a hospital. To date 183 patients have benefited from the waiver.

 

For Mr. Smith, an 86 year old gentleman who was living with his wife at home, it's meant a better quality of life.  Mr. Smith had found himself in the local emergency department for weakness and falls at home.  The emergency department assessed him and sent Mr. Smith back home with home care services for physical and occupational therapy. However, Mr. Smith continued to fall at home so the homecare therapist contacted the patient's primary care provider to update them on the continued problems he was having and recommended more intense daily therapy. 

 

The primary care practice reached out to Mr. Smith and asked him to come into the office for a visit. Mr. Smith and his family came in for his appointment when his provider saw a general overall physical decline, with increased weakness, which was leading to his frequent falls. Mr. Smith, his family, and his provider wondered if the medications he was taking was contributing to his falls. They decided to make some adjustments to his medications and they also agreed some time in a skilled nursing facility for more intensive rehabilitation could support him living at home safe and independently.

 

The family took Mr. Smith to the SNF of his choice where he stayed and participated in therapy for 13 days.  Mr. Smith returned home to his wife with out-patient services. Since Mr. Smith's discharge from SNF in March, he has had no falls, met his therapy goals and remains living independently at home with his wife.  Mr. Smith was never admitted to the hospital; he got the appropriate level of care directly after a visit with his primary care provider.

 

Because of Mr. Smith and the countless other patients who continue to benefit from our program, Beacon Health is looking to expand the number of participating SNF facilities to offer our patients more choices at approved facilities throughout our state, keeping patients as close to home and family as we can. We will continue to communicate and educate patients, home healthcare, emergency departments, hospitals, and primary care providers regarding the SNF waiver eligibility to make sure all our Pioneer Medicare patients are offered the appropriate level of care that will improve their health outcome and overall quality of life.

 

The healthcare world calls it achieving the Triple Aim. Beacon Health sees it more as doing what is right for our patients. By always putting patient and family needs at the center of our care, Beacon Health providers are able to build strong relationships with our patients; they trust us and turn to us to support their health. We use best practices to guide our care plans coupled with our trusting relationships with our patients and families which have increased their satisfaction, improved outcomes, and lowered the cost of healthcare.

 

In conclusion, Tori strongly urged the Senate Special Committee on Aging to recommend to Congress to eliminate the three hospital overnight requirement as an antiquated and artificial barrier for Medicare beneficiaries access to skilled nursing facility level of care.  

Answers to ACRONYMS OF THE MONTH

  • ACO - Accountable Care Organization; an organized set of providers who can manage the full continuum of care for their patients and that receive financial incentives to improve the quality, efficiency, and experience of care. Beacon Health is the largest state wide commercial ACO network.
  • TPA - Third-Party Administrator; processes claims and perfroms other administrative tasks for a benefit plan or insurer.
  • NCQA - National Committee for Quality Assurance; national quality and certification organization overseeing healthcare providers and plans.
  • PHI - Protected Health Information; any oral or recorded information that relates to the physical or mental health care of an individual.
  • CMMI - Center for Medicare and Medicaid Innovation; an office within Centers for Medicare and Medicaid Services (CMS) created in 2010 to research and test innovative payment and service delivery models for healthcare.