Medicaid Managed Care
Virginia Premier Health Plan
April 17, 2012
Virginia Commonwealth University Health System Health Plan Division
1
Today’s Presentation
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
Virginia Commonwealth University Health System Health Plan Division
2
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.
Virginia Commonwealth University Health System Health Plan Division
3
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.
Virginia Commonwealth University Health System Health Plan Division
4
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
Virginia Commonwealth University Health System Health Plan Division
5
Medallion vs. Medallion II
• Most Virginia Medicaid enrollees are required to receive
their medical care through a managed care plan.
• Virginia has two care plan categories established to
provide quality health care services to enrollees:
- Medallion PCCM (straight fee-for-service)
- Medallion II (administered through an MCO)
Virginia Commonwealth University Health System Health Plan Division
6
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
Virginia Commonwealth University Health System Health Plan Division
7
MCO Enrollment Process
• Enrollment in Managed Care:
– Determined eligibility for Medicaid
• DSS enters into system
– 15 - 45 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
Virginia Commonwealth University Health System Health Plan Division
8
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
Virginia Commonwealth University Health System Health Plan Division
9
Why Expand Managed
Medicaid Medallion II into
the Far Southwest?
Virginia Commonwealth University Health System Health Plan Division
10
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.
Virginia Commonwealth University Health System Health Plan Division
11
Why Virginia Premier?
About Us
Virginia Commonwealth University Health System Health Plan Division
12
VCU Medical Center & Virginia Premier
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
Virginia Commonwealth University Health System Health Plan Division
13
Our Mission
• 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.
Virginia Commonwealth University Health System Health Plan Division
14
Virginia Premier’s Service Area
Non-Service Area
Western
Far Southwest Area
Roanoke
Fredericksburg
Central VA
Danville/Lynchburg
Tidewater
•
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
Virginia Commonwealth University Health System Health Plan Division
15
Our Accomplishments
1. The Top Ranked Health Plan in Virginia for four consecutive years 2008, 2009, 2010, 2011
2. In 2011 VA Premier is ranked 26th 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
4. 2010 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
6. 2008-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)
8. 2007-2013 VPHP Awarded NCQA Accreditation Status – Top Rating
“Excellent”
9. Only Medicaid MCO serving the Roanoke area for 10 years with over 40,000
members
Virginia Commonwealth University Health System Health Plan Division
16
What does this mean for
my patients?
Member Benefits & Eligibility
Virginia Commonwealth University Health System Health Plan Division
17
Your Patients
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
Virginia Commonwealth University Health System Health Plan Division
18
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
Virginia Commonwealth University Health System Health Plan Division
Programs targeted for:
• Pregnancy
• Heart condition
• High blood pressure
• Asthma or other breathing
problems
• Mental health
• Diabetes
• Case management
19
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 www.RadMD.com or by calling NIA at 800-642-7578.
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 xrays and surgical extractions.
Virginia Commonwealth University Health System Health Plan Division
20
Member Services Department
For Members and Providers:
•
•
•
•
Toll-free number 800-727-7536.
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
Virginia Commonwealth University Health System Health Plan Division
21
Verifying Member Eligibility
• 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 www.navinet.net
4. Call VPHP Member Operations
Virginia Commonwealth University Health System Health Plan Division
22
Member ID Cards
Medallion II/FAMIS Plus
FAMIS
FAMIS Moms
Virginia Commonwealth University Health System Health Plan Division
23
Transportation
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.
1. 72 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 1-800-828-7953, Press 2,
8am - 5pm, M-F.
Virginia Commonwealth University Health System Health Plan Division
24
What does this mean for
my practice?
Provider Benefits & Services
Virginia Commonwealth University Health System Health Plan Division
25
Provider Benefits
• 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.
Virginia Commonwealth University Health System Health Plan Division
26
VPHP Provider Services
•
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.
Virginia Commonwealth University Health System Health Plan Division
27
Provider Service Representatives
• Abingdon:
Amanda Helton (276) 619-0966
ahelton@vapremier.com
Felicia Campbell (276) 619-0963
fcampbell@vapremier.com
Virginia Commonwealth University Health System Health Plan Division
28
What does this mean for
my practice?
Claims
Virginia Commonwealth University Health System Health Plan Division
29
Claims Department
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
www.vapremier.com.
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.
Virginia Commonwealth University Health System Health Plan Division
30
Claims Policies
1. 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-1500. 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.
Virginia Commonwealth University Health System Health Plan Division
31
Claims Customer Service
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:1-800-727-7536, 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,
www.navinet.net , 24/7 and is free of charge.
Virginia Commonwealth University Health System Health Plan Division
32
What does this mean for
my practice?
Medical Management
Virginia Commonwealth University Health System Health Plan Division
33
ER Services
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 1-800256-1982. 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.
Virginia Commonwealth University Health System Health Plan Division
34
Referrals
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 – www.navinet.net
– VPHP Medical Management – (888) 251-3063
Virginia Commonwealth University Health System Health Plan Division
35
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 www.navinet.net.
b. Fax an IP/OP Auth Form to VPHP which can be found at
www.vapremier.com
c. Call VPHP (888) 251-3063 and select the option for Medical
Management.
3. VPHP maintains a list of OP procedures that do NOT require preauthorization. The list can be found at www.vapremier.com
located under Medical Management and Utilization Management.
Virginia Commonwealth University Health System Health Plan Division
36
Appeals Medical Necessity
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) 819-5186. 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 23220-0244
Virginia Commonwealth University Health System Health Plan Division
37
Case Management Programs
•
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
Refer a patient for VPHP's Case Management Services by calling
Medical Management at 800-727-7536 or through the website:
www.virginiapremier.com
Virginia Commonwealth University Health System Health Plan Division
38
Integrated Case Management Program
Disease Management
(Population Health)
1
Virginia Commonwealth University Health System Health Plan Division
Disease Management
•Chronic Care
•Assessment &
education
•Quarterly contact
Level 1
•Intake Assessment -no Care Plan (CP)
•Care Coordination
•1-3 contacts
2
Level 2
•Assessment & updates to CP
•Monthly contact
3
Level 3
•Intensive CM
•Assessment & freq. updates to CP
•Weekly contact until sustained
improvement
39
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)
243-0937 or through the website at www.virginiapremier.com
Virginia Commonwealth University Health System Health Plan Division
40
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
Virginia Commonwealth University Health System Health Plan Division
41
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
Virginia Commonwealth University Health System Health Plan Division
42
What does this mean for
my practice?
Pharmacy Information
Virginia Commonwealth University Health System Health Plan Division
43
Pharmacy Benefits
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
800-361-4542.
Virginia Commonwealth University Health System Health Plan Division
44
Covered OTC Medications*
•
•
•
•
•
•
•
•
•
•
•
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
•
•
•
•
•
•
•
•
•
•
•
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.
Virginia Commonwealth University Health System Health Plan Division
45
Contact Information &
Closing Remarks
Virginia Commonwealth University Health System Health Plan Division
46
Contacts
• Medical Management
• Pre-Authorization: 888-251-3063 or www.navinet.com
• Radiology: National Imaging Associates, INC (NIA) 800-642-7578
www.radMD.com
• ER/Nurse Line: 800-256-1982
• Vision: VSP Vision 800-852-7600
• Lab Services: LabCorp 800-873-7251 or Solstas 800-653-2205
• Dental Services: Smiles for Children 888-912-3456
• Pharmacy: Envision 800-361-4542
• Claims
• Customer Service: 800-727-7536, option 2
• IVR: 800-727-7536 option 4, option 2
• Member Services
• Member Services/IVR: 800-727-7536 option 1
Virginia Commonwealth University Health System Health Plan Division
47
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!
Virginia Commonwealth University Health System Health Plan Division
48
Before Questions: A Word of Thanks
We recognize you are providing a needed
service to your community, and we sincerely
appreciate what you do.
Virginia Commonwealth University Health System Health Plan Division
49
Questions
Virginia Commonwealth University Health System Health Plan Division
50