Provider Update
Volume 22, Issue 1
January/February 2005
eHealth Conference Held in Louisiana
The Louisiana eHealth Conference brought together internationally recognized leaders in the
transformation of health care with Louisiana stakeholders in a one-day event to demonstrate that the future of health care is digital. The conference was held in Lafayette at the Cajundome Convention Center on Thursday, March 10, 2005.
Health care remains an industry that primarily moves on paper. However, the federal government has made a commitment to change this mode of operation. Under the administration of President George W. Bush, the U.S. Department of Health & Human Services created the national office of Health Information Technology (HIT) in 2004. This office has created a national HIT Road map, authorized the creation of a national electronic medical record standard, and committed to distribute an open source electronic medical record to physicians and small clinics in 2005.
Clearly, the health care delivery system is changing and information technology will propel the change. All stakeholders in the health care delivery system have a stake in this transformation---patients, providers, payers and policymakers. The Louisiana eHealth Conference shattered the myths about eHealth and demonstrated how information technology is the key to improving the quality of care by empowering patients, reducing medical errors, and eliminating duplicative processes and other inefficiencies in the current system.
The Louisiana eHealth Conference was a watershed event in the transformation of health care in our state. The conference presented speakers who addressed aspects of this transformation, based on eHealth projects which demonstrate that the change is underway in our state. It represented a unique opportunity for Louisiana's stakeholders to connect into the national developments, which hold the promise of better health care for all.
Additional information is available through the conference website: www.louisianaEhealth.org
Modifications to Louisiana Medicaid HIPAA Contingency Plan
Attention Hardcopy Submitters: We had previously announced that effective March 1, 2005, all hardcopy claims that are eligible for the 837 HIPAA mandated transaction submission will be held at least 21 days prior to final adjudication.
This modification is now on HOLD. All claims received for Dental, Long Term Care, Case Management and Non-Emergency Transportation Services and claims requiring attachments will not be delayed by this process. We encourage you to begin submitting electronic claims in the mandated 837 formats prior to this implementation to ensure that payments will not be delayed. If you have any questions, please call Provider Relations at 800-473-2783 or 225-924-5040.
Attention EMC Proprietary Submitters: LA Medicaid has started our Phase-In of Proprietary EMC submitters to the X12N 837 HIPAA mandated transactions. Below is a listing of the programs and the deadline dates for accepting proprietary EMC claims. Once the deadline has passed for a particular program, those EMC proprietary files will be returned to the submitter unprocessed. Therefore, we encourage you to move to the mandated HIPAA 837 as soon as possible. If you have not chosen a Vendor, Billing Agent, or Clearinghouse (VBC), go to
www.lamedicaid.com to find a VBC that has already been approved to submit the 837 HIPAA mandated transaction. If you have a question or need additional information regarding electronic billing, please call the HIPAA EDI Support Line at 225-237-3318.
Phase-In by Program with Deadlines
� October 31, 2004 - Hospital Inpatient/Outpatient/ Hemodialysis
� January 1, 2005 - DME/Ambulance
� March 31, 2005 - Professional (includes Physicians, Ambulatory Surgical Centers,
Physician services, Lab & X-Ray, Prenatal Clinics, TB Clinics, STD Clinics, EPSDT Health Services, Mental Health Clinics, Mental Health Rehabilitation, Rehabilitation Centers, Vision Ophthalmologists/Optometrists, Rural Health Centers, FQHCs, & Waiver)
� June 1, 2005 - Long Term Care, Dental
Flu Shots for Children
The Center for Medicare and Medicaid Services has issued the following clearance regarding the pediatric influenza vaccine for "high priority" Vaccine for Children (VFC) eligible children. In the event a Medicaid provider does not have VFC pediatric influenza vaccine on hand to vaccinate a "high priority" Medicaid child, the provider should use pediatric influenza vaccine from private stock, if available. The provider should not turn away, refer, or reschedule a "high priority" child for a later date if vaccine is available. The Office of Public Health VFC Program has an adequate supply of pediatric influenza vaccine. For information on the availability of or to order VFC pediatric influenza vaccine, contact the VFC Program at (504)483-1900. For a definition of "high priority" children, go to the CDC website at:
http://www.cdc.gov/nip/vfc/acip_resolutions/1004-1flu.pdf.
Change in CommunityCARE Procedures
Due to numerous problems with lack of reliability and documentation, effective January 1, 2005, U.S. mail is no longer an acceptable method of requesting or issuing CommunityCARE referrals/authorizations. Remittance Advise messages advising PCPs of the change in procedures were issued throughout the month of December, 2004. Hospital to PCP post ER-authorizations shall be requested and responded to via fax or Electronic Referral Authorization System (eRA). When referring a CommunityCARE recipient for specialty care, the PCP may elect to send the referral/authorization with the recipient and/or fax it to the other physician. If the referral/authorization request is denied a reason, for denial must be given.
Policy clarifications or procedural changes issued via Remittance Advise messages or Provider Updates may be viewed on the web at
www.laMedicaid.com.
PCPs Requesting CommunityCARE Enrollee Re-Assignment
In accordance with Federal guidelines, DHH must track PCP requests to unlink CommunityCARE enrollees from their practice. PCPs who want to unlink enrollees from their practice should first refer to the CommunityCARE handbook for acceptable reasons to request re-assignment of enrollees. They must then submit the request in writing to ACS State Health Services, the CommunityCARE/KIDMED contractor. Such requests are handled on a case by case basis. Simply notifying the enrollee will not ensure that the linkage will be closed. If the enrollee does not call the 800 number and request a PCP change, they will remain linked to that PCP. However once ACS is notified of a valid request to unlink an enrollee, the enrollee will be notified to select a new PCP. If the enrollee does not select a new PCP, he/she will be auto-assigned to a new PCP.
Administrative Authorizations
In some circumstances, it is appropriate for a CommunityCARE PCP to issue an administrative referral/authorization to another provider (transitional authorizations for PCP changes). Administrative authorizations are intended to address a number of situations that must be authorized for payment, but are not medical in nature. An administrative authorization does not imply that the PCP has recommended or endorsed a particular medical service or course of treatment.
Another instance where an administrative authorization may be used is when an enrollee is linked to a CommunityCARE PCP during the course of ongoing treatment (i.e. chemotherapy, occupational or physical therapy) already in progress for an existing condition. If the enrollee arrives for a prescheduled appointment without a referral from the CommunityCARE PCP, the treating provider should advise the enrollee before providing services that he/she is linked to a PCP and that the visit must be authorized by the PCP. The treating provider should then contact the PCP's office to request a referral/authorization. The treating provider must furnish the CommunityCARE PCP with appropriate medical information to support the medical necessity of the treatment for which the referral/authorization is being requested
The PCP shall not require the enrollee to be seen in his/her office prior to issuing an administrative authorization. It would be appropriate for the PCP to issue an administrative referral/authorization for a specific period of time until an office visit can be schedule to evaluate the enrollee's existing condition. The treating physician must advise the enrollee that the PCP is not obligated to issue additional referral/authorizations without the enrollee making an appointment for an office visit with the PCP. The intent is to avoid an adverse impact on the enrollee's health status as a result of an interruption of existing medical services.
Any questions regarding CommunityCARE policy may be directed to Unisys Provider Relations at 800-473-2783 or 225-924-5040or the CommunityCARE Program at 225-342-1304.
Asthma Disease Management
A new phase of Asthma Disease Management is being introduced by the Department this winter. Some of you are already familiar with the educational programs being provided to CommunityCARE recipients between the ages of 5 and 9 years by the nurses in the Quality Unit. They have done a tremendous job of educating patients as well as helping providers' offices develop asthma action plans. The next phase will reach across age groups and target patients experiencing more severe symptoms of asthma.
The pharmacists from the University of Louisiana - Monroe, who are on contract with Medicaid, will be implementing a telephone intervention for Medicaid clients with asthma who have been in the Emergency Department (ED) at least twice in the previous 6 months. During this telephone contact with the patient, the pharmacist will try to identify factors that lead to ED visits for uncontrolled
asthma, including the patients' understanding of appropriate medication administration. Since the pharmacist will have access to the Medicaid pharmacy data, they can tell how often the patient is filling prescriptions for his/her controllers and rescue medications. Once problems have been identified, the pharmacist will be able to give feedback to the patients' primary care physician. The pharmacist will also be able to direct the patient to education classes that are available in his/her area. During 2005, DHH will be identifying other educational opportunities and classes to address disease management issues. The pharmacists will have no way of knowing what medications were actually prescribed since the pharmacy data tracks only filled prescriptions. Therefore, the contact with the physician's office will be important so the provider will know when patients are not filling prescribed medications or are in need of additional education regarding appropriate use of their asthma medications.
The purpose of this initiative is to improve the asthma patient's quality of life through better asthma control. If there are questions or feedback from the providers' offices, please call Roxane Townsend, MD, Medicaid Medical Director at (225) 342-1164.
ICAP Updates
Implementation of the Inventory Client and Agency Planning (ICAP) reimbursement methodology for ICF-MR services is tentatively scheduled for July 1, 2005. The Notice of Intent adopting the provisions governing the ICAP reimbursement methodology was published in the January 20, 2005 issue of the Louisiana Register.
The ICAP Review Committee is responsible for review and final approval of any changes in the ICAP reimbursement methodology. The committee will be contacting providers to submit supporting documentation for those recipients, whose ICAP scores have decreased, thereby resulting in a higher level of reimbursement.
The Rate and Audit Section is revising the current cost report document to reflect the ICAP methodology. This revised cost report will be available for use for the 2005-2006 fiscal year. Medimax will notify providers when the cost report is finalized and Postlewaite & Netterville will conduct training for ICF/MR providers.
For further information on ICAP, providers should check the Department of Health and Hospitals website at
www.dhh.la.gov. If you have any questions, please contact Mary Norris at (225) 342-2768.
The Bureau of Health Services Financing Assumes Responsibility for Long Term Care Applications
The Long Term Care (LTC) financial application component of the contract was assumed by the Medicaid LTC eligibility workers effective December 1, 2004.
The Single Point of Entry (SPOE) call center, 1-877-456-1146, will continue informing all applicants and/or their families of their opportunity to make informed choices regarding how their needs can be best met in the community or institutional settings.
The Medicaid offices responsible for processing LTC financial applications are:
LTC APPLICATIONS - MEDICAID OFFICES
Valid October 18, 2004 but, subject to change
V1.0
| Region
|
Parish
|
Address
and Phone Number
|
| 1
|
East Jefferson, Orleans,
Plaquemines, St. Bernard and West Jefferson
|
Orleans
Regional Medicaid Office
Street
Address:
1010 Common Street, 4th Floor
New Orleans, La 70112
Mailing
Address:
P.O. Box 60840
New Orleans, La 70160-0840
Contact
Supervisors:
Ms. J. Kimbrough 504-599-0618
Ms. C. Clark
504-599-0638
Ms. M. Brown
504-599-0640
Fax: 504-599-0608
|
| 2
|
Ascension, East Baton Rouge,
Iberville, East Feliciana, West Feliciana, Point Coupee and West Baton
Rouge
|
East Baton Rouge Parish Medicaid
Mailing
Address:
P.O. Box 64808
Baton Rouge, LA 70896-4808
Street
Address:
2521 Wooddale Blvd.
Baton Rouge, LA 70806
Phone: 287-7401 (local to
Baton Rouge) or 1-877-287-7401 (toll free)
Fax: 225-922-0406
Contacts:
Marcia Strong � 225-922-2166
Pam Skelton � 225-922-3101
|
| 3
|
Assumption, Lafourche, St.
Charles, St. James, St. John, St. Mary and Terrebonne
|
Lafourche Parish Medicaid
Contact: Janet Gros, MAS
P.O. Box 1038
Thibodaux, La 70302
Phone: 985-449-5021 or
1-800-401-0132
Fax: 985-449-516 |
| 4
|
Acadia, Evangeline, Iberia,
Lafayette, St. Landry, St. Martin and Vermilion
|
Lafayette Parish Medicaid
Contact: Janet Garcille
P O Box 80708
Lafayette, LA 70598-0708
Phone: 337-262-1193 or 1-800-230-0690
Fax: 337-262-5173
|
| 5
|
Allen, Beauregard and Jeff Davis
Cameron and Calcasieu
|
Jefferson Davis Parish Medicaid
Contact: Angie Klumpp
P.O. Box 559
Jennings, La. 70546-0559
Phone: 337-824-5686
Fax: 337-824-0842
Calcasieu Parish Medicaid
Contact: Brenda Prejean
P.O.Box 3250
Lake Charles, La. 70602-3250
Phone: 337-491-2122
Fax: 337-491-2785
|
| 6
|
Rapides, Grant, Vernon and Winn
Avoyelles, Catahoula, Concordia, and LaSalle
|
Rapides Parish Medicaid Office
Contact: Caroline Edwards,
MAM, or Katherine Tyler, MA 3
P.O. Box 13708
Alexandria, La. 71315-3708.
Phone: 1-800-573-6220 or
318-487-5670
Fax: 318-487-5924
Avoyelles Parish Medicaid Office
Contact: Veronica Barton, MA
3
457 West Waddil Street
Marksville, LA 71351
Phone: 1-800-573-6220 or
318-253-5946
Fax: 318-253-6775
|
| 7
|
Bienville, Bossier, Caddo,
Claiborne, Desoto, Natchitoches, Red River, Sabine and Webster
|
Department of Health and Hospitals
Bureau of Health Services Financing
Shreveport Regional Medicaid
3020 Knight Street- Suite 100
Shreveport, La 71105
Phone: 1-800-256-3068
Fax: 1-318-862-9891
Contact
Supervisors:
Melinda Foster
Helen Smith
Mary Mason
|
| 8
|
East and West Carroll
Franklin, Caldwell and Tensas
Lincoln and Jackson
Morehouse
Ouachita and Union
Richland and Madison
|
East/West Carroll Medicaid Office
Contact: Sonya Hillman, MAM
702 East Jefferson St.
P.O. Box 1006
Oak Grove, LA 71263-1066
1-888-738-0792 or 318-428-3252 ext 147
Fax: 318-428-1033
Franklin/Caldwell/Tensas Medicaid Office
Contact: Pam Williams, MA 2
2406 West St.
P.O. Box 609
Winnsboro, LA 71295-0609
1-800-460-7726 or 318-435-2101 ext 259
Fax: 318-435-2139
Lincoln/Jackson Medicaid Office
Contact: Jackie Spencer, MAM
1102 East Georgia, Ste. B
P.O. Box 1609 - 71273
Ruston, LA 71270
1-888-436-6561 or 318-251-5051
Fax: 318-251-5056
Morehouse Medicaid Office
Contact: Donna Stevenson, MAM
240 Holt St.
P.O. Drawer 1095 (71221-1095)
Bastrop, LA 71220
318-556-7014 ext 13
Fax: 318-283-0864
Ouachita/Union Medicaid Office
Contact: Georgia Briggs, MAS
3100 Kilpatrick Blvd.
P.O. Box 14225
Monroe, LA 71207-4225
1-800-510-5378 or 318-362-3303
Fax: 318-362-4263
Richland/Madison Medicaid Office
Contact: Martha Godwin, MA3
114 Morgan St.
P.O. Box 539
Rayville, LA 71269-0539
1-800-460-7701 or 318-728-2316
Fax: 318-728-7847
|
| 9
|
Livingston
and St. Helena
St. Tammany
Tangipahoa
Washington
|
Livingston
Parish Medicaid Office
Contact: Patricia Stewart,
MAM
1279 Del Este Avenue
Denham Springs, LA 70726
Phone: 225-665-4388
Fax: 225-665-1983
St. Tammany Parish Medicaid Office
Contact: Faye Williams, MAM
21454 Koop Drive, Suite 1B
Mandeville, LA 70471
Phone: 985-871-1361
Fax: 985-871-1369
Tangipahoa Parish Medicaid Office
Contact: Carolyn Norman, MAM
or
Henry Bennett, MAM
121 Robin Hood Drive
Hammond, LA 70403
Phone: 985-543-4217
Fax: 985-543-4221
Washington Parish Medicaid Office
Contact: Pat Dixon, MAM
521 Ontario Avenue
Bogalusa, LA 70427
Phone: 985-730-2027
Fax: 985-732-6835
|
Louisiana Drug Utilization Review (LADUR) Education
Addressing Behavioral Pharmacy in the Louisiana Medicaid Program
By:
Sandy Blake, Ph.D.University of Louisiana at Monroe, School of Pharmacy and
Melwyn Wendt, Louisiana Department of Health and Hospitals
Issues...
� In the U.S., prescription drug spending for 2002 totaled $162.4 billion, four times what was spent in 1990.
� This ascending pattern of prescription drug utilization is also occurring in state Medicaid programs.
Spending for prescription drugs is one of the fastest growing components of medical costs in the United States. The Kaiser Commission on Medicaid and the Uninsured reported in October 2004 that spending in the U.S. in 2002 for prescription drugs totaled $162.4 billion, four times what was spent in 1990. The report continued by discussing three cost drivers:
� Increasing number of prescriptions,
� Changes in the types of drugs being used with more newer, higher-priced drugs being
prescribed, and
� Manufacturer price increases.[1]
This ascending pattern of prescription drug utilization is also occurring in state Medicaid programs. The Kaiser Commission on Medicaid and the Uninsured reported that in federal fiscal year 2002 (October 2001 � September 2002), prescription drugs accounted for an estimated $29.7 billion, an 11% share of total expenditures[2] The Commission went on to report:
� In federal fiscal year 2002, states reported that the most significant contributor to
higher Medicaid spending was prescription drugs,[3]
� Between 2000 and 2002, prescription drug expenditures increased 18.8 % per year,
� In 2002, fee-for-service Medicaid paid for over 525 million prescriptions,
� Even with the advent of the Medicare prescription benefit, Medicaid will continue to
be a major source of payment for prescribed drugs.[4]
The Kaiser Commission reported in November 2004 that, responding to this fiscal pressure, in fiscal year 2004, all 50 states implemented measures to control spending growth with 48 states implementing new pharmacy cost controls.[5]
Louisiana has not been exempt from the challenge of rising pharmacy costs in our Medicaid program. Figure 1 presents prescription drugs costs over the last 4 state fiscal years.
As the figure displays, not only have the absolute number of prescriptions risen over the past 4 years, but the cost per prescription (pre-rebate) has also risen leading to total pre-rebate pharmacy costs in SFY 2004 ($880,468,858) over 62% higher than SFY 2001 ($542,973,359).
Behavioral Pharmacy Costs and Utilization
Psychotropic and central nervous system drugs represent some of the most rapidly rising costs in the Medicaid program, significantly exceeding increases in other drug classes. While most are now aware of the positive impact of some of the newer agents, they are more costly than the older drugs and have a significant budget impact. Most recognize that some cost and quality controls are needed in behavioral pharmacy, especially given the budget constraints states are facing. However, the challenge for Medicaid programs across the country has been controlling the cost growth in these therapeutic classes while maintaining access to these medications with better side-effect profiles that reduce utilization of other medical and mental health services.[6]
A brief data analysis was undertaken to examine behavioral drug utilization in the Louisiana Medicaid program. For this purpose, a behavioral drug was defined as one belonging to one of the following therapeutic classes:
� Atypical Antipsychotics (H7T, H7X)
� Typical Antipsychotics (H2G, H2I, H2L, H2O, H7O, H7P, H7Q, H7R, H7S, H7U, H7V, H7Z)
� Antidepressants (H2H, H2J, H2K, H2N, H2S, H2U, H2W, H2X, H7B, H7C, H7D, H7E, H7J, H7N, L3P)
� CNS Stimulants (A1B, H2A, H2V, J5B, J8A).
An examination of paid pharmacy claims shows the increase in number and costs of behavioral drug utilization in the Louisiana Medicaid program (Figure 2).
Of the 1,063,241 recipients enrolled in Medicaid in SFY 2004, 152,380 (14.33%) received a prescription for one of the above-mentioned behavioral drugs. Of these:
� 31% take an antipsychotic
� 67% take an antidepressant
� 29% take a stimulant.
Of these, in the last month of SFY 2004 (June):
� 68.8% took only one behavioral drug
� 24.1% took two behavioral drugs
� 7.3% took three or more behavioral drugs.
Louisiana Medicaid Behavioral Pharmacy Management Program
Medicaid programs across the country are addressing this issue currently and/or in the future. Both the National Mental Health Association and the National Alliance for the Mentally Ill have strongly supported utilization control methods that use claims data review to address appropriateness of behavioral drug utilization.[6] In accordance with that, the Louisiana Medicaid Pharmacy Benefits Program and the Louisiana Office of Mental Health have formed a data-driven collaborative effort to improve mental health, reduce waste and increase the quality of behavioral pharmacy care in the Louisiana Medicaid program. Issues to be addressed include:
� Two or more antipsychotics
� Three or more atypical antipsychotics
� Concurrent use of three or more mental health drugs in the pediatric population
� Use of anxiolytics and sedative hypnotics for more than 60 days
� High dose atypicals
� Low dosage of atypicals with one or more inpatient admissions during the prior 60 days
� Multiple prescribers of atypicals
� Multiple switching of atypicals
� Two or more mental health medications from the same class for 60 or more days
� Non-compliance with mental health medications
� Adherence to published treatment guidelines.
The Louisiana Medicaid Pharmacy Benefits Program and the Office of Mental Health will address these issues using Medicaid programs already in place, such as the Drug Utilization Review (DUR) and disease management publications. Also, Medicaid providers will be given data reports designed to assist them in patient care, guidelines and treatment algorithms, and other educational literature.
References
1. Foundation, K.F., Prescription Drug Trends. 2004.
2. Bruen, B.a.G., Arunabh, Medicaid Prescription Drug Spending and Use. 2004, Kaiser Commission on Medicaid and the Uninsured.
3. Psychotropic Medications: Addressing Costs without Restricting Access. 2004, Center for Medicare and Medicaid Services.
4. Medicaid, K.C.o., Medicaid Prescription Drug Spending and Use. 2004, Kaiser Family Foundation.
5. State Fiscal Conditions and Medicaid. 2004, Kaiser Commission on Medicaid and the Uninsured.
6. Dougherty, R.H., Behavioral Pharmacy Benefit Management: Case Studies. 2004, Center for Health Care Strategies.