Connect Archives

September 2007

Saturday, September 1, 2007

Medicare Open Enrollment: What Physicians and Patients Need to Know

Medicare Open Enrollment is quickly approaching, and Health First Network encourages its physicians to support their patients through this process. Key dates, patient tips, and helpful information are included in this article.

Key dates to keep in mind and share with patients:

Sneak Peak
October 1, 2007: This marks the day that health plans can begin to offer a “sneak peak” of what’s to come. It is when health plans begin to advertise what their new plans will look like, generally speaking.

Full Disclosure
Mid-October: Medicare will disclose all of its plans in full. This is when physicians and patients will learn anything and everything there is to know about 2008 plans and benefits.

Annual Enrollment Period (AEP)
November 15 through December 31, 2007: During this period, Medicare patients have the most flexibility. They can choose to enroll in Medicare Advantage or, if they are already Medicare Advantage members, they can change plans. People have the option of making more than one change; however, it is important that they understand that the application with the latest date will become effective on January 1, 2008.

Open Enrollment Period (OEP)
January 1 through March 31, 2008: In this time frame, eligible individuals may make ONE change to a plan centered on their Part D coverage. This means that if an eligible person is in a plan that has no Part D coverage, they may only change to another plan with no Part D coverage.

Special Enrollment Plan (SEP)
In certain cases, qualified individuals may enroll in, disenroll from, or change to a different Medicare Advantage plan or Original Medicare. Time frames for this kind of enrollment are determined on case-by-case scenarios. SEP situations might include:

•Changes in residence
•Turning 65
•Termination of a Medicare Advantage contract

Enrollment for Dual Eligibles
In addition to the enrollment periods listed above, please note and let patients know that individuals who are dual eligible – meaning they qualify for Medicare AND Medicaid – benefit from a permanent open enrollment period. This group can make changes to their plans anytime during the year.

Tips to offer patients regarding the Medicare Enrollment process:

•Be open to switching plans. WellCare will introduce new plans this fall. This means more options from which to choose.
•Learn about each plan to determine which one is the best fit. Every person is different…so is every plan.
•Pay special attention to the pharmacy benefits/drug formularies. This is especially important for patients who rely heavily on medications.
•Don’t wait until the last minute. Every senior in America is making a decision regarding health care. The earlier individuals submit paperwork, the quicker it will be processed

Additional helpful information regarding enrollment:

•Let existing Wellcare members know they will be invited to an annual meeting on benefits and to be on the lookout for their invitation, which will arrive by mail sometime during the first week of November. Remind them to R.S.V.P.
•Inform all Medicare patients that WellCare will hold seminars regularly between October 1 and December 31, 2007 in locations throughout Escambia, Santa Rosa, and Okaloosa Counties. These seminars will be advertised in the media, as well as posted online at
•People with questions or who are seeking further information about WellCare can visit or call 850.484.8443.

Related Links

RAPS Review: Another Step Toward Effective Coding

Health First Network is committed to supporting physicians in their efforts to serve patients AND to build profitable and sustainable businesses. Toward these ends, the organization recently reviewed the WellCare charts of 69 physicians. The objective: to reinforce the importance of proper coding and, ultimately, to ensure physicians are collecting appropriate revenue for patient care.

This review resulted in finding 6,732 adjustments. Consequently, Health First Network staff filled out attestations forms with recommendations to physicians. Physicians signed off on the forms, and the Med3OOO claims department entered them as corrected claims.

The most common issue uncovered was that medical notes in the patient chart diagnosis were not carried over to the claim, mostly because of limited space for only four diagnoses. Health First Network encourages physicians and office administrators to be aware of this and maintain a focus on proper coding overall.

Effective diagnostic coding ultimately leads to higher reimbursement. Both Health First Network as an organization and its physicians as shareholders reap the financial benefits.

Parallel Journeys: Health First Network & Dr. William Whibbs:

How did you decide to transition to full-time medical director, and what do you look forward to most in this role?

I have worked with Health First Network from the start, in 1985. As the organization assumed more responsibility and greater financial risk, I began working as part-time medical director. Over time, as we continued to grow, it became more than just part time. Health First Network’s needs, coupled with my interest and experience in medical management, made the transition a natural progression.

I have been able to use all of my clinical experience in making practical and tactical decisions that balance the needs of patients, health plans, providers, and Health First Network. Practically speaking, all health care is local. Decisions about how it is delivered needs to be local, as well.

What I have enjoyed and look forward to enjoying as time goes on is the unique opportunity to serve all of the participants in the community health care delivery system.

How is your transition/growth reflective of Health First Network's?

My transition to full-time medical director directly is reflective of Health First Network’s responsibilities in providing managed care services in our community. The key to managed care is to manage and care. With Health First Network’s increased workload, we have a lot more to manage and to care for.

How will you stay connected to the hands-on side of medicine? Why is it important to maintain this tie in regards to your role as medical director?

I plan to continue a limited practice with the group that I have been with for the past 10 years. I feel it’s important to stay close to the “trenches” to maintain good perspective. It is important for me to function under the same circumstances that we, as an organization, are trying to manage so that I can experience firsthand how it works. Or if it doesn’t work, I can know what we need to change.

Why was the time right for Health First Network to expand its medical management?

The time was right because the stakes have increased, the problems in health care delivery are huge, and, as I said earlier, the best solutions are going to be found in the community we serve. The rest of the reality is that every community, including ours, has to deal with ever-growing state and federal bureaucracies. There are increasing numbers of regulations and expectations - both with government and private plans - that require full-time attention.

Do you have any additional comments?

At Health First Network, we all have an interest in how well the healthcare delivery system works. We are both providers and consumers of health care, giving us a unique perspective. We can view what needs to be done to improve care, and we can do it.

Dr. Thanh Duong-Wagner Becomes the Newest Member of the Board of Directors

A Vietnamese immigrant, who came to America as a young child, Dr. Thanh Duong-Wagner didn’t have it easy growing up. However, she was determined from a young age to make something of her life. It’s fair to say, having become a first-rate cardiologist that she’s done so with flying colors.

What she appreciates most about being a physician is “helping people.” Wagner said there’s nothing more gratifying to her than caring for patients in need, essentially giving them life.

Her life’s work has certainly made a difference, and now Wagner is about to give back in yet another way as the newest member of Health First Network’s Board of Directors. In this role, she will have the opportunity to touch the medical community at large and truly help shape health care in this region.

Wagner values Health First Network because of the fellowship it offers. She enjoys being part of a network with a shared vision. “It’s so important in today’s world, to be part of something, to not go it alone,” she said.

Take Note: Centers for Medicare and Medicaid Services Announce Reforms

This month, I had the opportunity to attend a conference presenting some of the reforms announced by the Centers for Medicare and Medicaid Services as it further transitions to more accurate payment systems and seeks to promote quality care for all hospitalized patients.

The workshop included information on transition strategies for ICD-10, Medicare Severity-Adjusted DRG’s, and the new Present-On-Admission Standards. The implementation of “Present on Admission” indicators begins as early as October 1, 2007 and affects acute-care hospitals. This includes Escambia and Santa Rosa County acute care hospitals and the Health First Network physicians who admit patients to these hospitals.

I will share information to network physicians on CMS proposals as rulings are released by CMS and published in the Federal Register.

Another recent development of note includes changes in how vaccines are billed and obtained for both Medicaid (including HealthEase) and Medicare (including WellCare) members. Both CMS and the State of Florida are revising billing procedures for reimbursement of immunization services.

Within the next two weeks, Health First Network will send out a “Red Memo” detailing some of these changes. Our hope is to provide our physicians with proactive strategies to help ensure compliance, avoid unnecessary denials, and improve bottom-line performance.

Included in this newsletter are links to two documents for physicians who see HealthEase members. Provided by the WellCare/HealthEase Health Plan, these “tip sheets” can serve as quick reference guides.

The first is a WellCare/HealthEase Formulary Reference Sheet, listing common therapeutic classes of drugs, formulary-preferred medications, prices, and suggestions.

The second is an Otitis Media Treatment Guideline Reference Sheet, which includes treatment recommendations and references. It is meant especially for Pediatrician and Family Practice offices.

Related Links