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Quarter 4 Provider Forum December 5, 2019
Quarter 4 Provider Forum
December 5, 2019
AGENDA
I. Dawn Marszal, Senior Director, Operations
• Maryland Department of Health ePREP update
II. Marlon Cooper, PharmD, Director of Pharmacy Services
• MDH Hepatitis C medication criteria update
• HIV medication carve-in for MCO’s
• MPC short-acting opioid medication policy update
III. Sammi Turner, Manager Quality Improvement
• Quality improvement initiatives
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MDH EPREP UPDATE
MDH extended the implementation of ePREP from December 1, 2019 to
January 1, 2020.
• Maryland Department of Health (MDH) requires all providers
delivering services to Maryland Medicaid members to have an active
enrollment status in the electronic Provider Revalidation and
Enrollment Portal (ePREP) every 5 years.
• Beginning January 1, 2020 claims system will validate billing and
rendering NPI against weekly MDH file.
• If billing or rendering NPI is not found on most recent file or does not
have an active status, claim will deny with specific denial reason.
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MDH EPREP UPDATE
Professional license verification in ePREP
• Providers are responsible for updating professional license information prior
to license expiration in the ePREP portal.
• If a provider fails to update her professional license expiration date in ePREP,
the provider’s enrollment status will “suspend” and claims submitted by the
provider will deny until the provider corrects the issue in ePREP.
• Explanation of payment will reflect the reason for claim denial specific to
ePREP. Example: EX2N means “Rendering provider ID suspended MD
Medicaid ePREP Enrollment- must review”
• The provider can resubmit claims for adjudication within timely filing
guidelines (180 days from date of service) once her status has been updated.
MDH EPREP UPDATE
• MDH Website: mmcp.health.Maryland.gov/pages/ePREP.aspx
• ePREP Portal: https://eprep.health.maryland.gov
• ePREP Call Center 1-844-463-7768
Pharmacy Updates
Marlon Cooper, PharmDDirector of Pharmacy Services
MDH HEPATITIS C MEDICATION CRITERIA UPDATE
Beginning January 1, 2020 in accordance to guidance from Senate Bill
(SB) 598, the Maryland Department of Health MDH is expanding the
Chronic Hepatitis C coverage to include patients regardless of the
fibrosis or Metavir score which stages liver scarring.
• The Maryland Department of Health (MDH) will continue to establish
clinical criteria for Chronic Hepatitis C treatment
• MCOs will continue to review prior authorization requests and clinical
documentation for Chronic Hepatitis C Therapy
• The Current Global Chronic Hepatitis Criteria and Prior Authorization
Form are located at
https://mmcp.health.maryland.gov/pap/docs/HCV%20%20Clinical%2
0Criteria%20updated%20%20March%2019%20final.pdf
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HIV MEDICATION CARVE-IN FOR MCO’S
Beginning January 1, 2020, all Maryland Managed Care Organizations (MCOs) will be responsible for providing and managing HIV medication therapy for its membership as part of the MCO’s pharmacy benefit according to the Maryland Department of Health (MDH).
• A comprehensive transition work plan is being executed minimal disruption with the transfer of benefit
• Claims for HIV medications will be processed without interruption for the first 180 days of 2020.
• Members new to therapy or changes to current therapy regimens may be impacted by established clinical criteria for prior authorization
• No copays will be charged for medications under this new plan benefit
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MPC SHORT ACTING OPIOIDS POLICY UPDATE
Starting October 1, 2019, MPC’s guidelines for prescribing opioid medication to new patients changed to align with FDA product labeling and CDC opioid prescribing guidelines.
• This policy will target new users of short-acting opioid products only.
• If the patient has a history of any opioid within the past 130 days, the claim will adjudicate as normal
• If the patient has a prescription for a cancer medication within a 180-day period, the claim will adjudicate as normal.
• Prior authorization requirements do not apply to patients actively being treated for cancer or in hospice care, end-of-life care, or palliative care
• Exceptions to these guidelines are subject to prior-authorization review.
• Initial overrides for 3 month duration, and subsequent overrides for 1 year duration
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Quality Improvement
MPC HEALTH FAIR EVENT
• Location: Eastpoint Mall by the food court
• Date: Dec 6th 9:30am-3pm
• Closing Gaps for HbA1c, lead, SSI assessments, Diabetic eye exams. Members who attend receive round trip transportation and a $75.00 Visa
300+ members are scheduled
Target population: Baltimore City/County/Harford/Anne Arundel
• Addressing Social/Economic disparities: Vendors include Social Services, WIC, Share agencies, ACCU, and more
• Addressing Access to Care for PCP provider attendance to provide meet and greet our members: Total Health Care, BMS, Chase Brexton, and Life Bridge
For more information please contact Quality Improvement Manager: Sammi Turner
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CLINIC DAY LAST CALL
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All members who attend a clinic day receive round trip transportation
HbA1c/Lead/SSI receive a $75.00 Visa card
BCS receive $100 Visa cards provided day of clinic
Contact for Clinic days:
Mary Sisson-Collier 443-713-4906 Amanda Hart – 443-713-4759 Barb Koonz – 443-713-4624
BCS Diagnostic Imaging Services (Washington Co) Tuesday 12/3 3:30p-7:30p
Lead/HbA1c/SSI Eastpoint Mall Friday 12/06 10a-4p
BCS Seton Imaging Saturday 12/7 9a-1p
LEAD Adventure Dental Landover Thursday 12/12 9a – 1p
BCS American Radiology (Fleet St.) Saturday 12/21 9a – 1p
VALUE-BASED PURCHASING
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Information is a reflection of NCQA HEDIS 2019 Technical Specification and is used only as a
reference to assist in improving your practice’s HEDIS/VBP rates
Measure Requirement CPT
Adolescent Well-Care ages 12-21 (AWC) Members must complete one comprehensive visit per
year.
99384, 99385, 99394, 99395
Well-child visit first 15 months of life (W15) Members must have 6+ well visits by age 15 months 99381, 99382, 99391, 99392, 99461
Breast Cancer Screening (BCS) Women 50-74 need to complete one mammogram in
the past 27 months. Exclusion: Bilateral Mastectomy
7705-77057, 77061-77063, 77065-77067
Lead Screening All members born in 2018 (not based on risk), must
complete a lead test before the end of 2019. Testing
can occur as early as 9 months of age
Only one code will meet compliance
83655
SSI Child- Birth to age 20
SSI Adult- 21-64
All members receiving Social Security Income should
complete at least one Ambulatory Care Visit with
PCP. This can be sick or well. No urgent care,
substance abuse, ED visits count
Any Ambulatory Care visit code or well visit code.
Asthma Medication Ratio Members must fill maintenance medication at least .05 to rescue inhalers
Pharmacy claim based
HbA1c Control The last reading in the measurement year must have value of <8
Lab based
Controlling High Blood Pressure Based on last blood pressure reading of the year. Reading must be less than can not equal 140/90
PROVIDER ASSISTANCE-BI-DIRECTIONAL DATA SHARING
EMR- Electronic Medical Record Access
• Network Agreement/ Data Sharing Agreement
• Allows Plan to provide Prospective reviews to improve rates
throughout the year
• Provider can request measure specific reviews
• Decrease resources to Provider/Plan during HEDIS season- no
faxing of records
Contact for EMR Access:
QI HEDIS Manager: Denise Redding
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PROVIDER ASSISTANCE-BI-DIRECTIONAL DATA SHARING
Supplemental Data
• Targets high volume providers (30+members in a specified measure)
• Providers provide a flat file extraction from EMR based on the
measurement requirements
• Flat files are submitted to plan by provider on a monthly basis
• Benefits:
Provides real time data
Encounter data: claim info not submitted to plan, FFS information
Supplemental Data Extraction Contact: QI Manager: Sammi Turner
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VALUE-BASED PURCHASING 2020
Value-based purchasing is a Pay for Performance Model of care. The state of Maryland uses HEDIS measures as well a
custom measure to monitor the performances of the Maryland Medicaid MCO’s
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EPSTD
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Assessments
• Lead Risk Assessment- Every Well Child Visit age 6 months-6years
• Tuberculosis Risk Assessment- Annual starting at age 1 month
• Cholesterol/Heart Disease Risk- Annual starting age 2
• STI/HIV Risk Assessment- Annually starting at age 11
Screenings
• Anemia Screening: Annual starting at age 11
• Lead Testing: Can start as early as 9 months of age and should be completed for 12 month and 24 month
• Hereditary/Metabolic Screening: Newborn screening with second completed 2-4 weeks of age
• Hemoglobinopathy Screening: 12 months and 24 months of age
• Critical Congenital Heart Disease: Newborns with rescreening at 24-48 hours of age
2020 PLANNING
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• Ongoing clinic days with expansion to Western MD and PG
county
• Member Incentives
• Incorporation of Provider Feedback
• Increase Supplemental Data
• Increase EMR access
PLAN INTERVENTIONS: MEMBER ENGAGEMENT
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Measure Definition Planned Activities
AWC Adolescent Well Care Visits promote annual visit- Social platform: text, e-mail, robo-call
SSI – Adult Ambulatory Care Visits (MD Custom) Alegis Home Visits- Launch April Clinic days- Launch May
SSI – Child Ambulatory Care Visits (MD custom) Clinic days- Launch May
AMR Asthma Medication Ratio Pharmacy collaboration- Outreach to members not filling prescriptions
BCS Breast Cancer Screening Clinic days- Launch May
CDC- HbA1C Control Comprehensive Diabetes Care – HbA1c <8 Alegis Home Visits- Launch April Clinic Days- Launch May Provider engagement- for follow-up care for member values <8
Launch April
CBP Controlling High Blood Pressure Create custom measure pending Inovalon capabilities
LSC-MD Lead Screenings for Children – Ages 12-23 Months (MD custom)- Any member born in 2018 must have lead testing completed in 2019
Clinic days- Launch April
W15 Well-child Visits for Children – First 15 months (6+ visits) Promote Healthy Infant Visit-6+ Marketing, Telephonic outreach
Q & A
