KCNPNM Questions for MCOs – September 14, 2011
WellCare Responses
1. Will Nurse Practitioners and Nurse Midwives continue to be eligible providers?
(A) WellCare values the care provided to Kentucky Medicaid recipients by Nurse
Practitioners and Nurse Midwives. We would welcome Nurse Practitioners
and Nurse Midwives to continue as eligible providers.
We appreciate the assistance already provided to ensure our revised standard
contract language makes this intention clear.
2. If so, what is the credentialing process and the timeline?
(A) Nurse Practitioners and Nurse Midwives will follow the same credentialing
process and timeline as other providers.
3. Is the credentialing done locally or by a national company?
(A) WellCare plans to complete Kentucky credentialing through our local in house
credentialing department and will not out source. Please note, in some
instances credentialing will be delegated to IPAs and/or PHOs.
4. Will you have a Credentials Committee and if so, will there be representation of Nurse
Practitioners on this committee?
(A) We do have a credentialing committee. At this time we do not have a Nurse
Practitioner on the committee but will take it under consideration.
5. How long will it take for confirmation during the application process?
(A) We are always working to enhance credentialing processes but the application
process can take up to 90-days.
6. Please describe any services for members provided by NPs and MNs which would
require prior authorization.
(A) Nurse Practitioners and Nurse Midwives will follow the same authorization
rules as other providers. They will be responsible for requesting a prior
authorization for any medically necessary EPSDT special services in the event
other health care, diagnostic, preventive or rehabilitative services, treatment or
other measures described in 42 U.S.C. 1396d(a) are not otherwise covered
under the Kentucky Medicaid Program. Please see our Provider Manual or
Quick Reference Guide (attached) for a summary of services that require
authorization and important billing/claim submission information.
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7. How will your formulary be developed? Will there be representation by Nurse
Practitioners (who are authorized by Kentucky statue to prescribe both non-controlled
and controlled substances) on your Pharmacy & Therapeutics (P&T) committee?
(A) The WellCare Clinical Pharmacy department manages the WellCare
formulary process. We establish the Pharmacy & Therapeutics Committee
which includes both internal and external pharmacists and providers. Our
clinical pharmacists review the drug information inclusive of clinical updates,
safety, efficacy, pricing, and utilization data to make recommendations to the
Committee. At this time, we do not have Nurse Practitioner representation.
However, Wellcare would consider participation by a Nurse Practitioner if
selected by our P&T chairman.
8. Please explain your claims process; including software requirements, denied claims
appeal processes and your billing cycle. If new software is required will you provide IT
assistance to NP providers of services? Does this differ for Rural Health Clinics?
(A) We have attached our Quick Reference Guide and Provider Manual that
address processes that include claim submission, EDI, and appeal and
grievance procedures. In addition, WellCare would be happy to coordinate a
Q&A session with our Provider Relations VP.
9. Current Medicaid regulations limit the number of visits for a patient to a Nurse
Practitioner for mental health treatment to four visits per year. This greatly impedes
access and continuity of services. Do you have the ability as an MCO to remove this
restriction?
(A) We are always interested in alternatives that provide greater access to care.
We have the ability to enhance traditional FFS benefit levels but would want
to engage in more discussions before making a decision.
10. Kentucky statute established the Medicaid Advisory council (MAC) on which nursing is
represented and also established a Technical Advisory Committee (TAC) on nursing
services. Will your MCO have a similar structure for obtaining input from provider
groups and consumers?
(A) WellCare will have a Provider Advisory Council and would welcome your
participation.
11. How can the coalition learn more about these committees and what will be the process
for submitting names of nursing representatives?
(A) We will forward information regarding the role and function of the Provider
Advisory Council following approval. Please send any recommendations with
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resumes and background information to Dr. Cheryl Shafer
(Cheryl.Shafer@wellcare.com), Sr. Medical Director, WellCare of Kentucky.
12. What will be your method of communicating with your providers and members? If we
have ideas about how to improve the communication between the MCO and providers
and the MCO and members, what is the mechanism for forwarding this input?
(A) WellCare will use several different methods of communicating with both
providers and our members. WellCare will establish an ongoing Quality and
Member Access Committee (QMAC) that will be comprised of members,
individuals from consumer advocacy groups or the community who represent
the interests of the member population. Among other things, the QMAC will
review and comment on quality, comment on Appeals and Grievances, review
member education and make suggestions for community outreach activities.
Communications to Members will additionally utilize the following:
1. Mailings for all members for initial enrollment and ongoing updates regarding
plan activities, including significant changes in our network.
2. Individual targeted mailings and phone calls for assessments, care planning and
education to assist members to facilitate access to, and appropriate utilization of
care.
3. Home visits to targeted special needs members to assess, educate and establish an
appropriate individualized care plan.
4. Website messages and updates on plan changes, information available and
network availability.
5. 24/7 Nurse advice line available for members with questions regarding health care
and access issues.
6. Community outreach efforts to connect with members through various
community based events and venues.
7. Text messaging health care reminders offered through our prenatal outreach teams
(Text for Babies)
Providers:
1. Web portal with resources and updated messaging
2. Provider orientation offered through web based training with provider relations
support
3. Provider “fax blasts” to communicate important messages quickly
4. Provider Services team to accept calls and issues for resolution and triage to
appropriate resource as needed.
5. Provider relations team in each region
6. Monthly reporting to PCPs on their members and care gaps.
The regional market has very strong leadership committed to serving the members
and providers in Kentucky. Multiple opportunities will be available for providers
to participate on committees and community forums.
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13. Obstetric patients who are not American citizens, but reside in KY are covered briefly be
a Medicaid Managed care program (2-3 months only during the entire pregnancy). Why
are they not covered for the duration of the pregnancy? It would seem that coverage
would encourage the patient to seek early prenatal care which would decrease preterm
deliveries and greater expense to the system for preterm pediatric care.
(A) Presumptive eligibility is covered under the Kentucky Administrative
Regulations. The regulation provides strict guidelines covering the process in
which a provider may make a determination of presumptive eligibility and for
the duration of the time period. As such, WellCare can neither expand nor
change the presumptive eligibility determination process.
14. What is the reimbursement for NP’s under the new plans, will there be cuts for NP’s?
(A) WellCare plans to pay Nurse Practitioners as they are under Medicaid today.
15. Does each managed care organization understand and acknowledge the role of the NP, or
are they primarily concerned with physicians as being listed as a PCP and the exclusive
healthcare provider?
(A) WellCare values the role and services provided by Nurse Practitioners. While
we cannot speak for other organizations on this issue, WellCare considers
Physicians, Nurse Practitioners, Certified Nurse Midwifes or other duly
licensed Providers who spend the majority of their clinical time providing
Primary Care Services to patients as Primary Care Providers.
16. Will there be any access to “Claims Paid Data” to assist providers in their attempt to
optimize the health of their patients (for instance if a patient is seen for high cholesterol, all
lave work completed, standards of care followed from a provider perspective but patient
never gets medication)? Since payment is outcome based.
(A) WellCare Provider Relations Reps and Case Management Staff will assist
Providers with analytical follow up and feedback in these areas.
17. What will the managed care aspect do to encourage, promote, and increase some aspects
of responsibility back on to Medicaid patients (ie. Reducing ER visits and requiring more,
appropriate office visits; smoking issues; requiring will child checks; etc.)?
(A) Wellcare focuses on empowering members to make positive choices to
improve their health and health care utilization through implementing several
initiatives to provide education and encourage proactive, appropriate use of
health care services. Examples include:
1. Identification of high risk/high utilizing members for inclusion in our disease and
case management programs
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2. Claims filters to identify patterns of inappropriate ER utilization and
implementation a program to divert repeat seekers of non-emergent care to other
care settings.
3. Implementation of both a PCP and pharmacy lock-in program for confirmed over
utilizers.
4. Member education and targeted programs to encourage smoking cessation, weight
reduction and other healthy lifestyle changes
5. Information provided to Primary Care Providers to identify members with care
gaps, including EPSDT visits.
6. Periodicity mailings to members to remind them of important preventive health
services.
7. Facilitation of referrals to specialty care, including behavioral health providers to
develop a holistic care plan for each member.
18. APRNs are increasingly functioning as primary care providers in the growing absence of
primary care physicians. What is the philosophy of the MCO toward the APRN as an
independent licensed practitioner, instead of as “only” an ancillary, “mid-level” provider
whose services may only be secondary to (less important than) physician services.
(A) WellCare desires to contract with APRNs and understands the important role
they fill in meeting healthcare needs of individuals. WellCare is also mindful
of the requirements under Kentucky law for an APRN to have a Collaborative
Agreement for Prescribing Authority (CAPA) with a physician and a valid
DEA number and separate CAPA for controlled substances. If an APRN
meets the requirements under the law to prescribe drugs then they will be able
to continue do so without additional supervision of a physician or requirement
that the member have physician contact.
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