Practice Tactics

Incontinence Supply Denials

UHA follows Oregon Authority Rules (OAR) 410-122-0630 for incontinence supplies coverage requirements. These can be found at here. UHA may be more strictly adhering to these OARs as part of our contract compliance.  In summary, incontinence supply approval requires:

• An annual provider visit (face to face or telehealth, within last 6 months) that documents the condition and frequency of daily use and need for other items (gloves, bed pads)
• A prescription that provide a covered diagnosis under the Prioritized List and the monthly amount of each item with up to 11 refills
• For residents of any care facility, a changing log for the last 30 days must be submitted
• Gloves are only supplied to caregivers, not members who change their own undergarments.
• Submission specific requirements include:
  • The initial request should be submitted no longer than 2 months from the date on the prescription for it to be current
  • To make amends/changes (extending authorizations), for example on size change requests, the date of the new item will remain the same date as the original PA.
  • We are working on assigning procedure codes into groups so you will no longer need to submit amend/extension requests for size changes. We will communicate this change more once it has been implemented.
  • Date changes will only be required when 1) supplies initially requested have been exhausted, or 2) when a new requests is required

Chiropractic Referral Reminders for PCPs

Coverage

• Chiropractic care is only covered for conditions related to the spine. This means it is not medically appropriate, per the HERC guidelines, for non-spine related conditions such as headaches, migraines, hip pain, shoulder pain, physiologic discomfort of pregnancy or routine maintenance for chronic conditions. See Guideline 56 for specific coverage criteria.
• If the members condition meets the criteria above, a total of up to 30 visits per rolling calendar year of any combination of the following therapies: chiropractic or osteopathic manipulation, acupuncture, and PT/OT treatment of the spine.

Initial Evaluations and Submissions

• UHA requires a PCP evaluation for a chiropractic referral, similar to Physical Therapy. The PCP medical notes need to address the spine-related symptoms and limitations the member is experiencing.
• An in-office PCP evaluation needs to include a physical evaluation of the spine and neurological exam if indicated. A telehealth visit is still acceptable with documentation regarding the spine-related symptoms and limitations the member is experiencing.
• UHA encourages PCP’s to send the referral directly to the specialist. The Chiropractor should submit the prior authorization (PA) request using the provider portal, CIM.
• The submitted diagnosis must be supported by the medical notes.
• A new PCP evaluation is needed when there is a lapse in chiropractic care of 60 or more days.
• UHA will not cover the following codes: 98943, 97010, 9712, 97014, 97022, 97024, 97028, 97032, 97034-97036, 97139. To help the provider when submitting a PA, UHA has created a Chiropractic Code Group. See our tutorial on these submissions on our website at https://www.umpquahealth.com/prior_authorizations/.

On-going Care

• The first request for ongoing visits should include the initial evaluation and initial Functional Rating Index score.
• All subsequent requests should include a re-evaluation visit and updated Functional Rating Index score.
• If a Prior Authorization is denied for lack of improvement per InterQual®, a PCP evaluation is required for re-evaluation of management of condition.

Clinical Corner

Clinical Advisory Panel adopts new Clinical Practice Guidelines

The Clinical Advisory Panel (CAP), whose members are composed of representatives from the community practices, met in March and approved a number of new Clinical Practice Guidelines (CPGs).

They added:

• The American College of Radiology Appropriate Use Criteria (ACR-AUC)
• Choosing Wisely
• Guidelines for the Diagnosis and Management of Asthma 2020 by the NBLHI

They also endorsed a new tool created by UHA Pharmacists that summarizes these asthma guidelines as well as the GOLD guidelines for COPD in a 1-page format that is aligned with the UHA drug formulary.

These four additions can be accessed on the CPG page: https://www.umpquahealth.com/clinical-practice-guidelines/

Policy updates:  CE05-Utilization Review

We have updated a number of policies that are featured on our  Provider Trainings page.  We have highlighted one below:

Prior authorization requests that require review by a Utilization Review Coordinator are assessed for medical appropriateness and necessity by using the following resources:

1. The Prioritized List of Health Services- all practice guidelines including ancillary and diagnostic service notes;
2. Health Evidence Review Commission (HERC) guidelines;
3. Oregon Administrative Rules (OAR);
4. InterQual® Care Guidelines
5. Up-to-Date ®- Wolters Kluwer;
6. CMS Medicare National Coverage Determinations and Local Coverage Determinations for DME
7. UHA Clinical Practice Guidelines adopted by Clinical Advisory Panel

Denials must finally be reviewed by a Doctor of Medicine or Pharmacy (for Rx requests).

Also see our other updated policies on our webpage at https://www.umpquahealth.com/provider-trainings/.

• CE01 – Grievance, Appeals, and Hearings
• CE05 – Utilization Review
• CE11 – Covered Services
• CE12 – Prior Authorizations
• CE21 – Adverse Benefit Determinations
• CE22 – Payment and Authorization of Hospital Admissions

Advanced Care Planning Available to All Residents of Douglas County

In February, we announced a specialized service for Advanced Care Planning (ACP) for UHA high acuity members by provider referral.  This one on one service facilitated by Iris Healthcare is known as Premier; more information is available under the Provider tab on our website at this link.

We are now excited to announce that UHA offers ACP for all residents of Douglas County, regardless of their insurance status.  This service is a web-based platform that asks questions that inform the creation of ACP documents at the conclusion of the digital interview.  (Think online income tax preparation.)   Since this empowers everyone to communicate their healthcare wishes to share with their family and caregivers, we call this service Empower.  Access to this service is available under the Member tab on our website at this link.

We encourage providers to create a link on their website to access the Empower service.  For information on how to do this, contact Kat Cooper at kcooper@umpquahealth.com.

On the Lookout

For the latest information on COVID vaccination in Douglas County, visit Douglas Public Health Network: http://douglaspublichealthnetwork.org/

For Better Care and Health

A recent perspective article in NEJM discusses how lessons learned from the Quality-Movement, spearheaded by the IOM, could be applied to Work-force Diversity; specifically: measurement, reporting, and incentives.

“Lack of workforce diversity has detrimental effects on patient outcomes, access to care, and patient trust, as well as on workplace experiences and employee retention. A substantial number of White medical students and residents hold biased views about race-based differences in pain perception that affect their treatment recommendations” … Addressing Workforce Diversity — A Quality-Improvement Framework – Lisa S. Rotenstein, M.D., M.B.A., Joan Y. Reede, M.D., M.P.H., M.B.A., and Anupam B. Jena, M.D., Ph.D.  To download full article, click here.

Roseburg Family Medicine Residency (RFMR) program, is a beacon on Workforce Diversity for Oregon

CME for Thee

A Town Hall about Traditional/Community Health Workers will be featured via Zoom on April 12 from Noon-1pm.  Check your emails for the link!

Community Health Worker Training

This course will help prepare students to serve as a Community Health Worker (CHW).

The course addresses all requirements as outlined by the Oregon Health Authority and upon receiving a passing grade, students will qualify to apply for accreditation as a Community Health Worker to the Oregon Health Authority for the State of Oregon.

Registration: https://bit.ly/3eb336m

Flyer at this link.

Value-based payment webinar series for providers (no-cost CME available)

Primary care, behavioral health, and maternity care providers are invited to a five-part webinar series focused on increasing readiness for VBP and taking advantage of the additional flexibility VBPs offer for innovatively redesigning care models.

• April 21, noon-1 p.m.: What do you need to know to negotiate VBP agreements?
• May 19, noon-1 p.m.: Learnings from COVID-19 and how they may impact the adoption of VBPs
• June 1, noon-1 p.m.: VBP for behavioral health providers: How do we keep from being left out?
• June 16, noon-1 p.m.: VBP and maternity care: What have we learned so far?

Speakers: Art Jones, Jeanene Smith, Janet Meyer (Health Management Associates)

See flier for full details and registration: https://www.oregon.gov/oha/HPA/dsi-tc/Documents/VBP-Webinar-Series-Spring-2021.pdf

Contact: OHA.VBP@dhsoha.state.or.us