Evercare of Texas
Provider Newsletter for
Harris, Travis and Nueces
service delivery areas
Summer 2010
Evercare of Texas Provider Newsletter for Harris, Travis and Nueces service delivery areas
Summer 2010
In This Issue:
Urge Members to “Beat the Heat”
4–5
Managing Congestive Heart Failure
6–7
Evercare Assists Providers in Expediting Care for Children of Migrant Farm Workers
Save Time and Money With Electronic Payments And Statements (EPS)
Remind Patients About Annual Checkups
Evercare of Texas Locations
®
Harris Service Area
Nueces Service Area
9702 Bissonnet
Suite 2200W
Houston, TX 77036
400 Mann Street, Suite 901
Corpus Christi, TX 78401
San Antonio Area
5800 Granite Parkway, Suite 900
Plano, TX 75024
Travis Service Area
6200 Northwest Parkway
San Antonio, TX 78249
www.EvercareHealthPlans.com/
TX_StarPlus
1250 Capital of Texas
Highway South, Ste. 360 (Bldg. 1)
Austin, TX 78746
2
3
Annual Surveys Slated for July-August
Advanced Health Care Directives
Dallas/Fort Worth Service Area
Page(s)
www.evercarehealthplans.com/TX_StarPlus
8
9
10
11
As summer approaches
and the temperatures
soar, providers should
counsel members on how to beat the heat.
Urge members to “Beat the Heat”
Statistics show that hundreds of Texans
die each summer from heat stroke. In
2004 alone, there were 258 deaths due
to the Texas heat. Those mostly at risk of
heat stroke are very young children and
older adults. People with chronic illnesses
and those without air conditioning also
are at risk for heat stroke.
How can you help to protect members
from heat stroke? When talking with your
patients, a gentle reminder of what to do
and what not to do is helpful in educating.
Remind members of the following:
• Avoid going outside when the
temperature exceeds 90 degrees.
• Dress lightly.
• Drink plenty of fluids, and keep cool.
While this advice sounds simple, it isn’t
always easy for the frail and elderly to do.
As you all know, many people consume
medications that increase urination – like
some medicines for high blood pressure
or heart failure. If you have a member
who takes that kind of medicine, please
educate him or her. Advise to adjust fluid
intake to cope with the summer heat.
Keeping cool during long heat waves
is difficult too. While a simple fan may
be enough to keep cool when the
temperature is below 90 degrees outside,
it’s not enough when the temperature is
higher. Air-conditioning is a MUST when
the mercury goes above 90 degrees.
If you know of a member who doesn’t
have air-conditioning, advise him or her
to spend the hottest part of the day at
the mall, in a library, or with a friend who
has it. Your conversation may be the
needed reminder for those members.
Evercare of Texas
3
Annual Surveys Slated for July –
Each year, Evercare is required by
the Health and Human Services
Commission to survey providers
for compliance with After-Hours
Accessibility and Appointment
Availability standards. The providers
are selected according to membership
panel size. Providers will receive an
after-hours survey phone call and an
appointment availability survey via fax from
Provider Relations in July-August. The annual
surveys are part of an effort to ensure that members
are able to reach a physician after regular business hours and
obtain necessary appointments in a timely manner. The brief surveys
measure each office’s ability to comply with established standards.
After-Hours Accessibility
Evercare, or a contracted entity, will call selected PCPs
after normal business hours to ensure that access to medical
care is available 24 hours a day, seven days a week. Evercare
guidelines require PCPs to have an answering service that is
able to reach the physician, an answering machine indicating
how to reach the physician or another designated provider
accepting calls. Providers must return all member calls
within 30 minutes. The survey is part of a federally and state
mandated monitoring audit and declining to participate
may cause the provider to be non-compliant with contract
requirements. Results of the July-August survey will be
reported to the Evercare Quality Improvement Committee.
For your reference, the measurable standards are listed below:
Acceptable After-Hours Accessibility Standards
• The office telephone is answered after hours by an
answering service that meets language requirements
of the major population groups and which can contact
the PCP or another designated medical practitioner.
• All calls answered by an answering service must be
returned within thirty (30) minutes;
4
• The office telephone is answered after normal business
hours by a recording in the language of each of the
major population groups served, directing the member
to call another number to reach the PCP or another
provider designated by the PCP. Someone must be
available to answer the designated provider’s telephone.
Another recording is not acceptable to meet the
standard; and
• The office telephone is transferred after office hours
to another location that meets language requirements
where someone will answer the telephone and be able
to contact the PCP or another designated medical
practitioner, who must return the call within thirty
(30) minutes.
Unacceptable After-Hours Accessibility Standards
• Office telephone is only answered during office hours;
• Office telephone is answered after hours by a recording
that tells members to leave a message or send a page;
without the option of calling another number to reach
a provider.
www.evercarehealthplans.com/TX_StarPlus
August
• Office telephone is answered after hours
by a recording that directs members
to go to an Emergency Room for any
services needed; and
• Returning after-hours calls outside
of the thirty (30) minute timeline.
Appointment Availability
Based on the type of member appointment
needed, providers are required to adhere
to specific standards for scheduling
appointments. Evercare’s appointment
availability standards are as follows:
• Emergency care is provided
immediately upon presentation
at the service delivery site;
• Urgent care appointments must take
place within twenty four (24) hours
of the appointment request;
• Routine primary care appointments must
take place within fourteen (14) calendar
days of the appointment request;
• Routine specialty care referrals must be
provided within 30 days of request;
• Pre-natal care must be provided within
14 days of request, except for high-risk
pregnancies or new members in the
third trimester, for whom an appointment
must be offered within five (5) days, or
immediately if an emergency exists;
• Overdue or upcoming well-child
checkups, including Texas Health Steps
medical checkups, must be offered no
later than 14 days after enrollment for
newborns and no later than 60 days of
enrollment for all other members under
the age of 21.
• The survey will also include a question
on office wait times, for which the health
plan standard is less than 15 minutes.
Questions regarding these annual surveys
can be directed to your Provider Relations
Representative.
Evercare of Texas
5
Managing Congestive Heart Failure
A primary-care physician’s guide to best practices
Last quarter, Evercare ran an article in our provider
newsletter about a local physician whose Healthcare
Effectiveness Data and Information Set (HEDIS®) scores
were above-average for diabetes care, as compared to
our health plan average. This quarter, Evercare
congratulates Dr. Jacqueline Carruthers, a
primary-care physician located in Houston,
Texas, for leading HEDIS® measures for
the management and treatment of
congestive heart failure (CHF).
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Jacquel
These results mean that of Dr. Carruthers’
patients diagnosed with congestive heart failure,
64 percent are prescribed ACEi-ARBs as compared to
only 39 percent of other CHF patients in our health plan
with this diagnosis.
We interviewed Dr. Carruthers to understand the methods
to her management of cardiovascular conditions and her
thoughts on what attributed to her successful results.
Measure
Plan average Dr. Carruthers’
result
result
Prescribing
ACEi-ARBs
39%
64%
Prescribing
Beta-Blockers
62%
91%
Screening
for LDL-C
59%
Dr. Carruthers’ office works closely
with cardiologists in the Houston
area and communicates with
them on a regular basis. The great
relationships that she has developed
with consulting cardiologists, as well
as good electronic medical records,
allow her to follow her patients closely.
“I’m doing some of the same things that
a cardiologist would do, like reading the same
articles and journals, following the appropriate standard
of care, keeping up with journals,” explains Dr. Carruthers.
“Establishing a routine similar to a cardiologist and following
the same standards of care … well, it’s hard to go off track
with heart disease.”
The electronic medical record used in Dr. Carruthers’ office
tags specific diagnoses and flags a chart alert for patients
with certain conditions. For example, a RED flag in a
patient’s medical record is indicative for the office staff
to follow a specific protocol or order specific tests. The
electronic medical record allows for tracking, which makes
the office more efficient. When retrieving a patient name,
it also displays the diagnosis in a prominent location.
Talk It Over
82%
The No. 1 Killer
According to the American Heart Association, an estimated
5.7 million Americans are living with heart failure, and
670,000 new cases are diagnosed each year. Dr. Carruthers
6
“I understand that heart disease is the No. 1 killer in
America. If you can prevent it, you can save a life,” says
Dr. Carruthers. “I am diligent about adhering
to and using the tests recommended by the
American Association of Cardiologists
for controlling heart disease. I educate
patients every chance I get, not only
on heart disease, but also about
chest pain and non-angina type
symptoms like shortness of breath,
chest pain and fatigue.”
MD
To fully appreciate this article, the
reader must understand what’s
being measured and how this
relates to your practice. The
following results illustrate the
care and services provided for
STAR+PLUS Medicaid members
by Dr. Carruthers’ office during the
measurement year from July 2008 to
June 2009. The measures are based on
clinically-accepted best practices.
understands this fact and capitalizes on every chance to
educate her patients.
For Dr. Carruthers, education is also a key characteristic
in her practice. She makes it a habit to candidly discuss
with patients that heart disease is the No. 1 killer, ensuring
that the patient understands this fact. She discusses issues
including weight, sleeping habits, the importance of
medications, the proper medications, as well as the costs
of those medications, and allows plenty of time to answer
questions. In keeping a patient’s budget at the forefront
www.evercarehealthplans.com/TX_StarPlus
Networking proves important
every time she educates, Dr. Carruthers often prescribes
combination drugs (drugs with two or more active
ingredients) or generic drugs.
“I try very hard to stay within a patient’s budget. If they
can’t afford a specific medication, they won’t adhere to
the regimen. I also give samples whenever I can,” says
Dr. Carruthers.
She acknowledges the factors that may influence a
patient’s care, including the role of family support in
medications adherence. “In today’s world there is a
different climate in the doctor-patient relationship.
There are so many parties involved – the government,
the patient’s family and extended family. It’s important
to try to explain to all parties to ensure they all understand
the disease.”
While talking with her patients, Dr. Carruthers tries to
teach them to ask questions and learn about their disease.
She provides articles or directs them to the Internet for
basic patient information to read.
Like Dr. Rhonda Barnes-Jordan, who was featured in last
quarter’s newsletter, Dr. Carruthers also schedules patients
with certain medical problems on the same day to ensure
that procedures are not overlooked. All cardiology
patients normally have appointments on Wednesday.
In addition, physician assistants work with the cardiology
patients on education and specific tests and procedures.
When asked of Dr. Carruthers what led to her practice
outperforming other physician practices in
our health plan, she acknowledged that
a complete understanding of heart
disease and patient education were
the successful factors.
Dr. Carruthers opened a new
practice about five years ago
in an underprivileged area
of Houston. “Evercare was
instrumental in my being
able to build this office,”
says Dr. Carruthers. “The
volume of Evercare patients
was instrumental. It allowed
me to build an 11,000
square foot facility
and serve many
underprivileged patients.”
We had a chance to visit with one of Dr. Carruthers’ cardiac patients, Bill
(patient name changed to protect
privacy), and asked his feedback on
whether Dr. Carruthers and her staff did anything special to help him manage
his cardiac illness.
“The best thing that Dr. Carruthers did for me was refer
me to my cardiologist, Dr. Domingo Gonzalez, who then
networked with other cardiologists to find the cardiac
surgeon who performed the surgery,” explains Bill.
“Through their networking with each other, I was able
to find the right surgeon and have the surgery in February
of 2009. I feel better than I have in 15 years. I was born
with a birth defect that was discovered in middle school,
but over time, my condition progressively got worse,
which eventually led to surgery.”
Bill also added that Dr. Carruthers has a professional
and fabulous staff who care for and look out for the
patients’ needs. This particular practice also employs
nurse practitioners, who carefully review charts and
stay abreast of a patient’s condition. Additionally,
Dr. Carruthers has made it easy for Bill’s family to attend
office visits together. Both he and his mother-in-law
had surgery and always attend their checkups on the
same day, making it very convenient for the whole family.
Medical Director’s Note:
Three beta-blockers have the strongest evidence for reducing
mortality in patients who have heart failure –
bisoprolol, carvedilol, and metoprolol succinate.
Similarly, ACE-i therapy reduces mortality
and improves quality of life. In patients
unable to tolerate ACE-i, ARBs are
an alternative. In those unable to
tolerate either class, hydralazine
and long-acting nitrates
may help.
Drugs to avoid for patients
who have heart failure
include NSAIDs, calcium
channel blockers, and most
antiarrhythmics because
they can adversely affect
clinical status. [http://circ.
ahajournals.org/cgi/reprint/
CIRCULATIONAHA.
109.192064]
Evercare of Texas
7
Advance Health Care Directives
Evercare is required to maintain written policies and
procedures regarding advance directives. Our written
policies include any limitations on implementation of an
advance directive due to a matter of conscience. We clarify
whether any conscientious objections are raised by Evercare
or by individual providers, and describe the range of medical
conditions or procedures affected by the conscientious
objection. If your members or family members have a
conscientious objection related to the execution of an
advance directive, please have them contact their service
coordinator to notify us of their specific issue.
Evercare is required to inform all members of their rights
with respect to advance directives. In our member materials,
we encourage all Evercare STAR+PLUS members to discuss
their wishes with their PCP or their service coordinator.
Providers must document in a prominent part of the
member’s current medical record whether or not the
member has executed an advance directive. The provision
of care cannot be conditioned, and a member may not
be otherwise discriminated against, based on whether
or not the member has executed an advance directive.
Member’s Rights and Responsibilities Related to Advance Directive
• Members have the right to receive medical care even if
the member does not have an advance directive.
• Members must inform physicians and other health care
providers if they have formulated an advance directive.
• Members have the right to change or cancel advance
directive at any time.
• Provider Responsibilities related to advance directives
• Members have the right to obtain clear and concise
information with regard to the different types of
advance directives available to them, and when an
advance directive will take effect.
• Members are expected to discuss advance directives
with their PCPs, as well as family members, friends, and
other individuals who are involved in their health care.
• Members must comply with state and federal laws
regarding the witnessing and notarizing of advance
directive documents.
• Members must keep advance directive in a safe place
that is accessible to family members or other
responsible individuals.
• Members are expected to give copies of the advance
directive to their PCPs, as well as family members,
friends and other individuals who are involved in their
health care.
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• Providers must comply with all state and federal laws
regarding advance directives.
• Providers must ask if adult members have an advance
directive, and include existing advance directive in
the member’s medical record.
• Providers cannot require a member to have an
advance directive in order to receive medical care,
nor can they prevent a member from having an
advance directive.
• Providers must not execute advance directive until the
member is no longer able to give informed consent.
• Providers must maintain written policies for their office
staff regarding advance directives.
• Providers must ensure that members understand
their rights and responsibilities with regard to their
advance directive.
www.evercarehealthplans.com/TX_StarPlus
Evercare Assists
Providers in
Expediting Care for Children of
Migrant Farm
Workers
Evercare of Texas strives to meet the unique needs of all of our members and
endeavors to support our providers in reaching this goal. The Frew vs. Hawkins
Corrective Action Order for Managed Care filed 04/27/2007 mandates Texas
Medicaid Managed Care contractors, and their providers, must allow special
provisions for accelerating services to children of migrant farm workers. Evercare
policies have been developed to identify children of migrant farm workers enrolled
in our plan, to accelerate and monitor the services they receive, and to report
this data to the Health and Human Services Commission (HHSC). Due to the
frequent transition of these members in and out of Medicaid service
plan areas, efforts are focused on identifying member needs
and implementing a service plan which supports the
migratory patterns of these members.
Historical data indicates that many of the children
of migrant farm workers obtain delayed, limited
or fragmented medical and dental care. These
children experience difficulty with access to
care. Their caregivers often do not understand
their medical needs. Language barriers
are sometimes present which results in
inadequate care coordination. These
children also have specific increased risk
factors for health problems.
Evercare identifies a child of a migrant farm
worker and reports that child to HHSC. At
that point, service coordination is expedited.
For example, the member’s Service
Coordinator may work with the PCP or other
service providers to arrange for expedited
THSteps visits, assistance with scheduling
a comprehensive assessment within 30 days
of enrollment with Evercare, or coordinate a
referral for specialists or ancillary services.
Providers are encouraged to seek assistance from
Evercare, if needed, as these members
often transition in and out of their designated
HHSC has designated a Frew Advisory Committee to develop and
PCP enrollment lists. Providers may contact
endorse initiatives to promote access to care for children enrolled in
Evercare at 1-800-349-0550 and ask for the
Medicaid. During the February 2008 meeting, the committee endorsed
member’s Service Coordinator for assistance
an initiative called the “Migrant Health Proposal Plan.” This plan provides
in care coordination and help finding
insight as to where these children live, an increased understanding of
community resources. Providers may contact
their needs and an improved communication and coordination of care
their Senior Network Account Manager
with these families. Evercare will continue to provide education and
directly if they encounter difficulties in
resources for PCPs and ancillary providers as additional plans and
expediting referrals to specialists or other
information become available related to the needs of children of
providers. Providers may also access the
migrant farm workers.
following Migrant Clinician’s Network Web
site for resources on locations of Migrant
Children of migrant farm workers have an increased need for prompt
Health Centers, patterns of migrant migration,
medical care and detailed care coordination with follow-up. An active
common migrant health problems, migrant
partnership between providers and Evercare will allow these members to
educational materials, and other additional
experience an improved level of health care services without interrupting
resources: http://www.migrantclinician.org.
the family’s lifestyle needs. Please contact your Evercare Senior Network
For more information, contact the Migrant
Account Manager if you have additional questions about these members.
Clinician’s Network at 1-512-327-2017.
Evercare of Texas
9
Save Time and Money with Electronic Payments and Statements (EPS)
Have you wanted to enroll in Electronic Payments and Statements
but just haven’t done so? If so, this is your friendly reminder!
Turn your claims payments and statements into electronic format.
Here’s how:
To register online for this feature, follow
these easy steps:
Or by fax:
1. Log onto www.UnitedHealthcareOnline.com.
1. Contact the EPS Help Desk at 1-866-842-3278
to request a registration form.
2. Choose “claims and payments.”
2. Fax the completed enrollment form to 1-800-765-6766.
3. Choose “electronic payments and statements.”
4. If you already have a user ID and password, enter
these in the spaces.
If you do not have a user ID and password, choose
“click here” and enter your provider information.
5. After your registration is complete, you will receive
an e-mail confirmation.
6. Y
ou will begin to receive payments electronically
in 7 to 10 business days.
EPS is an electronic feature that allows providers to get
reimbursed electronically, rather than receiving a physical
reimbursement check. The service is available to providers
at no cost and helps streamline and simplify the payment
process for Evercare and SecureHorizons** claims, as well
as claims submitted for UnitedHealthcare members.
**Not available for Nueces service delivery area.
All network and non-network providers
are eligible to enroll in EPS
• Hospitals
• Laboratories
• Physicians
• Long-term services and support providers
• Other health care professionals
Product types
EPS is available for the following product platforms:
• Commercial United Healthcare products
• Medicare (Harris and Travis service delivery areas only)
• Medicaid STAR+PLUS (Harris, Travis and Nueces
service delivery areas)
After the registration process is complete, a Provider
Relations Representative will contact you personally
to discuss and ensure your satisfaction with this service.
While this is not mandatory, we do encourage you to take
advantage of the service as it is sure to create efficiencies
within your office by reducing the time your staff spends
von manual processing and claim payment reconciliation.
If we can help with this transition, or if you have additional
questions, please do not hesitate to contact the EPS Help
Desk at 1-866-UHC-FAST (1-866-842-3278), Option 5.
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www.evercarehealthplans.com/TX_StarPlus
Remind Patients About Annual Checkups
At Evercare, our goal is to help all of our members to live healthier lives.
Important steps in achieving that goal are to promote healthful lifestyles and to encourage strong relationships between our members and their physicians. We encourage every member to see their physician at least once a year for
preventive care.
Because some members tend to go to the doctor only when
something is bothering them, their office visits may be too narrowly
focused on the chief complaint. We want our members to have an
annual checkup in which you can provide important preventive
services, including screenings for pre-symptomatic disease and
important lifestyle messages on diet, exercise and substance use. These things are so important that we make annual exams a benefit of every Evercare plan and there is no member copay.
For you, the busy physician, the annual exam is an opportunity
to do a comprehensive exam, to document your findings in an
unhurried manner, to review medications with your patient and
to code all of the member’s health problems and sequelae.
It’s mid-year. Have you reached out to members to get them in
for an annual checkup?
Evercare of Texas
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Evercare of Texas
Provider Relations: 1-888-303-6162
9702 Bissonnet, Suite 2200W
Houston, TX 77036
In This Issue:
• Beat the Heat
• Accessibility Surveys
slated for July-August
• Advance Health Care Directives
• Managing Congestive
Heart Failure
• Electronic Payments and Stements
• Expediting Care for
Children of Migrant Farm Workers
• and more!
Locations:
Evercare® of Texas
Harris Service Area
9702 Bissonnet
Suite 2200W
Houston, TX 77036
Evercare of Texas
Travis Service Area
1250 Capital of Texas
Highway South, Ste. 360 (Bldg. 1)
Austin, TX 78746
Evercare of Texas
Dallas/Fort Worth Service Area
5800 Granite Parkway, Suite 900
Plano, TX 75024
Evercare of Texas
Nueces Service Area
400 Mann Street, Suite 901
Corpus Christi, TX 78401
©2010 UnitedHealthcare Services, Inc.
Evercare of Texas
San Antonio Area
6200 Northwest Parkway
San Antonio, TX 78249
EVTX10MC3237751_000