1. 100: Dollars for helping MA plans with diagnosing patients properly. If your doctors suspect a patient has a condition that hasn’t been formally diagnosed or coded this year, they can get $100 financial incentives as part of a diagnosis rewards program – about two thirds of MA plans in our poll this month say they pay this to PCPs, some pay more or less. ‘It’s for identifying a condition that’s not been diagnosed and coded but should be…but it works both ways – like if you figure out a patient no longer has a condition’
2. Divorce or Separation? A Tennessee couple we are interviewing Monday has been advised to separate and stop living together otherwise they’ll lose their Medicaid benefits. The wife has battled epilepsy and seizures, the husband—who served ironically as a mental health counselor for 47 years until taking early retirement to help with what he thought would be a way to ensure his wife would have coverage for medications, now sees his wife 1x a month. Full story next week.
3. PostPartum: Aetna Behavioral Health is collaborating with its medical management division to assist in identifying depression in pregnant and postpartum women with the ‘Beginning Right Maternity Program” for members and providers. The program uses a clinical case management process including behavioral health and comorbidity assessment, case formulation, care planning and focused follow ups. The program refers members with depression to condition management and a behavioral health specialist enhances engagement. Nurses reach out to members who have lost their babies to offer condolences and behavioral health resources. A hotline is used: 800-CRADLE-1.
4. Oxygen Policy Denial: Portable oxygen for home use will now be denied will now be denied by United Healthcare if the only qualifying blood gas study was performed during sleep.
5. Outcomes Based Pay Program: If Karen Collins, chief of common sense for fictional vice president Serena in television’s VEEP read this, she would surely say this is a great idea if your patients aren’t sick. Otherwise, tread carefully. The concept is the latest payer-program to pay for outcomes: CAC Focus is a new Cigna collaborative accountable care program for provider groups who think they can manage care and succeed in an outcomes-based reimbursement program. Groups qualify if they have at least 1,500 aligned primary care patients. Cigna says it will assist groups in getting the program off the ground.
6. No More Pre Approval: In a new policy, Aetna no longer will require precertification observation stays more than 24 hours and also won’t require pre approval for anti-emetic drugs delivered via an injectable or infusion like Emend IV for nausea.
7. Newborn Blue Policy Change: Blue Michigan change this policy in May so that even if a newborn isn’t added to the insured parent’s health plan contract within required timeframes (which happens more than you think) the MCO will cover both the facility and professional inpatient claims for the newborn during the first 48 hours for vaginal deliveries and 96 hours for c-sections. ‘Going to do this as an extension of the mom’s maternity benefit,’ a source confirmed. The policy is actually going to be retroactive to January 2017 due to the vast number of complaints. The only kicker is that the MCO won’t pay the newborn claim if they find out the mom had other coverage on the birthday.
8. Special Olympics Partner: For those of you looking for social investment with your practice, this one fits the bill: Kaiser Permanente has signed a three-year agreement as the “Official Health Partner” for the Special Olympics Southern California. This means Kaiser is the designated medical group for the games; clinicians from the group will volunteer at competitions throughout the year, including the 2018 Summer Games June 9 at California State University
9. Cardio Deibrillator Medical Necessity Added: Blue Kansas, as of this spring, considers wearable cardioverter-defibrillators to prevent sudden cardiac death medically necessary. ‘They are a bridge to ICD placement’ for patients within 40 days of an MI who the plan says have ‘sustained ventricular tachycardia/ventricular fibrillation that occurs more than 48 hours after index MI.
10. Extra Point: Our two oldest girls got their US Citizenship this week. We celebrated with some sweet frog yogurt and a pop quiz on American History. Being in healthcare, I asked who the first physician was in the US. Our youngest, Tommy, said Dr Phil and my daughter Sophie said Dr. Baker. I generously gave them both partial credit. I was still reeling from the fact both thought the Civil War was fought in 2005. Only Mukue nailed it, sort of, naming Elizabeth Blackwell, who was the country’s first female to get into medical school. She had a leg up on us since the doctor was part of a book report she did in middle school. I personally think all three of the answers are interesting given the trend in healthcare today toward more telemedicine and reliance on what celebrity physicians like Dr. Oz tell us, as well as the throwback trend of physicians going into the home as Dr. Baker did when poor Laura had a tummy ache on the prairie. And then there’s women in healthcare—the trend is no doubt reversing as we reported a couple months ago with females now for the first time accounting for the majority of medical school students.