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Virginia Commonwealth University Health System Health Plan Division 1 Medicaid Managed Care Virginia Premier Health Plan April 17, 2012.

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Presentation on theme: "Virginia Commonwealth University Health System Health Plan Division 1 Medicaid Managed Care Virginia Premier Health Plan April 17, 2012."— Presentation transcript:

1 Virginia Commonwealth University Health System Health Plan Division 1 Medicaid Managed Care Virginia Premier Health Plan April 17, 2012

2 Virginia Commonwealth University Health System Health Plan Division 2 1.Introduction to Medicaid Managed Care 2.Why Virginia Premier? 3.What does this mean for my patients? Member Benefits and Eligibility 4.What does this mean for my practice? Provider Benefits and Services Claims Medical Management Pharmacy Today’s Presentation

3 Virginia Commonwealth University Health System Health Plan Division 3 Managed Care Organizations Major changes in the health insurance industry have occurred: –Managed Care networks have become more prevalent –Government funded programs ensure health care services are accessible to the elderly and low-income population These changes resulted from: –Rising health care costs –The need to shift the financial risk from the State to Managed Care Organizations –Competition among health care providers –The need for enhanced services to improve access to care, promoting disease prevention, ensuring quality care, and reducing Medicaid expenditures.

4 Virginia Commonwealth University Health System Health Plan Division 4 What is an MCO? DMAS defines an Managed Care Organization (MCO) as an arrangement for the delivery of health care in which a health carrier undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis, which Includes any credentialing requirements intended to influence the cost or level of health care services between the health carrier and the one or more providers with the respect to the delivery of health care services; and Requires or creates benefit payment differential incentives for covered person to use providers that are directly or indirectly managed, owned, under contact with or employed by the health carrier. Managed Care Organizations offer programs geared toward improving health and managing care to improve efficiency, quality and access to care for recipients.

5 Virginia Commonwealth University Health System Health Plan Division 5 Benefits of Managed Care Services Available to Managed Care Participants include: –24-hour nurse line –Enhanced pre-natal programs –Preventative programs –Case management services –Disease management services –Health education –Discharge planning –No referral necessary

6 Virginia Commonwealth University Health System Health Plan Division 6 Medallion vs. Medallion II

7 Virginia Commonwealth University Health System Health Plan Division 7 Medallion II Eligibility Medallion II eligible persons include non ‐ institutionalized individuals in the following covered groups: – Families and Children –Aged, Blind or Disabled Non-eligible persons for Medallion II include: –Dual eligible –Individuals on certain waivers –Individuals confined to nursing homes, or free-standing mental health facilities

8 Virginia Commonwealth University Health System Health Plan Division 8 MCO Enrollment Process Enrollment in Managed Care: –Determined eligibility for Medicaid DSS enters into system – days after eligibility the enrollee is entered into system MCO pre-assignment takes place –Enrollee is notified by letter Given the opportunity to select an MCO of their choice –If no call is made Enrollee is assigned to the pre-assigned MCO

9 Virginia Commonwealth University Health System Health Plan Division 9 MCO Enrollment Process Enrollee has 90 days after effective date to change MCO’s for any reason –Before the18th of the month: Effective 1st of following month –After the 18th of the month: Enrollment delayed another month

10 Virginia Commonwealth University Health System Health Plan Division 10 Why Expand Managed Medicaid Medallion II into the Far Southwest?

11 Virginia Commonwealth University Health System Health Plan Division 11 Why Expand into the Far Southwest? Shift the burden and financial risk from the State to Managed Care Organizations. Reduce the burden placed on PCPs to effectively manage members. Managed Care Organizations provide outreach staff for member home visits Care management for effective discharge planning Care management programs specifically focused on Medicaid population (asthma, diabetes, OB care) Improve access to care, quality and reduce Medicaid expenditures for the overall benefit of tax payers.

12 Virginia Commonwealth University Health System Health Plan Division 12 Why Virginia Premier? About Us

13 Virginia Commonwealth University Health System Health Plan Division 13 VCU Medical Center Academic medical center in Central Virginia Referral center for Mid-Atlantic States 32,500 admissions and 500,000 outpatient visits MCV Hospitals Teaching hospital of the VCU Health System 779 licensed beds 20.5% share of the Richmond inpatient market 80,000 patients treated annually in hospital’s emergency department-region's only Level I Trauma Center Children’s Hospital of Richmond Pediatric specialty hospital 60 licensed beds MCV Physicians 566-physician, faculty group practice Virginia Premier Health Plan (VPHP) Medicaid Health Plan-since 1995 VCU Medical Center & Virginia Premier

14 Virginia Commonwealth University Health System Health Plan Division 14 Virginia Premier Health Plan, a managed care organization partnered with Virginia Commonwealth University Health System, meets the needs of underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive, and financially viable healthcare. Our Mission

15 Virginia Commonwealth University Health System Health Plan Division 15 Virginia Premier’s Service Area VA Premier currently has the largest Medicaid Service Area of all health plans With offices in Abingdon, Richlands, Wise, Roanoke, Harrisonburg, Virginia Beach, and Richmond, we believe in hiring locally and supporting the community with employment opportunities

16 Virginia Commonwealth University Health System Health Plan Division 16 1.The Top Ranked Health Plan in Virginia for four consecutive years , 2009, 2010, In 2011 VA Premier is ranked 26 th Nationally out of over 200 Medicaid Health Plans 3.Through Virginia Premier’s nationally recognized Healthy Heartbeats Prenatal program, we have decreased the number of preterm and low-birth weight babies Best Practice Award for Anti-Depressant Medication Management - DMAS awarded 5.The Center for Health Care Strategies awarded DMAS and VPHP the Innovation Award for Improving Health Care Quality for Racially and Ethnically Diverse Populations VPHP was awarded the “Recognizing Innovation in Multicultural Health Care Award” by the National Committee of Quality Assurance (NCQA) 7.Virginia Premier is the only Virginia health plan that operates its own transportation system, inclusive of vans that will be utilizing alternative fuels (Compressed Natural Gas / Propane fueled vehicles) VPHP Awarded NCQA Accreditation Status – Top Rating “Excellent” 9.Only Medicaid MCO serving the Roanoke area for 10 years with over 40,000 members Our Accomplishments

17 Virginia Commonwealth University Health System Health Plan Division 17 What does this mean for my patients? Member Benefits & Eligibility

18 Virginia Commonwealth University Health System Health Plan Division 18 Your patients benefit from: An expanded team of healthcare professionals to assist in accessing the right care, at the right time, in the right setting Increased involvement in their personal health care. Access to a network of specialists Programs targeted to address their individual healthcare needs Your Patients

19 Virginia Commonwealth University Health System Health Plan Division 19 Programs targeted for: Pregnancy Heart condition High blood pressure Asthma or other breathing problems Mental health Diabetes Case management Member Benefits Include Benefits Physician visits – well and sick Hospital services Emergency care Laboratory services Prescription drugs Family planning services X-ray/imaging Mental health services Home health services Rides to medical appointments Maternity and high risk pregnancy care Newborn care Immunizations (shots) for children Physical, occupational, and speech therapies Routine eye exams & glasses for children Routine eye exams for adults

20 Virginia Commonwealth University Health System Health Plan Division 20 Ancillary Services Labs VPHP maintains a list of approved labs that may be performed in the physician’s office. All other lab test(s) must be performed by LabCorp or by Solstas Labs. Lab procedures performed in the office must be performed in accordance with your CLIA certification level. Providers may bill one draw fee per patient. Radiology NIA will provide utilization management services for outpatient CT, CTA, CCTA, MRI, MRA, PET Scan, and Nuclear Cardiology imaging procedures. You may obtain prior authorization through the NIA Web site at or by calling NIA at www.RadMD.com Vision Routine eye exams and eyeglasses are covered through Vision Service Plan (VSP). Members may self-refer for routine vision services to a participating VSP optometrist without obtaining a referral from their PCP. Dental Dental services for children are provided by the DMAS Smiles for Children program. Adult dental services are limited to medically necessary oral surgery and associated diagnostic services such as x- rays and surgical extractions.

21 Virginia Commonwealth University Health System Health Plan Division 21 Toll-free number Hours of Operation: 8 am to 5 pm, Monday-Friday Offer Spanish/Bilingual reps Assist providers and members with the following types of issues: PCP Selection and Provider Participation Eligibility Verification Transportation Scheduling Member Orientation and Education Member address changes and ID card Request Member Services Department For Members and Providers:

22 Virginia Commonwealth University Health System Health Plan Division 22 Member eligibility must be verified monthly (a list of assigned members will be sent to you monthly) and prior to rendering services. Virginia Premier provides four convenient methods to verify member eligibility: 1. DMAS Automated Voice Response System - recommended 2. Interactive Voice Response System 3. NaviNet – a free web based program that allows providers to view member eligibility, claim status and authorizations 4. Call VPHP Member Operations Verifying Member Eligibility

23 Virginia Commonwealth University Health System Health Plan Division 23 Member ID Cards Medallion II/FAMIS PlusFAMIS FAMIS Moms

24 Virginia Commonwealth University Health System Health Plan Division 24 VPHP provides non-emergency transportation to members who do not have readily available transportation. VPHP operates a fleet of vans used to transport members with offices located in Abingdon, Richlands and Norton hour prior notification is required to schedule transportation. 2. Must be a VPHP member with valid ID card. 3. Appointments are scheduled based upon availability of service. 4. Non-emergent transportation is not a covered service for FAMIS recipients. 5. Non- Emergency Ambulance transportation is arranged through Virginia Premier’s Member Services, call , Press 2, 8am - 5pm, M-F. Transportation

25 Virginia Commonwealth University Health System Health Plan Division 25 What does this mean for my practice? Provider Benefits & Services

26 Virginia Commonwealth University Health System Health Plan Division 26 An expanded team of healthcare professionals working with you to meet your patient’s needs –Outreach –Transportation –Health Educators –Case Managers –Disease Managers PCP’s have the potential to see growth as new members are assigned to their panels. Greater access to your patients information across the healthcare continuum. Provider Benefits

27 Virginia Commonwealth University Health System Health Plan Division 27 Dedicated Provider Services Representatives located in our Abingdon office conduct regular site visits to network providers and act as a liaison between the provider and Virginia Premier. They assist providers with issues, answer questions and conduct educational in-services, as needed. Conduct quarterly educational meetings between VPHP and Participating Providers. Quarterly Newsletters to Providers. VPHP’s convenient self service applications such as Navinet and IVR allow providers to check claims, eligibility and authorizations when it’s convenient for them. VPHP has three local offices located in Abingdon, Richlands and Norton. This allows us to interact with our providers and members and develop business relationships within these communities. VPHP Provider Services

28 Virginia Commonwealth University Health System Health Plan Division 28 Abingdon: Amanda Helton (276) Felicia Campbell (276) Provider Service Representatives

29 Virginia Commonwealth University Health System Health Plan Division 29 What does this mean for my practice? Claims

30 Virginia Commonwealth University Health System Health Plan Division 30 1.Claims are processed within Virginia 2.On average, 99% of claims are processed within 30 days of receipt (Medicaid standard is 90%) with a total overall accuracy of 99.8%. 3.VPHP strongly encourages providers to consider filing claims electronically which will assure claims are submitted timely, reduces timely filing denials, and reduces claims administrative costs. A complete listing of all EDI Clearinghouses that VPHP accepts can be found at the VPHP website at 4.Providers may receive payments and remits electronically. In order to receive EFT from VPHP visit our website at and click on the Claims and select the Forms tab to download the EFT forms. To receive ERA’s please contact your clearinghouse directly. Claims Department

31 Virginia Commonwealth University Health System Health Plan Division Timely Filing: Participating providers are required to submit their claims to VPHP within the timeframe established in their provider contract. 2. Claim Appeals: Appeals for denied claims must be submitted to VPHP within 60 days of the original date of the denial. Should a claims processing error be attributable to Virginia Premier, providers have up to 365 days after receipt of payment to appeal. 3. Claim Forms: Provider, ancillary and out patient services should be submitted to VPHP on the CMS Hospital and facility claims should be submitted to VPHP on the UB04 form. Providers must use original claim forms. 4. Pre-Authorization: For services that required an authorization that number should be submitted to VPHP in Box 23 if the CMS-1500 form. 5. Coding: Providers should always refer to the most current versions of the CPT and ICD9 coding manuals when billing services. Claims Policies

32 Virginia Commonwealth University Health System Health Plan Division 32 1.Please contact the claims customer service department if you have claims issues, however, if you have issues that are not resolved to your satisfaction please then contact your local Provider Service Representative. To reach the Claim Customer Service Department call: , Option 4. 2.Claims Customer Service can assist with questions related to claims: a.verify claim status b.researching claims issues and denials 3.Claim status and claim line detail can also be viewed on Navinet, 24/7 and is free of charge. Claims Customer Service

33 Virginia Commonwealth University Health System Health Plan Division 33 What does this mean for my practice? Medical Management

34 Virginia Commonwealth University Health System Health Plan Division 34 1.In the case of sudden onset of an unexpected medical condition and time permits, VPHP members are instructed to contact their PCP for medical advice. If the member is unable to reach their PCP or the situation arises after business hours, members are instructed to call the Nurse Advice Line at The PCP or Nurse Advice Line will assess the member’s medical condition and instruct the member on obtaining appropriate medical care. 2.If a PCP directs a member to the ER then the office should notify VPHP the next business day so the claim can be paid without retrospective review. 3.Emergency Room services that do not meet the Prudent Layperson standard will be reimbursed for a medical screening or “triage fee” only. 4.Members may also be directed to participating Urgent Care Centers for treatment of non-life threatening emergencies. ER Services ER Services

35 Virginia Commonwealth University Health System Health Plan Division 35 1.VPHP does not require referrals to participating (in-network) specialist for its members enrolled with our Medallion II and FAMIS plans. 2.A written report from the specialist to the PCP informing them of the evaluation and care rendered should be sent after the members visit. 3.Members are required to visit participating providers for care and services. Referrals to non-participating specialists are permitted only if the required specialist is not available through the Virginia Premier network and the service is pre-authorized by VPHP. 4.Please utilize one of the following options to obtain an out of network authorization/referral. –Navinet – –VPHP Medical Management – (888) Referrals

36 Virginia Commonwealth University Health System Health Plan Division 36 Pre-Authorization 1.VPHP requires providers to obtain pre-authorizations from the health plan for certain services, procedures and all hospital admissions. Failure to obtain pre- authorization from VPHP for services will result in a denial of the services and the provider will be held responsible for the services. 2.In order to pre-authorize services, select one of the following: a.Enter the request online through Navinet at b.Fax an IP/OP Auth Form to VPHP which can be found at c.Call VPHP (888) and select the option for Medical Management. 3.VPHP maintains a list of OP procedures that do NOT require pre- authorization. The list can be found at located under Medical Management and Utilization Management.www.vapremier.com

37 Virginia Commonwealth University Health System Health Plan Division 37 1.The Medical Necessity Appeals process is a mechanism through which a member’s representative, attending physician/provider or facility can request a review of a non-certification decision by VPHP. Appeals will be considered if received within thirty (30) days of the decision. 2.There are 2 types of Medical Necessity Appeals: ­Expedited Appeal: may be requested when a denial is made by VPHP prior to, or during the course of treatment. If the member / or provider feels that VPHP’s decision is not acceptable, a request to appeal should be faxed to VPHP’s Medical Management dept (804) Once the appeal is received, VPHP will select a physician of the same or related specialty to review the case. This physician will be responsible for returning a decision within three (3) calendar days of receiving the information. ­Standard Appeal: Standard appeals are generally made after services have been rendered. All documentation and/or medical records should be faxed or mailed to: Virginia Premier Health Plan, Inc. Medical Management/ Quality Appeals PO Box 5244 Richmond, VA Appeals Medical Necessity

38 Virginia Commonwealth University Health System Health Plan Division 38 VPHP offers an Integrated Case Management Program for all members that are high risk and who require complex medical interventions. The Case Management Team works closely with the member's PCP to coordinate healthcare services across the continuum of care. Case Managers may also intervene when patients t demonstrate non-adherence to their treatment plan. Circumstances that warrant referral to the Case Management Team include: –Presence of progressive, chronic, or life-threatening illness –Need for inpatient or outpatient rehabilitation –Readmissions or high utilization of the ER –High risk pregnancies –Acute/traumatic injury, or an acute exacerbation of a chronic illness –Complex social factors –Children with Special Health Care Needs Case Management Programs Refer a patient for VPHP's Case Management Services by calling Medical Management at or through the website:

39 Virginia Commonwealth University Health System Health Plan Division 39 Disease Management (Population Health) Integrated Case Management Program Level 3 Intensive CM Assessment & freq. updates to CP Weekly contact until sustained improvement Level 2 Assessment & updates to CP Monthly contact Level 1 Intake Assessment -no Care Plan (CP) Care Coordination 1-3 contacts Goals: Prevention + Self = Management + Cost Control Disease Management Chronic Care Assessment & education Quarterly contact

40 Virginia Commonwealth University Health System Health Plan Division 40 Disease Management Programs VPHP is pleased to welcome members to its disease management programs. These programs will help members better understand their condition and keep them updated on new information. Our programs are based on nationally accepted guidelines and support the physician-patient relationship at no cost to the member. Available programs:  Asthma  Childhood Nutrition  COPD  Diabetes  Healthy Heartbeats (High Risk Pregnancy)  Heart Disease  BiPolar and Schizophrenia To refer a member to Disease Management, please call (866) or through the website at

41 Virginia Commonwealth University Health System Health Plan Division 41 Healthy Heartbeats is VPHP’s prenatal care program that includes pregnant members from conception through birth. Awarded “Best Practice” Goal: To improve health outcomes of mothers and infants by: Creating a partnership between the member, Obstetrician, and Virginia Premier Decreasing low birth weight and premature infants born into the plan Increasing early and consistent prenatal care Improving nutritional status of mothers and infants Increasing knowledge of the importance of prenatal care

42 Virginia Commonwealth University Health System Health Plan Division 42 Program Components Prenatal Doctor Visits MD’s receive $25 for submitting OB registration Prenatal Classes Special Teen Classes WIC Enrollment Home and Outreach Visits Case Management Incentive Awards

43 Virginia Commonwealth University Health System Health Plan Division 43 What does this mean for my practice? Pharmacy Information

44 Virginia Commonwealth University Health System Health Plan Division 44 1.Pharmacy benefits are administered by Envision. 2.VPHP’s Preferred Drug List is a combination of open and closed therapeutic classes. If the medication being dispensed has a generic equivalent version then the generic medication should be dispensed unless brand is specifically requested by the physician on the members prescription. If you have questions regarding prescription drug products that require authorization please contact Envision. 3.Certain medications may have drug quantity limits and /or follow a step therapy program. 4.Drug Prior-Authorizations: Medications requiring prior authorization and excluded medications desired for the appropriate medical management of a patient may be requested by calling Envision at Pharmacy Benefits

45 Virginia Commonwealth University Health System Health Plan Division 45 Generic oral analgesics for pain relief Generic oral antipyretics for fever control Generic ferrous sulfate Generic antacids Generic antidiarrheals Generic antifungals (topical and vaginal) Generic scabicides and Pediculicides Generic Calcium Supplements Generic cough and cold products Generic antihistamines Generic antihistamine/decongestants Covered OTC Medications* Generic anti-ulcer Generic laxatives Generic prenatal vitamins Generic topical corticosteroids Generic vitamins & minerals Generic nicotine replacement therapy Insulin Insulin syringes Blood Glucose Diagnostics Glucometers Urines tests *OTC benefits are only available to Medallion II/FAMIS Plus members only. OTC medications must be written on a physicians RX pad in order to be covered.

46 Virginia Commonwealth University Health System Health Plan Division 46 Contact Information & Closing Remarks

47 Virginia Commonwealth University Health System Health Plan Division 47 Medical Management Pre-Authorization: or Radiology: National Imaging Associates, INC (NIA) ER/Nurse Line: Vision: VSP Vision Lab Services: LabCorp or Solstas Dental Services: Smiles for Children Pharmacy: Envision Claims Customer Service: , option 2 IVR: option 4, option 2 Member Services Member Services/IVR: option 1 Contacts

48 Virginia Commonwealth University Health System Health Plan Division 48 Summary 15 years of experience in Virginia VPHP is owned by a center that treats patients like yours, so we understand your challenges –It is our goal to make your work easier and become your preferred Health Plan We recognize the community-wide benefits of promoting healthy living for members We look forward to partnering with you!

49 Virginia Commonwealth University Health System Health Plan Division 49 Before Questions: A Word of Thanks We recognize you are providing a needed service to your community, and we sincerely appreciate what you do.

50 Virginia Commonwealth University Health System Health Plan Division 50 Questions


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