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The InsIde sTory - Fall 2015 www.swhp.org 1

Provider Relations Provider Interactive Voice Response (IVR) System .................................................. 2 ICD-10 Helpful Documents ............................................................................................... 2 Prescriber Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs ................................................................................................. 3 Balance Billing Scott & White Health Plan Members .............................................4

Quality Improvement (QI) Chronic Obstructive Pulmonary Disease ..................................................................... 5 Best Practices for ADHD Care in Children ...................................................................6 Asthma Medications .......................................................................................................... 7 Adolescent Well-Care Visits ............................................................................................8 Colorectal Cancer Screening Best Practices ...............................................................9 Cardiovascular Best Practices ....................................................................................... 10

Care Coordination Division (CCD) Scott & White Health Plan Medical Coverage Policies Update ............................11 SWHP/ICSW Utilization Management Criteria for Inpatient Services and Selected Benefit Coverage Determinations 2015 .......................................12

The Inside Story Staff ..............................................................................................................14

In This Issue

Thesecondhalfof2015isprovingtobejustasbusyasthefirsthalfwasforScott&WhiteHealthPlan(SWHP).OurnewProviderInteractiveVoiceResponse(IVR)Systemwentliveon08/14/2015.TheProviderIVRwasimplementedtoofferafasterwayforyoutoobtaininformationaboutmemberenrollmentstatus,memberbenefits,andclaimsstatus. WealsoworkeddiligentlytopreparefortheconversionfromICD-9toICD-10thatoccurredon10/01/2015.SWHPteamedwithseveralproviders,clearinghouses,andvendorstoconducttesting.Inaddition,weconductedtwoICD-10TrainingSeminarsandcreatedanICD-10FrequentlyAskedQuestionsandICD-10TrainingPowerPointthatarecurrentlyavailableontheSWHPwebsite. SWHPiscurrentlyworkingonanewwebsitedesignthatisscheduledtolaunchinNovember

Volume 21 Issue 3 FALL 2015

2015.Weareveryexcitedtoofferanenhancedanduser-friendlydigitalexperiencetoourmembersandproviders! Asweapproachthenewyear,SWHPisimplementingvarioustools,processes,andpoliciesandprocedurestoensureweareincompliancewithalloftheupcomingregulatoryrequirementsthatgointoeffectthroughout2016,includingAffordableCareActAdministrativeSimplification,providerenrollmentrequirementsforwritingprescriptionsforMedicarePartDdrugs,providerdirectoryaccuracyrequirements,andetc. Welookforwardtoourongoingpartnershipswithallofourprovidersaswecollaboratetocontinuetoprovidehigh-qualityandcost-effectivecaretoourSWHPmembers.

2 www.swhp.org The InsIde sTory - Fall 2015

Provider Relations

PROVIDER INTERACTIVE VOICE RESPONSE (IVR) SYSTEM

ICD-10 HELPFUL DOCUMENTS

Scott&WhiteHealthPlan(SWHP)isexcitedtoannouncethatournewProviderIVRwentliveon08/14/2015.TheProviderIVRwasimplementedtoofferafasterwayforyoutoobtaininformationaboutmemberenrollmentstatus,memberbenefits,andclaimsstatus.ByutilizingtheProviderIVR,younolongerhavetowaitonthephonetospeakwithaCustomerServiceAdvocate(CSA).Please note that the information received from the Provider IVR is generated from the same system that the CSAs use. Therefore, there is no need to wait to speak with a CSA on the phone to validate the information received from the Provider IVR. Werealizethatyouarebusydeliveringhealthcareservicestoourmembers,sowewanttoofferyoutoolstoobtaintheinformationyouneedefficiently.

YoucanaccesstheProviderIVRdirectlybydialing1-800-655-7947orbycallingtheSWHPCustomerAdvocacyDepartmentphonenumberat1-800-321-7947andselectingoption1.TheProviderIVRisavailable24hoursaday,7daysaweek.Ifthesystemisunavailableorishavingtechnicaldifficulties,thenyouwillberoutedtoaCSAforassistance.

SWHPvaluestherelationshipsthatwehavewithourproviders,andwearecommittedtoprovidingyouwiththehighestlevelofservice.

Scott&WhiteHealthPlan(SWHP)valuestherelationshipsthatwehavewithallofourparticipatingprovidersthatdeliverhigh-qualityandcosteffectivehealthcaretoourSWHPmembers.Welookforwardtocontinuingourpartnershipwithyouasweworkcollaborativelytomeetthevariousfederalandstaterequirementsthatarebeingmandated.Assuch,wehavecreatedsomehelpfuldocumentstoanswermanyofyourquestionsandprovideyouwithvaluableinformationregardingtherecenttransitiontoICD-10onOctober1,2015.Wewanttoprovideasmuchassistanceaswecantoourproviderpartnerstoensureeveryonehasasuccessfulconversion,withourtopprioritybeingtoavoiddisruptioninservicestoourSWHPmembers.To access the ICD-10 PowerPoint Training and ICD-10 Frequently Asked Questions (FAQs) documents that we have available, please visit the SWHP website at https://swhp.org/providers/training-education.

IfyouhaveanyquestionsorneedassistancelocatingtheICD-10materialsonourwebsite,pleasedonothesitatetocontacttheSWHPProviderRelationsDepartmentat1-800-321-7947,ext.203064or254-298-3064.


Provider Relations

PRESCRIBER ENROLLMENT REQUIREMENTS FOR MEDICARE

PART D DRUGSTheCentersforMedicareandMedicaidServices(CMS)finalizedruleCMS-4159-FonMay23,2014,whichrequiresphysiciansandothereligibleprofessionalswhowriteprescriptionsforPartDdrugstobeenrolledinanapprovedstatusortohaveavalidopt-outaffidavitonfilefortheirprescriptionstobecoveredunderMedicarePartD.CMSoriginallyplannedtoenforcethisrequirementbeginningDecember1,2015.However,CMSmaderevisionstoruleCMS-4159-FonMay6,2015.TherevisedruleispublishedasCMS-6107-IFC,whichwentintoeffectonJune1,2015.

UndertherevisedruleCMS-6107-IFC,CMSisdelayingenforcementoftheprescriberenrollmentrequirementsuntilJune1,2016.TherevisedrulealsoencouragesPartDsponsorsandpharmacybenefitmanagers(PBMs)tobeginoutreachactivitiestoMedicarePartDprescribersnolaterthanJanuary1,2016.Therefore,prescribersmaybecontactedmultipletimesfromthevariousPartDsponsorsandPBMswithwhomtheyparticipate.

CMS strongly encourages prescribers of Part D drugs to submit their Medicare enrollment applications or opt-out affidavits to their Medicare Administrative Contractors (MACs) before January 1, 2016. This will provide the MACs with sufficient time to process the prescribers’ applications or opt-out affidavits and avoid prescription drug claims from being denied by the Part D plans, beginning June 1, 2016.

Formoreinformation,pleasevisittheCMSPartDPrescriberEnrollmentwebsiteat:http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Prescriber-Enrollment-Information.html.


Provider Relations

Balance Billing the PatientScott&WhiteHealthPlan(SWHP)doesnotallowcontractedproviderstobalancebillpatientsforcoveredservices.

BalancebillingisthepracticeofbillingthepatientforthedifferencebetweenwhatSWHPpaysforcoveredservicesandthe"retail"priceyouchargeuninsuredpatientsforthoseservices.

Review Your Participating Provider Agreement for DetailsInyourparticipatingprovideragreement(contract)withSWHP,itstatesthatyoushallnotlooktoSWHPmembersforpaymentforcoveredservices,excepttotheextentthattheapplicablePlanspecifiesacopayment,coinsurance,ordeductibleortheserviceisnotacoveredbenefit.

Balance Billing Rules under MedicareTheCenterforMedicareandMedicaidServices’(CMS)MedicareManagedCareManual,Chapter4,Section170,statesinpart,“MedicareAdvantagemembersareresponsibleforpayingonlytheplan-allowedcost-sharing(copaymentsorcoinsurance)forcoveredservices.”

Ifamemberinadvertentlypaysabill,whichisSWHP’sresponsibility,youmustrefundtheamounttotheenrollee.

Foradditionalinformationorquestions,pleasecontacttheSWHPProviderRelationsDepartmenttoll-freeat1-800-321-7947,ext.203064orlocallyat254-298-3064.

Balance Billing Scott & White Health Plan Members


Quality Improvement (QI)

AccordingtotheCentersforDiseaseControlandPrevention(2015),6.8millionadultswerediagnosedwithChronicObstructivePulmonaryDisease(COPD)duringthepastyear,equaling2.9%oftheadultpopulation.WithCOPDbeingstatisticallyprevalent,itisimperativethatpatientsreceiveappropriatetestingtoconfirmthediagnosisofCOPD.

SpirometryplaysavitalroleindeterminingtheseverityofCOPD,butcanalsoplayaroleindeterminingtheseverityofotherconditionslikeasthma.Spirometrycandetermineexactlyhowsevereeachrespectiveconditionisandcanhelpdeterminetheultimatecourseoftreatment.

Scott&WhiteHealthPlan(SWHP)monitorsaHealthcareEffectivenessDataandInformationSet(HEDIS)measurededicatedtotheUseofSpirometryTestingintheAssessmentandDiagnosisofCOPD(SPR).SPRisbrokendownbydeterminingifamemberreceivedappropriatetestingtoconfirmthediagnosisofCOPDwithinsixmonthsofthediagnosisdate(HEDIS2015).

WhendiagnosingsomeonewithCOPD,pleaseremembertoordertheappropriatetestingtoconfirmthediagnosisandtodeterminetheseverityoftherespiratorycondition.

References

CentersforDiseaseControlandPrevention.(2015).ChronicObstructivePulmonaryDisease(COPD): ChronicBronchitisandEmphysema.Retrievedfromhttp://www.cdc.gov/nchs/fastats/copd.htm.

HEDIS2015TechnicalSpecificationsforHealthPlan(Volume2).(2014).Washington,D.C.National CommitteeforQualityAssurance.

Chronic Obstructive Pulmonary Disease



Best Practices for ADHD Care in ChildrenAttentionDeficitDisorder(ADD)andAttentionDeficitHyperactivityDisorder(ADHD)arecommondiagnosesinchildren(www.nimh.nih.gov).Parentsoftenbringtheirchildrentoadoctorforanevaluationwhenfocusingatschoolandathomebecomeanissue.HyperactivityispresentinsomebutnoteverychildwithADHD.Teachersarefrequentlythefirsttonoticefocusproblemsinschoolagechildren.“SymptomsofADHDmayinclude:stayingfocusedandpayingattention,difficultycontrollingbehaviorsandhyperactivity”(www.nimh.nih.gov).

VariousmedicationscanbeusedtotreatADHDinchildrenbasedontheindividualchild’ssymptoms.TheseincludeCNSStimulants,Alpha-2Receptoragonists,andotherADHDmedications.Thesemedicationscanhavevarioussideeffectsthatneedtobemonitoredtoachievethetreatmentresponseneeded.

Scott&WhiteHealthPlan(SWHP)workswithBaylorScott&WhiteHealth(BSWH)physiciansandtheNationalCommitteeforQualityAssurance(NCQA)tomonitorthetreatmentandtheprescribingofmedicationsforschoolagechildrenwithADHD,ages6to12yearsofage.PrescriptioncomplianceismonitoredperprescriptionrefillsbytheSWHPClaimsDepartment.

SWHPisincomplianceifthepatienttakesADHDmedicationfor10monthswithonlyamaximum45daygapbetweendays31and300.Themeasureallows10monthsofmedicationperyearsincemanyparentstaketheirchildrenofftheADHDmedicationontheweekendandduringthesummermonths.

Follow-upcareisessentialintreatingchildrenwithADHD.IntheInitiationPhase,childrenareprescribedanADHDmedication.ThenintheContinuationandMaintenance(C&M)Phase,patientsarerequiredtohaveatleastthreefollow-upvisitsperyear(HEDISManual2015).

WhileADHDisoftenthoughtofasachildhooddisorder,itcanlastintoadulthood.ADHDinchildreniscommonlyassociatedwithothermentalhealthconditionsinadulthood,soitisveryimportantforthechildtogettheproperdiagnosisandtreatmentattheearliestagepossible(www.cdc.gov/ncbddd/adhd).

References

NIH.(n.d.).NIMH-Attention Deficit Hyperactivity Disorder (ADHD).RetrievedJune25,2015,from http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

NCQA.(2014).BehavioralHealth.HEDIS 2015 Technical Specifications for Health Plans(2015ed.,pp.172-176). Washington,DC:NationalCommitteeforQualityAssurance.

www.cdc.gov/ncbddd/adhd



AccordingtotheCentersforDiseaseControlandPrevention(2008),over1.2millionadultsandover590,000childreninTexaswerediagnosedwithasthmain2008.AsthmaisstatisticallyprevalentinTexas,anditisimperativethatmembersdiagnosedwithasthmahavetheappropriatemedicationstohelpmanageandcontrolvariousstagesofasthmaorasthma-relatedconditions.

First,therearerescuemedications,whicharespecificallydesignedtoprovideimmediatereliefforasthmasymptomsastheyoccur.Itisimportanttomakesurethatrescuemedicationsarenotoverused.Second,therearecontrollermedications,whicharespecificallydesignedtoworkoveraperiodoftimetohelpalleviateinflammationintheairwaysoverthecourseoftime.

AccordingtotheMayoClinic(2012),ifanindividualdoesnotusetheircontrollermedicationsasprescribedbytheirprimarycarephysician,thatindividual’sasthmacanpotentiallybecomeuncontrolledandincreasetheirriskofamajorasthmaattack.

TheScott&WhiteHealthPlan(SWHP)monitorsaHealthcareEffectivenessDataandInformationSet(HEDIS)measurededicatedtoMedicationManagementforPeoplewithAsthma(MMA).MMAisbrokendowntoindividualsthatwereonanasthmacontrollermedicationforatleast50%andatleast75%ofthetreatmentperiod(HEDIS2015).

IndividualsdiagnosedwithpersistentasthmaareincludedintheMMAmeasure.Persistentasthmaisdefinedas:oneEDvisitwiththemaindiagnosisofasthma,oneinpatientencounterwiththemaindiagnosisofasthma,fouroutpatientvisitswithdifferentdatesofservice,andtwoasthmamedicationdispensingeventsorfourasthmamedicationdispensingevents.Pleaserememberthatanymemberthatisdiagnosedwithpersistentasthmashouldbeprescribedanasthmacontrollermedication.

References

AsthmainTexas.(2008).Retrievedfromhttp://www.cdc.gov/asthma/stateprofiles/asthma_in_tx.pdf

HEDIS2015TechnicalSpecificationsforHealthPlan(Volume2).(2014).Washington,D.C.National CommitteeforQualityAssurance.

MayoClinicStaff.(September8,2012).Asthmamedications:Knowyouroptions.Retrievedfrom

http://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma-medications/art-20045557?pg=1

Asthma Medications



Adolescenceisoneofthemostdynamicstagesofhumandevelopment.Adolescenceisatimewhenteensexperiencedramaticphysical,cognitive,social,andemotionalchanges.Itisatthistimewhenmanyphysicalandmentalhealthconditions,substanceusedisorders,andhealthriskbehaviorsfirstbegintoappear.Infact,threeoutoffouradolescents,ages12–19,reportengaginginatleastonetypeofriskybehavior,suchastheuseandabuseofalcoholandothersubstances,unprotectedsex,pooreatingandexercisehabits,andphysically-endangeringbehaviors(DHHS,2014).

HealthyPeople2020notedthat“theleadingcausesofillnessanddeathamongadolescentsandyoungadultsarelargelypreventable”(Hensley-Quinn&Osius,2008).Infact,$700billionisspentannuallyoncostsdirectlyandindirectlyassociatedwithpreventableadolescenthealthproblems(Hensley-Quinn&Osius,2008).AccordingtoHealthyPeople2020,“behavioralpatternsduringthesedevelopmentalperiodshelpdetermineyoungpeople’scurrenthealthstatusandtheirriskofdevelopingchronicdiseasesinadulthood”(Hensley-Quinn&Osius,2008).TheCentersforDiseaseControlandPrevention(CDC)estimatesthat16%ofhighschoolstudentshaveseriouslyconsideredsuicidewith13%reportingthattheyhadactuallycreatedaplantodoso(CDC,2015a).Also,theCDCstatesthatalmost9outof10cigarettesmokerstriedtheirfirstcigarettebytheageof18(CDC,2015b).

Acomprehensivewell-carevisitforadolescents,ages12to21,canprovidethescreening,healthcounseling,andtreatmentnecessarytoaddressfivekeyareasofadolescenthealth: 1. Mentalandbehavioralhealth 2. Tobaccoandsubstanceuse 3. Violenceandinjuryprevention 4. Sexualbehavior 5. Nutritionalhealth

Itisextremelyimportantthatadolescentsreceiveannualwell-carevisitsforearlyidentificationandappropriatemanagementandinterventionforconditionsandbehaviorsthat,ifnotaddressed,canbecomeseriousandpersistintoadulthood.

What Counts as a Well Care Visit?

Awell-carevisitoccurswithaPCPorOB/GYNinaclinicalsettingduringthecalendaryear.Thefollowingdocumentationmustbenotedinthemember’smedicalrecord: 1. Healthhistory 2. Physicalandmentaldevelopmenthistory 3. Physicalexam 4. Healtheducation/anticipatoryguidance

Asickvisitandawell-carevisitcanbebilledatthesametime,butallthecomponentslistedabovemustbeincludedinthemember’smedicalrecord.Sportsphysicalsarealsoagreattimetocompleteawell-carevisitaslongasallthecomponentsofthewell-carevisitarenotedinthemedicalrecord.

References

CDC.(2015a,March).SuicidePrevention:YouthSuicide. Centers for Disease Control and Prevention.

CDC.(2015b,July).YouthandTobaccoUse.Centers for Disease Control and Prevention.

DHHS.(2014,February).PavingtheRoadtoGoodHealth:StrategiesforIncreasingMedicaidAdolescentWell-CareVisits, Department of Health & Human Services.

Hensley-Quinn,M.andOsius,E.(2008,May).SCHIPandAdolescents:AnOverviewandOpportunitiesforStates.State Health Policy.

Adolescent Well-Care Visits



Althoughtheincidenceofcolorectalcancer(CRC)intheU.S.hasbeendecliningby2%to3%peryearoverthepast15years,itcontinuestobethesecondleadingcauseofcancer-relateddeaths(Randel,2012).Because90%ofallcasesofCRCoccurinpeopleover50yearsofage,theAmericanCollegeofGastroenterology(ACG)continuestorecommendtheuseofacolonoscopyasthepreferredstandardforscreeningevery10yearsbeginningatage50(Rex,2009).However,theACGalsorecognizesthatmanypatientsarenotwillingtoundergoacolonoscopyforavarietyofreasons.Assuch,theACGguidelinesstatethatinthesecases,analternatemethodoftestingshouldbeusedtoscreenforCRC.Thisincludesflexiblesigmoidoscopy(FlexSig),computedtomography(CT-scan),guaiac-basedfecaloccultbloodtests(GFOBT),andimmunochemicalbasedfecaloccultbloodtesting(FIT)untilthememberisover75yearsofageorhasanestimatedlifespanoflessthan10years.ThisleavesbothourprovidersandourpatientsaskingwhattestIshouldhave,when,whataretherisks,andwhatarethebenefits.Toaidinthediscussionofacareplan,Iofferthebelowtable.

Again,weashealthcareprovidersknowtherisksandbenefitsofeachofthesetests.However,ourmembersaretheoneswhomustbewillingtocompletetheprep,spendtheirtimetogetthetestdoneorsubmitasample.Bydiscussingalltheoptionswithourmembers,theycanchoosethemethodofCRCscreeningthatworksbestforthem.ThiswillincreaseourcomplianceratesandallowScott&WhiteHealthPlantocatchthiskillerearly.Whileourmembersseethisaspatient-centeredcare,wewillreapthebenefitsofsignificantcostsavingsinthelongrun.

References

Randel,A.(2012).ACPReleasesBestPracticeAdviceonColorectalCancerScreening.American Family Physician,86(12),1153-1154.

Rex,D.K.,Johnson,D.A.,Anderson,J.C.,Schoenfeld,P.S.,Burke,C.A.,&Inadomi,J.M.(2009).ColorectalCancerScreening. American Journal of Gastroenterology,104,739-750.

Colorectal Cancer Screening Best Practices

TestSensitivity / Specificity

Cost Frequency Barriers Risks

Colonoscopy High High 10yearsBowelPrep,Cost,Limited

Availability

Postpolypectomomybleeding,perforation,diverticulitis,severe

abdominalpain,death

FlexSig Medium High 5years BowelPrep,CostPerforation/bleeding,false

negatives

CTScan Medium High 5years BowelPrep,Cost

Low-doseradiationexposure,additionaldiagnostictestingandproceduresmaybeneedforlesionsthatmightnotbe

clinicallysignificant

Guaiac-BasedOccultBlood

TestingVariable Low Annual

2-3samplesfromconsecu-tivestoolsathome

FalseNegatives

FITTesting High Low Annual1samplefromastool

samplecollectedathomeNomajorrisks



Cardiovascular Best PracticesNumerousresearchstudieshaveshowntimeandtimeagainthatwhenitcomestothebestpracticesforprotectingtheheart,theanswerisassimpleasourABCs: • Aspirin(asappropriate) • BloodPressureControl • CholesterolManagement • SmokingCessationStill,“thesocialandenvironmentaloriginsofCVD[cardiovasculardisease]havelongbeenrecognizedasmediatedinlargepartbylifestylesandbehaviorsthataremodifiable.Cardiovascularhealthinchildrenpredictssubsequentcardiometabolichealthinadulthood,affirmingtheimportanceofmaintaininghealthylifestylebehaviorsfromearlyinlife”(Pearsonetal,2013,p.1732).Thequestionthenbecomes,“howdowebestmodifythesebehaviors?”Bandura’sSocialLearningTheoryposesthatwelearnthelifestylebehaviorsthroughmodelingofsociallyacceptablebehaviors.FactistheNationalInstituteofHealth(NIH),CentersforMedicareandMedicaidServices(CMS),CentersforDiseaseControlandPrevention(CDC),AmericanCollegeofCardiology(ACC),AmericanAcademyofFamilyPhysicians(AAFP),andtheAmericanHeartAssociation(AHA)arealllookinginthesamedirection;improvingindividualhealthbyimprovingcardiovascularhealthandeducationatthecommunitylevel.InSeptember2011,theDepartmentofHealthandHumanServices(HHS)launchedtheMillionHeartsInitiativewiththegoalofpreventing1millionheartattacksandstrokesby2017.OneinnovationtheypresentedwasthatofHeart360.MemberswereencouragedtorecordhomeBPreadingsatleast3-4timesperweekandsharethemwiththeirpharmacist.PharmacistswereempoweredtomakeadjustmentstoRxdosagesbasedonthesereadings.Attheendofthe6-monthpilot,57%ofthepreviouslyuncontrolledHTNpatientswerenowcontrolledascomparedtothecontrolgroupusingstandardoffice-basedcare’s37%.Asimilarprogram,theAmericanPharmacists’AssociationFoundation’sAshevilleProject,alsoallowedforpharmacy-basedmedicationtherapymanagement(MTM)forpatientswithHTNordyslipidemia.Again,pharmacistswereinvolvedinbothmembereducationandadjustmentsofmedications.Overthecourseof6years,thisprogramactuallyreducedcostsforasthma,CVD,depression,anddiabetesbyover$1200permemberperyearandyet50%moremembersmetgoals.

AnotherstudywaslaunchedtolookattheeffectsofculturallycompetentcareforAfrican-AmericanswithHTN.Thisprogramentailedtrainingthenurses.Again,patientswereencouragedtotakehomeBPreadingsandreportthemtothenursingstaff.ThenurseswerealsotrainedtoanswerpatientquestionsregardingBPmonitoring,medicationadherence,andotherareasofculturallycompetentcare,aswellas,torelayBPreadingstotheproviders.Attheendofthestudy,nursehealthcoachingwithculturallycompetenteducationresultedina36%increaseinHTNcontrolratesascomparedtothebaselineofoffice-basedvisits.Meanwhile,theCDCandCMSteameduptoimprovecommunitybasedunderstandingoftheneedtoimproveantihypertensivemedicationadherencethroughtheEpi-Exchange.Simplyput,theyworkedtogethertooptimizememberaccesstobothpublichealthandclinicalresources.Intheprocesstheynotonlyincreasedtransparencyabouthowtoaccessresourcesandinformation,butconfirmedthatwhenevidence-basedbestpracticeswerecollaboratedthroughdata-sharingacrossdisciplines,patientcomplianceratesincreaseddramatically.Onecaneasilyfindnumerousotherstudies,butitissufficienttosaytheyallhaveonethingincommon.Theyhaveallchangedtheirfocusfromtreatmentbasedsolelyonofficevisitstopatient-centeredcarebasedonindividuallifestylesandcommunitybasedresources.Howcanwemakeourbestpracticesuserfriendlyforthecommunity?Theanswerremainsthesame,weuseourABCs:Aspirin,HomeBPMonitoring,CholesterolManagement,andSmokingCessation,butwithatwist.Wenowfocusonthememberasawholeandnotjustwhatweseeatoneofficevisit.Whentheentirehealthcareteamcollaboratestosendaconsistentmessageinanenvironmentofpatient-centeredcare,onlythencanwesaywehaveachievedtheCVDbestpractices.

ReferencesCDC.(2015).Million Hearts; Innovatiuons & Progress Notes.RetrievedSeptember2,2015fromhttp://millionhearts.hhs.gov/about_mh.html.

Pearson,T.A.,Palaniappan,L.P.,Artinian,N.T.,Carnethon,M.R.,Criqui,M.H.,Daniels,S.R.,Turner,M.B.(2013).AmericanHeartAssociationGuideforImprovingCardiovascularHealthattheCommunityLevel,2013Update;AScientificStatementforPublicHealthPractitioners,HealthcareProviders,andHealthPolicyMakers.Circulation,127,1730-1753.doi:10.1161/CIR.0b013e31828f8a94.


Care Coordination Division (CCD)

Scott & White Health Plan Medical Coverage Policies UpdateScott&WhiteHealthPlan(SWHP)ispleasedtoannouncethereleaseofthefollowingMedicalCoveragePolicies.Youcanfindthesepoliciesonourwebsiteathttps://swhp.org/providers/policies.

Number Title CommentR003 OccupationalTherapyR007 AutologousChondrocyteImplantationR010 HearingAids-Bone-AnchoredR011 BotulinumToxinInjectionforChemodenervationR014 ApolipoproteinEGenotypeofPhenotypeR015 Non-InvasiveNerveConductionTestingR018 IMRTforBreastCancerR101 RegionalSympatheticBlocksR112 SpeechTherapyR129 OrganTransplantationR130 VagusNerveStimulationR213 CoverageDeterminationFinalUpdate043 INRHomeTestingUpdate208 PrivateDutyNursingR012 CompressionGarmentsR074 OccipitalNerveStimulationR082 PhonophoresisR099 PulsedDyeLaserTreatmentR110 SleepApneaR141 InfertilityR201 VentricularAssistDeviceR205 DeepandDoubleBalloonEnterscopyR214 ChiropracticServicesR215 MedicationsCoveredUnderMedicalPolicyR037 GeneticTestingR044 HyperbaricOxygenTherapyR078 SpinalCordStimulatorsR084 VertebroplastyKyphosplasySacroplastyR028 DurableMedicalEquipmentR029 AlzheimersDiseaseBiochemicalMarkersR030 OsteoporosisBoneTurnoverMarkersR031 EpiduralAdhesiolysisR035 ColdTherapyDevicesR036 GastricElectricalStimulationR045 ImmuneGlobulinTherapyR048 IncontinenceAlarmsR050 CancerVaccinesR067 NeutralizingAntibodyTestinginMultipleSclerosisR064 GenderReassignment

TheSWHPMedicalCoveragePoliciesarereviewedonanannualbasistoassurecontinuedrelevanceandtokeepthemcurrent.ThisreviewisconductedbySWHPMedicalDirectors.Eachpolicyisreviewedusinganumberofresources,suchas:1. Medicalliterature2. InterQual®guidelines3. SWTechnologyAssessmentDeterminations4. SpecialtySocietyorothernationalguidelines

OncepolicieshavebeenreviewedbytheSWHPMedicalDirectors,theyaresentforspecialtyreview.RecommendationsfromthespecialtyreviewersareconsideredatasubsequentMedicalDirectorCommitteeMeeting,andafinaldecisiononthecontentofthepoliciesunderconsiderationismade.

Thereviewprocessfortheabovepolicieshasbeencompleted,andtheyhavenowbeenpublishedtothewebsite.YourcommentsandsuggestionsregardingtheMedicalCoveragePoliciesarealwayswelcomeandmaybeforwardedto:[email protected].



TheScott&WhiteHealthPlan(SWHP)/InsuranceCompanyofScott&White(ICSW)InsurancePolicyalsoreferredtoasEvidenceofCoverage(EOC)orStandardPlanDocument(SPD)isthecontractforcoverageofthehealthcareservicesthatanindividualpurchasedoranemployerpurchasedfortheiremployees.SWHP/ICSWprovidesavarietyofbenefitplanstomeetpurchaserneeds.

BenefitplansincludebenefitsrequiredbylawtobeofferedbytheSWHP/ICSW,aswellas,purchaserpreference(ASO).ThepurposeofSWHP’sUtilizationManagement(UM)ProgramistomanageservicesaccordingtothetermscontainedintheInsurancePolicy.Allbenefitplansrequirecoveragetobecontingentuponmedicalnecessity.SWHP’sUtilizationManagementCommitteeadoptsordevelopsevidence-basedcriteriatodeterminemedicalnecessity.Annually,SWHPprovidesproposedcriteriatophysiciandirectorsofBaylorScott&WhiteHealth’sMedicalServicesDivisionsandcontractednetworkphysiciansforreviewandfeedback.SWHP/ICSWMedicalDirectorsevaluateallfeedbackprovided.TheresultingapprovedfinalcriteriasetsandtheHealthCareManagementGuidelines(targetlengthofstay(LOS))areforwardedtotheSWHP/ICSWUMCommitteeforreviewandapproval.

2015criteriaincludeInterQual®,internalpolicies,targetLOS,criteriadevelopedandapprovedduringTechnologyAssessmentmeetings,andmedicalcoveragepolicies.

TheapprovedcriteriaareusedbytheUMStaffasaguidelineonly.SWHP/ICSWMedicalDirectorsmakealldenialofcoveragedeterminations.AnypersonmakingdecisionsonUM,includingformularycoveragedeterminationsarebasedonmeetingcriteriaforappropriatenessofcareandservicesandaresubjecttothetermsandlimitationsoftheInsurancePolicy.SWHP/ICSWdoesnotofferincentives,includingcompensationorrewards,toPractitionersorotherindividualsconductingutilizationreviewtoencouragedenialsofcoverageofservicesorofferfinancialincentivesthatencouragedecisionsthatresultinunderutilizationofservices.SWHP/ICSWdoesnotuseincentivestoencouragebarrierstocareandservices.

MedicalDirector(s)compensationisnotbasedonutilizationofservicesdenials.SWHP/ICSWdoesnotmakedecisionsregardinghiring,promotingorterminatingitspractitionersorotherindividualsbaseduponthelikelihoodorperceivedlikelihoodthattheindividualwillsupportortendtosupportthedenialofbenefits.

SWHP/ICSWmonitorsforevidenceofunderutilization,overuse,andmisusethroughtheQualityImprovement(QI)Committee’sreviewofMEDInsightreports,HEDIS®measures,QITeammeasuresandcomplaintdata.Evidenceofunderutilization,overutilizationandmisusewillbediscussedwiththeindividualphysician,aswellastargetedMemberoutreachasappropriate.Individualcoveragerequestsarediscussedwiththeindividualphysicians/providersmakingtherequestonbehalfofaMember.

SWHP/ICSWUMStaff,includingMedicalDirectors,areavailablebytelephone24hoursperday,7daysperweekorbyappointmentat1-254-298-3088ortollfreeat1-888-316-7974.Thestaffisavailable

SWHP/ICSW Utilization Management Criteria for Inpatient Services and Selected Benefit Coverage Determinations 2015



todiscussUMand/orcoveragedeterminations,includingbenefitprovisions,guidelines,criteriaortheprocessesusedtomakedeterminations.TheSWHP/ICSW“oncall”nursewhohasaccesstoaSWHP/ICSWMedicalDirectoroncallisavailableafterhours.

Appealrights,includingexpeditedappeals,reconsiderationrightsand/orIndependentReviewOrganization(IRO)optionsarealwaysprovidedwithanydenialissued.Practitionersmayrequesttoreviewcriteriaatanytimeincludingatthetimeofacase-specificdetermination.Criteriawillbeprovidedbyfax,phone,andemailorthroughanonsiteappointmentwiththeCareCoordinationDivision(CCD)managementstaff.CCDcanbereachedbycallingthetollfreenumberat1-888-316-7947ordirectlyat1-254-298-3088. Inanefforttoimprovecommunicationwithnon-EnglishspeakingMembers,SWHP/ICSWusestheinterpretiveservicesofAT&T.Membersdonothavetocallaspeciallineforthisservice.WhencontactingSWHP/ICSW,MembersmaynotifytheCCDstaffand/orCustomerAdvocatesoftheirprimarylanguageandthecallwillbecompletedwiththehelpofanAT&TinterpreteratnochargetotheMember.CCDStafffollowsestablishedinternalSWHP/ICSWpoliciesrelatedtoprovisionofinterpretiveservicesforSWHP/ICSWMembers. SWHP/ICSWutilizesatollfreeTTYnumber1-800-735-2989toassistwithcommunicationservicesforMemberswithhearingorspeechdifficulties.TheTTYnumberislistedontheSWHPwebpageatwww.swhp.organdisalsoincludedinyourMembercorrespondenceandMemberpublicationmaterials.


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