Connect Archives

February 2010

Thursday, February 04, 2010

CREDENTIALING EXTENDERS

Effective July 1, 2010 HFNI will begin processing claims for physician extenders in the same manner as Medicare. If a physician extender performs a service, that service should be billed by that extender using his/her provider identification information. Heretofore, we allowed the extender to bill using the supervising physician’s provider identification information. The physician extender services will be paid according to Medicare guidelines.

One implication of this is that all physician extenders must be credentialed. You must fill out an application for each/every extender in your office. The completed applications will then be reviewed by our Credentials Committee. Our policies for credentialing extenders are contained in The Credentials Program Policies and Procedures Manual which is provided below.

Please be advised that just as it is your responsibility to inform HFNI of additions/changes to the physician(s) in your office, it is also your responsibility to give us the credentials information for your extenders and to keep that information current.

You should contact Jenny Caillouet at (850) 438-4487 to receive applications for your extenders. We have allowed five month lead time for the applications to be completed and processed. As stated previously, for dates of service July 1, 2010 and beyond, physician extender claims will be processed in the same manner as traditional Medicare.

Your usual cooperation is appreciated.

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PCP CLOSED PANEL POLICY

Health First Network has received several questions asking about physician panel closings. The Board of Directors discussed this at their January meeting and would like to offer the following clarifications:

- A physician may close his/her panel at any time giving 90 days notice.

- Health First Network’s definition of a closed panel is that the physician accepts existing patients only. Our contracts with every health plan prohibit not seeing patients if the health plan changes.

- If a physician closes his/her panel the closure must be for all sources. The physician cannot close his patients to just Health First patients or to just managed care patients. It must be closed across the board and this will be monitored by HFNI staff.

- A PCP can close his/her panel to a product of HFNI if he/she has 100 assigned members in that product. The current HFNI products are Vista commercial, Vista Healthy Kids, HealthSpring and WellCare.

- Obviously if a physician has either elected not to participate in a product or cannot participate in a product the policy is not applicable to that product.


REQUIRED FRAUD AND ABUSE TRAINING

Since 2009, CMS (Center for Medicare and Medicaid Services) has mandated that all delegated and contracted Providers who provide services and/or benefits to Medicare Advantage members, and first tier, downstream or business-related entities of Medicare Advantage Plans complete an annually required training program on Fraud, Abuse and Waste. Health First Network staff members recently completed their annual training through an on-line power point presentation that took about 30 minutes.

A no-cost user-friendly program is available on the HealthSpring website. To access the program click on the HealthSpring link provided below. At the conclusion of the powerpoint presentation, there is an Attestation form to complete.

WellCare also has a training program available on their website. To access their program click on the WellCare link provided below. As of this writing, the WellCare website requires a pre-paid fee of $14.95 to take the training.

The training on Medicare Fraud, Abuse and Waste on any of the above mentioned Medicare Advantage Plans meets the compliance standard for all or any of the plans. The training can also be done through the CMS website, however, the CMS programs are long and detailed. Currently, CMS is reviewing, but has not ruled on a proposal to modify the annual training requirement for Physicians, as the Medicare practitioner enrollment applications require applicants certify to having read and understood the Penalties for Falsifying Information contained in the application and state the applicant will not present or cause to present a false claim to Medicare. Requiring the additional fraud, waste and abuse certification is being viewed as redundant, however, the requirement has not yet been lifted.

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HEDIS QUICK REFERENCE GUIDE

All Health Plans from Medicare to Commercial to Medicaid are currently, or are in the planning stages of migrating to Quality Reporting. “Pay for Performance” typically uses one of two formats, HEDIS and PQRI. Within PQRI, there are over 170 reporting categories. The HEDIS Quick Reference Guide has to do specifically with HEDIS, but you will notice significant overlap between HEDIS measures and PQRI. It is important that appropriate ICD-9, CPT, and required code modifiers are reported correctly. The codes listed on the HEDIS Quick Reference Guide are specific to the office setting to be reported on the 1500 Form. We would suggest that offices review the list and become familiar with it, or get in the habit of adding the codes. It will soon be required reporting. If you have a question, please contact us. Health First Network will continue to monitor trends and keep HFNI Physicians aware of any significant changes.

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2010 WELLCARE FORMULARY CHANGES

For the 2010 WellCare Medicare Formulary Changes please click on the link below.

For the complete WellCare Medicare Formulary for 2010, visit www.wellcare.com.

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HFNI SHAREHOLDER MEETING NOTICE

The Annual HFNI Shareholder’s meeting will be held on Thursday, May 6, 2010 at 6:00 p.m. at Health First Network.

HEALTH FIRST NETWORK SPONSORS BLOOD DRIVE

Dr. William Whibbs On January 18th, Health First Network sponsored a blood drive for the businesses located near our office on South Palafox Street. Participating companies besides HFNI included Smith Barney, Merrill Lynch, EmCare and The Department of Financial Services. The bloodmobile arrived at 9:30 a.m. parking in the HFNI lot. By 10 a.m. the Northwest Florida Blood Center began the collection process. By 2 p.m. they had collected blood from 22 individuals. We are proud to report that of the five people in the HFNI office eligible to give blood, we had 100% participation.