July 15, 2016 Video Conference Locations: PHC Southeast Regional Office at 4665 Business Center Dr, Fairfield

PHC Southwest Regional Office at 495 Tesconi Circle, Santa Rosa PHC Northeast Regional Office at 3688 Avtech Parkway, Redding PHC Northwest Regional Office at 1036 5th Street, Suite E, Eureka

Meeting Agenda

1. Standing Agenda Items 1.1. Welcome and Introductions – Chairperson Bill Byrnes, Clinic Manager, Community Medical Centers

1.2. Approval of Minutes 1.3. Review of Agenda

2. Presentation

2.1. Palliative and Supportive Care Medicine – Susan C. Stone, MD

3. Old Business 3.1 None

4. New Business 4.1. PHC Update 4.2. Report from Physician's Advisory Committee – Robert Moore, MD, MPH 4.3. Report from the Claims Department – Rebecca Mannella 4.4. Report from Member Services – Shauncey Jenkins, Maria Cabrera 4.5. Report from Provider Relations – Online Services Phase II – Lynne DiModica 4.6. Community Events, Health Fairs and Trainings: All Attendees

Meeting Adjourned

Provider Advisory Group 4665 Business Center Drive,

Fairfield, CA

Lunch: 12:00 Meeting 12:30

Mission Statement: The Provider Advisory Group of the Partnership HealthPlan of California will act as a liaison between the Health Care Services providers and the HealthPlan. The Group will make recommendations and provide a

forum for providers to have ongoing input into the activities of the HealthPlan.

PARTNERSHIP HEALTHPLAN OF CALIFORNIA

MEETING MINUTES

Committee: Provider Advisory Group (PAG)

Date/Time: May 20, 2016 12:30 p.m. – 1:30p.m.

Members Present: Patrisia Contreras-Vigil, Neville Wall, Nagarathna G. Manjappa, MD, Noelia DeTorres, Pam Sakamoto, Margaret Pay, Megan Armstrong

PHC Staff Present: Mark Netherda, MD, Rebecca Mannella, Joan Russell, Bonnie Fries, Jill Tarap, Jean Levato, Carol Parker

AGENDA ITEM

DISCUSSION/CONCLUSIONS RECOMMENDATIONS /

ACTION DATE RESOLVED

1. Standing Agenda Items 1.1. Welcome and Introductions 1.2. Approval of Minutes 1.3. Review of Agenda

1. None.

1.1. Meeting called to order by Chairperson Patrisia Vigil. 1.2. Minutes from 3/18/2015 reviewed and approved. 1.3. Agenda was reviewed and approved.

1. 1.1 1.2. Approved. 1.3. Approved.

5/20/2016

2. Presentations

2. Neville Wall, Manager of Provider Partnerships for Beacon Health Strategies, gave a presentation to the group on Mental Health Services for PHC Members.

Medi-Cal behavioral health care is divided across the Medi-Cal Managed Care Plan, services provided by the County, and County-funded Substance Use Disorder Services. Medi-Cal Managed Care

Ways to refer to Beacon include: member self-referral, family member referral, referral by the PCP and referral by behavior health providers.

Forms for PCP referral, level of care transition, and a screening form to determine level of impairment are all available on the Beacon website at http://www.beaconhealthstrategies.com

Beacon is actively recruiting providers to increase member access to mental health services.

2. Presented as information only

5/20/2016

3. Old Business 3.1. None. 3. Presented as information only.

5/20/2016

4. New Business 4.1. PHC Updates and Report from Medical Directors Forums

4.2. Report from Claims

4.1.1. James Cotter, MD, Regional Medical Director for Solano and Yolo Counties at Partnership HealthPlan of California reported on activities at PHC.

PHC is holding Medical Directors Forums in several regions. These forums give Medical Directors in the communities an opportunity to get updates on activities at the health plan.

There have been changes to the QIP Programs for the 2016-2017 interval, including different measures including a Specialist provider access initiative.

The Palliative Care pilot program has enrolled 82 patients thus far. The Coalition for Compassionate Care of California website at

http://coalitionccc.org/ offers training courses and webinars for providers regarding the California End-of-Life Option ("Right to Die") Act.

The UCSF Clinical Consultation Center offers free confidential clinician-to-clinician telephone consultation focusing on substance use evaluation and management for primary care clinicians through the Substance Use Warmline at (855) 300-3595.

PHC is promoting Motivational Interviewing (MI) Skill Development training on June 8 that will focus on helping providers to talk with their patients to promote behavioral change.

The California Medical Association is a member of Save Lives California, a coalition dedicated to passing a significant tobacco tax increase. Revenue generated by this user fee will fund existing health care programs, smoking prevention, and research into cures for cancer and other tobacco-related diseases.

The Managing Pain Safely program has seen a 50% reduction in opioid use since inception. The further this progress, PHC has adopted the CDC recommendations for using opioid pain medications for acute pain. These new prior authorization requirements for short-acting opioids will be effective June 1, 2016.

4.2. Rebecca Mannella, Claims Resolution Manager, spoke to the group regarding Claims

issues. Claims Inquiry Form (CIF) is used to request an adjustment to a submitted

claim. While the Claims billing limit has been extended to 12 months, the CIF and Appeal timeliness requirements have not changed. Recently Claims is finding many providers are skipping the CIF process and going directly to the Appeal process.

A CIF gives providers two chances to add or correct any information on denied claims. Provider have six months from the date of the original claim to submit a CIF. If the claim has not been resolved, the provider may submit an Appeal within 90 days.

An Appeal is the final step in the claims appeal process. If the claim is denied at the Appeal stage, there is no other recourse available to providers.

4. Presented as information only.

5/20/2016

4.3. Report from Provider Relations

4.3.1. Bonnie Fries, Provider Online Data Specialist, gave an update on PHC e-Systems. Phase II of the redesigned online services platform will be launched in July 2016.

Phase II consists of eClaims, ER Notification and Advice Nurse Reports modules. Updates will be posted on the PHC website www.parthershiphp.org

4.3.2. Joan Russell, Manager of Provider Education, updated the group on California Senate Bill (SB) 75 – Full Scope Medi-Cal for All Children.

SB 75 provides full scope Medi-Cal coverage for all children under age 19,regardless of immigration status.

Up to 12,500 known children are eligible for Full Scope Medi-Cal under PHCbeginning June 1, 2016.

PHC is working with members to identify CCS-eligible children and ensurecontinuity of care. Every effort will be made to maintain assignment to currentPCP.

5. ProviderQuestions, Topics of Interest, Announcements, and Upcoming Events

5. Upcoming Events: Napa Valley Food Resources holds a Free Fruit and Vegetable Market on the 3rd

Friday of each month at Ole Health, 1141 Pear Tree Lane, Napa. Ole Health is coordinating a Health Fair to be held June 10 at Far Niente Winery.

5. Presented as informationonly.

5/20/2016

Meeting Adjourned Next Scheduled meeting: July 15, 2016 in Solano County. 5/20/2016

PHC – Provider Advisory Group – May 20, 2016 in Solano County Minutes prepared and submitted by: Carol Parker

Chairperson Patrisia Contreras-Vigil DatePatrisia Vigil 5/25/2016

Supportive and Palliative Care Medicine

At the Table of Healthcare Reform

Susan C Stone MD MPH

Director Outpatient Supportive and Palliative Medicine

SRMH

Conceptual Shift for Palliative Care

Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness ‐ whatever the diagnosis. 

The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.

Palliative Care Language Endorsed by the Public

How Specialists View Us

Anti cancer therapy: curative, life prolonging or palliative intent

Supportive care

End of lifeHospice 

Palliative Care

6 months

Supportive versus palliative care: what’s in a name? a survey of medical oncologists and midlevel provide at a comprehensive cancer center. MD Anderson Cancer Center referrals to palliative care occur late in the 

trajectory of illness

Name palliative care and hospice was a barrier to early patients’ referral

100 medical oncologists and 100 midlevel providers

More participants preferred the name supportive care (80%, 57%) compared with palliative care (27%, 19% P < 0.0001). 

Medical oncologists and midlevel providers stated increased likelihood to refer patients on active primary (79%versus 45%, P < 0.0001) and advanced cancer (89% versus 69%,P < 0.0001) treatments to a service‐named supportive care.

What’s in a name?

Perceived more frequently by medical oncologists and midlevel providers as a barrier to referral (23% versus 6% P < 0.0001)

Fadul N, Elsayem A, Palmer JL et al. Cancer 2009; 115: 2013–2021.

What happens to the patients?

Benefits of Supportive and Palliative Care

Quality care

Patient centered

Achieves triple aim

Fiscally wise

Palliative Care Service Palliative Care Team

Purpose : Insures:  Communication between Patient, Family and all Healthcare 

providers Collaboration with Primary Care Physicians and Specialists in 

Developing the Plan for Care  Collaboration with Partner Hospice programs and Case 

Management Programs. Social Work consult for Provision of referrals to appropriate 

Community Support Organizations Definition of immediate and long‐term goals of care Advance Care Planning

Quality 

Many published studies confirming the improved outcomes and patient/caregiver/provider satisfaction with care.

How do we define quality?

Evidence: Palliative Care Improves Value

Quality improves Symptoms Quality of life Length of life Family satisfaction Family bereavement outcomes

Care matched to patient‐determined  goals

Costs reduced Hospital costs decrease Need for hospitalization/ICU decreases

Value of health care = qualitycost

For high value care must deliver best care in alignment with patients needs and desires

TRIPLE AIM:

Right care for the right patient at the right time/cost.

National Quality Forum: Palliative Care is One of Six National Priorities for Action

http://www.nationalprioritiespartnership.org/Priorities

13

The Value Equation- 2Denominator problems

Insurance premiums increased by >200% in the last 10 years.

U.S. spending 17% GDP, >$8400/person/yr 

Nearing 35% of total State spending

Despite high spending, 15% of our population has no insurance, and half are underinsured in any given year.

Health care spending is the #1 threat to the American economy and way of life.

International Comparison of Spending on Health, 1980–2009

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

United StatesCanadaGermanyFranceAustraliaUnited Kingdom

0

2

4

6

8

10

12

14

16

18

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

United StatesFranceGermanyCanadaUnited KingdomAustralia

* PPP=Purchasing Power Parity.Data: OECD Health Data 2011 (database), version 6/2011.

Average spending on healthper capita ($US PPP*)

Total expenditures on healthas percent of GDP

17Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

EFFICIENCY

17

Medical Spending in the U.S.$2.9 trillion in 2010

Where does palliative care come in?

The sickest and most vulnerable 5% of patients account for 50% of all healthcare spending

Medicare Payment Policy: Report to Congress. Medpac 2009 www.medpac.gov

Health Affairs 2005;24:903-14.

CBO May 2009 High Cost Medicare Beneficiaries www.cbo.gov

nchc.org/facts/cost.shtml

Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.

Sun Sentinel (Broward County edition)Tuesday, August 9, 2011

Population Health and Palliative Care

Synergy

Palliative care: focuses on improving the quality of life of patients with serious illnesses and their families.

Population health:focuses on improving the health of populations, with a special emphasis on reducing disparities in health outcomes and improving the value of health care.

Role of Population‐Based PC

Will need to emphasize primary palliative care. 

Frontline practitioners must be able to deliver key elements of palliative care including prognostication, goals discussions, and symptom management.

Population-based palliative care will need structures that:

• Support palliative care in communities and populations. include laws that facilitate advance care planning and orders for life sustaining treatment (eg, POLST forms), as well as laws and employer policies that support family leave to care for seriously ill relatives patients and their families to expect higher standards of communication,

• shared decision making,and symptommanagement

The goal of population‐based palliative care should be

to promote optimal well‐being in the face of serious,

life‐threatening illness for patients and their families.

This vision is based on the World Health Organization’s

1946 definition of health as “complete physical, mental

and social well‐being.

Over 10 000 people qualify for Medicare per day

Begin to transform the health care system from theoriginal 1965 version of Medicare that focused on payment foracute treatment, to a system of payment that ensures  competent,  coordinated, and compassionate health care shift from fee‐for‐service reimbursement that rewards volume to incentives for improving health of populations.

95% of respondents agree that it is important that patients with serious illness and their families be educated about palliative care.

92% of respondents say they would be likely to consider palliative care for a loved one if they had a serious illness.

92% of respondents say it is important that palliative care services be made available at all hospitals for patients with serious illness and their families.

Once informed, consumers are extremely positive about palliative care and want access to this care if they need it:

Exceptionally High Positives

Although the world is full of suffering, it is full also of the

overcoming of it.

Helen Keller

Optimism 1903

  

 

 

  CIF vs. Appeal of Claims

When PHC expanded the claims billing limit to 12 months on 7/1/2014, the CIF/Appeal submission and timeliness requirements remained unchanged at 6 months from the date of the RA. Recently we are finding that many providers are going straight to the Appeal process and skipping the CIF process.

A CIF gives providers two chances add or correct any information on their denied claims. Providers must submit the initial CIF within 6 months of the denial, and may submit a re-CIF within 90 days of the first CIF outcome. If providers go straight to Appeal they are getting only the one opportunity to make any changes. Therefore, it is in the provider’s best interest to follow the CIF process because, as indicated, the Appeal decision is the final outcome for your claim.

CIF submission timeliness: Providers have six months to CIF a claim from the original date of the denial on the PHC RA. CIFs received after six months are subject to automatic denial. PHC will acknowledge receipt of the CIF within 5 working days and will respond with a Claims Inquiry Response (CIF) Letter indicating the outcome of the CIF review within 45 days. If the claim submitted with the initial CIF does not appear on an RA or a Claims Inquiry Response Letter has not been received, the provider may file an Appeal. The provider must include all copies of the Claims Inquiry Acknowledgements or PHC dated correspondence with the Appeal. CIF denials for timeliness cannot be appealed by the provider. Upon receipt of the outcome of a CIF, providers have a onetime window of 90 days from the date of the CIF denial on the PHC RA to re-CIF their claim with additional corrections. Appeal Submission timeliness: A provider may submit a "Claim Appeal" within 90 days of the CIF denial. Failure to submit an appeal within the 90-day time period will result in the appeal being denied. A claim which is submitted on appeal has already been reviewed and denied by the Claims Department two separate times once on the original claim submission and once as the result of a CIF submission and/or a re-CIF. Appeals regarding RAF/TARs will be addressed through the PHC Health Services Department. Appeals regarding non-claim issues are addressed by the PHC Provider Relations Department. An Appeal is the final step in the claims appeals process. Claims denied for timely filing are not appealable.

Please refer to the PHC provider manual on our website: www.partnershiphp.org for information and instruction on how to use the eCIF function. 

FROM THE CLAIMS DEPARTMENT

Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org

PHC Online ServicesRedesign Phase II

For Provider Advisory Group

July 2016

Background

• Years ago, Partnership HealthPlan of California (PHC) developed an online platform to verify member eligibility. Technology advanced and our infrastructure became outdated.

• In order to improve stability, functionality and speed, we began to redesign the platform.

• Phase 1 was launched 7/31/15, consisting of 5 modules.

• Today we announce Phase 2, which will launch in production at the end of the summer.

• Phase 2 is currently being tested in limited release with our pilot providers.

Presentation Goals

Goals for today’s presentation:

• Give you a brief overview of Online Services Redesign Phase 2

• Show you the new modules

• Answer your questions related to the platform

New Modules

• Advice Nurse Reports

• ER Notification and ER Alert

• eClaims: Claims Search, Check Search, EOP

• eCIF and ReCIF

• Code Look-up

Functions related to authorizations are unchanged for now; continue to access

authorizations through the original portal.

We are actively redesigning the authorization module and will introduce it at a later

date.

Dashboard Change

• Clinical Modules:Advice Nurse ReportsER Notifications

Advice Nurse Reports

• PHC members can call our advice nurse after hours with their medical concerns.

• When a PHC member assigned to your practice calls our advice nurse, a triage report is generated.

• You will be able to pull the Advice Nurse Report directly from our online services site.

ER Notification

• We are actively looking for ways to decrease avoidable Emergency Department visits

• Hospitals can message the assigned PCP when their patient visits the Emergency Department.

• This module has migrated to the redesigned site.

• Export ER Notifications to pdf file or Excel.

• Alert your employee(s ) by email that an ER Notification was submitted.

ER Notification

• Claims Modules

Claims

• Search for claims by member, by Check Number, by Remittance Advice

• View Check Status: Written, paid, etc

• View Payment vehicle: EFT vs. paper

• Submit eCIF, retract eCIF, Submit Re-CIF

Search for Check Number

Search for Claim

Enter eCIF Data

eCIF Service Line Detail

View eCIF

Monday - Friday8 a.m.- 5 p.m.

Telephone Support707-863-4100

For support, email:eSystemsSupport@Partnershiphp.org

www.Partnershiphp.org

Partnership HealthPlan of California

• Which site you need support for Original or Redesigned• Brief description of issues (include screen shot if possible)Remember: If patient information is included, send your request by Secure Email

User name

Billing NPI Number

Tax ID

Contact Phone Number