1. Working together to provide quality care for MDwise members
Show me the Money
Working together to provide quality care for MDwise members
P0607

2. Indiana Health Coverage Programs
FSSA
Traditional Medicaid
OMPP
Hoosier Healthwise
Risk-Based Managed Care
MDwise
MHS
Anthem
MAXIMUS
MDwise (Care Select)
ADVANTAGE (Care Select) HP
590 Program
Healthy Indiana Plan
Anthem Blue Cross
Blue Shield
Enhanced Services Plan
(ESP)
Care Select
Cenpatico
Behavioral Health
Magellan Health
Services
Managed Behavioral Health Organizations
FSSA= Family & Social Services Administration
OMPP= Office of Medicaid Policy and Planning
Maximus= Enrollment Broker
P0607

3. Who is MDwise?
MDwise is a local, not-for-profit company serving Hoosier Healthwise, Care Select and Healthy Indiana Plan (HIP) members.
MDwise believes that everyone deserves to have health coverage.
MDwise Hoosier Healthwise covers 270,000 children, pregnant women, and eligible families.
P0607

4. Who is MDwise?
P0607

5. What is Risk-Based Medicaid?
MCE’s are paid a per member per month fee; this is called a capitated rate 
The capitated premium covers the cost of the care for all covered services for the patients.
The MCE’s assume financial risk for services of members; thus the name “Risk-Based” does not mean the patients are “high risk”.
P0607

6. Benefit Package Coverage
Package A – Standard Plan
Full coverage for children, low-income families.
Package B – Pregnancy Coverage Only
Pregnancy-related, postpartum care, family planning, pharmacy, transportation, urgent care services for some pregnant women.
Package C – Children’s Health Plan
Preventive, primary, and acute care services for some children under 19 years old.
Package P – Presumptive Eligibility
Presumptive eligibility for pregnant women. (RID # starts with 550)
Package E – Emergency Only
Limited to treatment for medical emergency conditions.
P0607

7. NCQA
National Committee for Quality Assurance is the organization that accredits Managed Care Organizations (MCO’s).
Mission
To improve the quality of health care. Vision
To transform health care quality through measurement, transparency and accountability.
Values
Our passion is improving the quality of health care.
We stand for accountability throughout the health care system.
P0607

8. NCQA created HEDIS Effectiveness Data & Information Set
Healthcare
Effectiveness
Data &
Information
Set
A set of standardized performance measures
Ensures that consumers have reliable information on the performance of
MCO’s.
>90% of health plans use HEDIS to measure performance
on important dimensions
of care and service.
P0607

9. Pay for Performance or P4P are Incentivized HEDIS Measures
A contractual activity of MCO’s
P4P is an incentive to meet quality measures for providers in the commercial, Medicaid and Medicare insured populations.
1.0% of the MDwise capitated payment is withheld, and paid to the MCO when quality goals are met.
P0607 9

10. Pay for Performance – P4P
Supplemental payment based on measured performance against a target
Incent high quality care by shifting greatest reimbursement to highest quality providers and plans
Incent provider offices to increase visits or improve processes.
Site contests or office contests to improve quality of care.
P0607

11. Pay for Performance – P4P
Provider incentives based on claims submissions.
Provider incentives based on meeting targeted measures.
Site contests by increasing a measure or bringing in the most members requiring services in a given measure.
Provider incentives adding provider staff or equipment that can help increase a quality measure or quality of care to members.
P0607

12. HEDIS contains 71 Quality Measures:
          
Asthma Medication Use
Persistence of Beta-Blocker Treatment after Heart Attack
Controlling High Blood Pressure
Comprehensive Diabetes Care
Breast Cancer Screening
Antidepressant Medication Management
Childhood and Adolescent Immunization Status
Advising Smokers to Quit & offering assistance to quit….and others
P0607

13. OMPP Incentivized HEDIS Measures
Adolescent well-care
Well-care for children ages 3-6 years
Well-care for children, 0 – 15 months
Timeliness of prenatal care
Frequency of prenatal care
Timeliness of postpartum care
7 day follow-up of a behavioral health stay
LDL-C screenings for diabetic members
Cervical cancer screenings
Follow – up care for children prescribed ADHD meds
P0607

14. How do we Compare? MDwise NCQA 90th%tile Cervical Cancer Screening
74.45%
79.5%
LDL-C
(Diabetes Care)
68.61%
82.5%
Follow-Up after Hospitalization for Mental Illness (7 Days)
48.22%
64.2%
P0607

15. How do we Compare? MDwise NCQA 90th%tile Timeliness of Prenatal Care
89.54%
92.2%
Timeliness of Postpartum Care
75.67%
72.7%
Frequency of Prenatal Care
82.73%
81.0%
P0607

16. How do we Compare? MDwise NCQA 90th%tile
Six or More Well-Care Visits in the First 15 Months of Life
60.83%
73.9%
Annual Well-Child Visit Ages 3-6
72.99%
80.3%
Annual Well-Child Visit Adolescents
53.28%
56.7%
P0607

17. How we Promote Quality Care
Provider and staff education
Network Improvement Program (NIP) Team
Billing and process audits
ManagedCare.com
Member education
Reminder Calls about appointments to members
Member incentives:
Well Child (3 – 6 and 12 – 21)
Provider incentives
Disease/Health management services for members with diabetes
Disease/Health management for members with asthma
P0607

18. How NIPT Can Help…..
The Network Improvement Programs Team assists MDwise departments in the outreach and education of its providers and delivery systems.
NIP Team Responsibilities:
Created to take improvement efforts to a higher level
Educating providers on HEDIS and ROQ standards.
Providing physicians information about their quality performance
Diagnose office practices that may result in missed opportunities to provide care or cause services to not be billed correctly
Creating and distributing reference/educational materials and tools
P0607

19. NIP Reports
P0607

20. NIP Reports
P0607

21. NIP Reports
P0607

22. Disease/Health Management
RN’s identify & evaluate members with unique healthcare needs
Develop individualized plan of care
Assist in overcoming barriers to care
Risk assessment
Maintains contact with PMP and member
Implements interventions for identified needs.
P0607

23. Disease Management Goals
• Empower member with self-management tools, education and awareness
• Promote the Asthma/Diabetes action plan in the home, school, and provider office
• Encourage adherence to the physician’s treatment plan
• Reinforce self-management goals: problem-solving techniques, overcoming barriers, and establishing goals
• Provide physicians with member specific utilization information including pharmacy, emergency room, and outpatient visits
• Promote relationship between the member and his/her physician(s)
• Promote healthy lifestyle choices
P0607

24. Opportunities for Improvement
Maximize every member interaction to provide preventive and well-care.
Well care visits for children when they are in for acute care
Schedule the 15th month EPSDT (Early Periodic Screening, Diagnosis, and Treatment) visit prior to the 15th month of life
LDL-C screens for diabetics when in for acute care
Document all components of prenatal and postpartum care and submit for well-care visits.
Staff who does scheduling can identify members who need services to schedule in a timely fashion
Ensure proper billing for services rendered.
Be sure that the documentation is complete
P0607

25. Converting Acute Visits to Well Visits
P0607

26. P0607

27. Documentation for Well Child Visits
Developmental milestones
Review diet and nutrition
Previous problems addressed?
Address obesity and other chronic problems
Ask about smoking, starting at age 10 yrs.
Mental and physical assessment
BMI – record & discuss
Unclothed exam
Provide anticipatory guidance & counseling
Do routine testing (lead, vision, hearing)
P0607

28. HealthWatch/EPSDT/Bright Futures
Preventive healthcare program
Emphasis is given to early detection
For members from birth to 21 years old
Required care for Medicaid members
Assures availability and accessibility of
required health care resources
These components of care are a required part of the well-child assessment
P0607

29. Opportunities
If a member contacts the primary medical provider’s (PMP’s) office for a sore throat (sick visit) the office should take the opportunity to provide preventive care and schedule a well child visit if the member is due for services.
If the PMP office receives a list of non – compliant members, the office should reach out to the members and schedule preventive services.
P0607

30. Opportunities
A PMP office could take the opportunity to convert a sick visit into a well – child visit when the member is in the office for acute care.
If the PMP office has electronic medical records (EMR), implement alerts to reflect the non – complaint members in the quality measures.
P0607

31. Opportunities
If a member is being seen for an initial prenatal visit or post partum visit, all the components of a preventive well – child exam are provided. The appropriate V20.2 or V70.0 can be submitted as a secondary diagnosis code and count towards the AWC measure.
If all components of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services were provided, remember to submit the appropriate – or – with the V20.2.
P0607

32. Opportunities
If all components of EPSDT were not provided, remember to submit the appropriate E&M code along with V20.2, V70.0, or V70.3 to ensure the services count towards the HEDIS measure.
If EPSDT services were provided along with acute care, be sure to submit the appropriate EPSDT code along with the E&M code and the 25 modifier to ensure the services are counted towards the HEDIS measure.
P0607

33. Quiz……..
If the PMP office provides immunizations and well care at the same visit, can I bill for both?
How do I bill for both services and how do they count towards the HEDIS measure?
When can I bill for the following combination and V20.2 as primary?
If a pregnant adolescent member is seen for prenatal care, how is the claim coded to count towards the HEDIS measure?
Can a sick visit and a preventive visit be billed and reimbursed n the same date of service (DOS)?
P0607

34. Quiz……..
Is MDwise currently at the NCQA 90th percentile for the well – child 3 – 6 measure?
Name 2 examples of provider incentives?
Name 2 examples to promote quality of care within the MDwise network.
Give an example of a disease management goal?
Give an example for an opportunity for improvement?
What is a goal of the EPSDT program?
P0607

35. Resources MDwise website : www.MDwise.org
My Wellness Zone:
American Academy of Pediatrics
P0607

36. American Academy of Pediatrics

37. P0607

38. Thanks for your hard work!
Questions?
P0607

39. Handouts HEDIS poster Well – Child Mini Poster
Quality PDF
EPSDT grid
Network Improvement Program Charts
P0607