PROVIDERNewsletter

MEDICARE | 2013 | ISSUE II

PROVIDER RESOURCES

WEB RESOURCESVisit www.wellcare.com to access our Preventative and Clinical Practice Guidelines, Clinical Coverage Guidelines, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) documents, Pharmacy Guidelines and other helpful resources. Providers may also request hard copies of any of the above documents by contacting their Provider Relations representative. For additional information, please reference your Quick Reference Guide at www.wellcare.com/Provider/QuickReferenceGuides.

PROVIDER NEWSRemember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com to find copies of the latest correspondences. Use the area on the right labeled “Member/Provider Secure Sign-In.” You will see Messages from WellCare located in the right-hand column.

ADDITIONAL CRITERIA AVAILABLE Please remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for several medical procedures, devices and tests, are available via the provider resources link at www.wellcare.com/Provider/CCGS.

PROVIDER SATISFACTION SURVEYWellCare Health Plans, Inc. continues to focus efforts on the experiences of both our members and providers. In order to better understand and remain well informed about our valued provider network, we conducted the Provider Satisfaction Survey again in 2012. The survey concentrated on a variety of subjects including call center/member services, provider relations, continuity/coordination of care, provider network, utilization and quality management, finance issues, pharmacy and drug benefits, and overall satisfaction and loyalty.

As in 2011, extensive reviews of our 2012 survey results are under way to ensure that our focus is aligned with the needs of our providers. Current areas of focus include enhancing provider services at the local level, claim processing and issue resolution, enriching administrative tools/capabilities and a renewed emphasis on quality. The Provider Experience team is continuously engaged with several cross-functional teams working on these initiatives, and others that are aimed at better serving our providers. We anticipate incremental gains on several initiatives in 2013 and continued improvement beyond. Stay tuned as these efforts will be further communicated as the year progresses.

Very shortly, WellCare will again conduct a Provider Satisfaction Survey. This follow-up survey will be used to measure progress from last year’s effort to better evaluate how we can become more effective and productive business partners.

Your participation is encouraged – and appreciated – as together we strive to positively impact our members’ overall quality of care.

REMINDER...Cosmetic procedures are a covered benefit only when determined to be medically necessary. These services require clinical review to determine that they are being provided for the improvement and restoration of bodily function and not solely for the improvement of the patient’s appearance and/or self-esteem.

DISEASE MANAGEMENT – IMPROVING MEMBERS’ HEALTHDisease Management is a free, voluntary program that assists members with specific chronic conditions. Members are assigned a Disease Nurse Manager who can help the member with:

• Education and understanding of his/her specific condition

• Identification of adherence barriers and ways to overcome them

• Individualized life modification suggestions to improve daily life

• Self-management of his/her condition to improve health outcomes

• Motivational coaching for encouragement with the struggles along the way

• Improved communication with his/her primary care provider and health care team

Disease Management can assist your members with the following conditions:

• Asthma

• Chronic Obstructive Pulmonary Disease (COPD)

• Congestive Heart Failure (CHF)

• Coronary Artery Disease (CAD)

• Diabetes

• Hypertension

• Obesity

• Smoking

For more information, or to refer a member to Disease Management, please refer to your Quick Reference Guide at www.wellcare.com/Provider/QuickReferenceGuides.

SECURE PROVIDER PORTAL – BENEFITS OF REGISTERINGOur secure online Provider Portal offers immediate access to an assortment of useful tools. Providers can create individual sub-accounts for staff member’s use, if needed.

All providers who create a login and password using their WellCare Provider Identification (Provider ID) number have access to the following features:

• Claims submission status and inquiry: Submit a new claim, check the status of an existing claim, and customize and download reports.

• Member eligibility and co-payment information: Verify a member’s eligibility and look up specific co-payments.

• Authorization requests: Submit authorization requests, attach clinical documentation and check authorization status. You can also print and/or save copies of authorization forms.

• Training: Take required training courses and complete attestations online.

• Reports: Access reports such as active members, authorization status, claims status, eligibility status and more.

• Provider news: View the latest important announcements and updates.

• Personal inbox: Receive notices and key reports regarding your claims, eligibility inquiries and authorization requests.

HOW TO REGISTERPlease visit www.wellcare.com/registration/provider to register. After registering, make sure to retain your login and password information for future reference.

HOW CASE MANAGEMENT CAN HELP YOU Case Management helps members with special needs. It pairs a member with a case manager. The case manager is a nurse or licensed clinical social worker who can help the member with issues such as:

• Complex medical needs

• Solid organ and tissue transplants

• Lead poisoning

• Children with special health care needs

• Chronic illnesses such as asthma, diabetes, hypertension and heart disease

We’re here to help you! For more information about Case Management, or to refer a member to the program, please call us at 1-866-635-7045. This no-cost program gives access to a registered nurse (RN) or licensed clinical social worker (LCSW) Monday –Friday from 8 a.m. to 5 p.m.

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WELLCARE IS NOW CORE PHASE I AND II COMPLIANTWellCare Health Plans, Inc. is pleased to announce that as of January 1, 2013, we are Phase I and II compliant per the CAQH® Committee on Operating Rules for Information Exchange® (CORE) guidelines.

The CORE objectives are designed to make it easier for physicians and hospitals to access patient insurance information before or at the point of care. CORE operating rules are streamlining eligibility, benefits and claims data by allowing providers to submit a request – using the electronic system of their choice – to obtain a variety of coverage information for any patient and from any participating health plan. Providers will receive more consistent and predictable data regardless of health plan.

CORE Phase I and II compliance enhancements include the ability to provide you with more detailed co-pay and coinsurance information for multiple services, including:

• Professional office visits

• Emergency services

• Hospital inpatient

• Hospital outpatient

To learn more about CAQH and the CORE initiative, please visit www.caqh.org.

PROVIDE WELLCARE WITH YOUR UPDATED INFORMATIONAs a reminder, please provide WellCare with any updated information or changes that could affect your status with the Plan. For example, be sure to inform WellCare in writing within 24 hours of:

• Any revocation or suspension of your DEA number

• Suspension, limitation, or revocation of your license, certification or other legal credential authorizing you to practice

In addition, please inform the Plan in writing immediately of changes to:

• Loss of liability insurance

• Licensure status

• Tax identification numbers

• Telephone number

• Status at participating hospitals

• Addresses

By keeping your information up to date, you are helping to improve member accessibility. You will also help to ensure all correspondence, claim payments and notifications the Plan sends will get to your correct location.

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ASSESS POTENTIAL HEALTH CONCERNS FOR YOUR OLDER PATIENTSWellCare encourages you to dedicate a few minutes during a patient visit to discuss the following health concerns with your older patients.

FALL RISK MANAGEMENTAsk your patients if they fell or almost fell, but were caught by someone, or managed to grab hold of something just in time. Fall prevention is one of the biggest safety concerns for older patients, especially those who live alone. Slip and fall accidents are one of the leading reasons seniors go to the hospital. An important aspect of injury prevention is to educate patients about how to prevent falls. This includes wearing sensible shoes and using an assistive device. This is especially important for seniors as their balance may be impaired, leading to increased falls.

ASSESS PHYSICAL ACTIVITY AND KEEP YOUR PATIENTS MOVINGTalk to your patients about their physical activity. You may want to advise them to start, increase or maintain their level of physical activity to maintain and/or improve their health. Regular physical activity can improve strength, balance, coordination and flexibility, and goes a long way toward fall prevention.

URINARY INCONTINENCE (UI)In addressing a topic as sensitive as this, it is important to put patients at ease so they will feel comfortable discussing such a private issue with you. Loss of bladder control is common among older patients. UI may be underreported because patients do not believe that anything can be done about it. Underlying health problems may contribute to incontinence, such as menopause for women and enlarged prostate for men.

If the patient is experiencing symptoms of urinary incontinence, discuss treatment options that may include bladder training, physical therapy or, sometimes, just a simple change in toileting habits may bring relief.

CHECK FOR OSTEOPOROSIS Assess your patients’ bone health. Because osteoporosis can be asymptomatic for a prolonged period of time, do bone mineral density (BMD) testing, if applicable.

With age, bones tend to shrink in size and density, which weakens them and makes them more susceptible to fracture. The U.S. Preventive Services Task Force (USPSTF) recommends BMD testing on all women age 65 and older, all men age 70 and older, and other patients based on their clinical profile.

You may want to provide tips for preventing bone loss and the progression of osteoporosis. For example, suggest to patients to include plenty of calcium and vitamin D in their diets, and consider strength training to increase bone density and reduce the risks of osteoporosis. Medication management is a treatment option to slow bone loss and maintain bone mass, when applicable.

Always remind your patients that it’s never too late to adopt a healthy lifestyle. As their physician, you cannot stop the aging process, but your patients can minimize the impact by making healthy lifestyle choices with your guidance.

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CMS MEDICARE QUALITY AND PERFORMANCE STAR RATINGSPHARMACY QUALITY MEASURESCMS gauges plans’ performance via multiple quality and performance measures to allow beneficiaries to make informed decisions about their health care. We want to provide you with the specific list of quality measures that CMS evaluates and ask that you help us keep our members on track.

ADHERENCE• A member is adherent if the proportion of days covered (PDC) is greater than 80 percent for a particular class

of medications.

– This is defined by the member having continuous medication coverage (determined by pharmacy days’ supply claims) greater than 80 percent of the plan year starting from the first fill of the medication.

• Adherence is reported as three separate measures:

– Diabetes medications:

◊ Biguanides, sulfonylureas, thiazolidinediones and DPP-IV inhibitors

– Hypertension medications:

◊ ACE inhibitors, ARBs, direct renin inhibitors

– Cholesterol medications:

◊ Statins

• Members are allowed to switch medications within a class and remain adherent.

DIABETIC PATIENTS NOT ON AN ACE/ARBDiabetic patients (those identified as having a claim for a diabetes medication) not currently on an ACE inhibitor, ARB, or direct renin inhibitor.

USE OF HIGH-RISK MEDICATIONSMembers 65 years or older with at least two fills for a high-risk medication. Most common high-risk medications include:

• Zolpidem/zaleplon

• Glyburide

• Cyclobenzaprine/carisoprodol

• Promethazine

• Hydroxyzine

• Amitriptyline

• Digoxin (doses > 125 ug)

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WAYS TO REDUCE YOUR PATIENTS’ RISK OF COMPLICATIONS FROM DIABETES MELLITUSThe following national statistics and other general information on diabetes were adapted from the Centers for Disease Control and Prevention (CDC) National Diabetes Fact Sheet: National estimates and general information on diabetes in the United States.

• 25.8 million Americans have diabetes – 8.3 percent of the U.S. population. Of these, 7 million do not know they have the disease.

• In 2010, about 1.9 million people ages 20 or older were diagnosed with diabetes.

• The number of people diagnosed with diabetes has risen from 1.5 million in 1958 to 18.8 million in 2010, an increase of epidemic proportions.

• Diabetes is the seventh leading cause of death listed on U.S. death certificates.

• Cardiovascular disease is the leading cause of death among people with diabetes – about 68 percent die of heart disease or stroke.

• The overall risk for death among people with diabetes is about double that of people without diabetes.

• Total health care and related costs for the treatment of diabetes run about $174 billion annually.

• Of this total, direct medical costs (e.g., hospitalizations, medical care and treatment supplies) account for about $116 billion.

• The other $58 billion covers indirect costs such as disability payments, time lost from work and premature death.

As you can see from the facts listed above, diabetes is becoming more prevalent. Please educate your patients on a self-care plan so they can take control of their disease and lower their risk of complications.

Encourage diabetics to use the following as a guide to self-care:

1. Know their diabetes ABCs.

• A is for the A1C (blood glucose) test. Results should be < 7.

• B is for Blood pressure. It should be below 120/80.

• C is for Cholesterol. LDL should be less than 100 and HDL above 40 to lower the patient’s chances of having a heart attack, stroke or other associated diabetic problems.

• S is for Smoking. Encourage patients to be nicotine free and provide them with the Quit Smoking website www.smokefree.gov.

2. Stay at a healthy weight by staying on a diet that achieves a BMI in the normal range.

3. Check their blood glucose during the day; know their blood glucose targets and how to use the results to manage their diabetes.

4. Participate in 30 minutes of physical activity 2–4 days per week.

5. Abstain from alcohol or consume it in moderation.

6. Schedule periodic medical checkups to include an annual retinal eye exam by either an ophthalmologist or optometrist, and an annual dental examination to find and treat any problems early.

7. Be mindful of their foot care, being sure to check their feet every day for cuts, blisters, red spots and swelling, and call you right away about any sores that don’t go away.

8. Report any changes in their eyesight.

9. Stay up to date with their age-appropriate vaccinations.

10. Use stress management techniques that reinforce positive health care behaviors.

Please refer to your Quick Reference Guide at www.wellcare.com/Provider/QuickReferenceGuides for contact information to refer diabetic members to the Plan’s Disease Management program. This program is at no cost to the member. As part of the program, a registered nurse will help educate members via telephone. One of the goals of the program is to empower members to further increase their self-management skills and follow your prescribed plan of care.

Sources: Centers for Disease Control and Prevention (CDC) National Diabetes Fact Sheet: National estimates and general information on diabetes in the United States, Updated January 2011. National Diabetes Education Program (NDEP) at http://www.ndep.nih.gov/publications

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HELPING PATIENTS WITH RHEUMATOID ARTHRITISAccording to a U.S. government survey on arthritis statistics, one out of every four adults in America will have arthritis by 2030. There are over 50 million people who suffer from arthritis. According to the Centers for Disease Control and Prevention, people with rheumatoid arthritis (RA) die up to 10 years earlier than those who do not have this disease.

Together, we can help your patients become more educated about the disease process, maximize current treatment methods and avoid common mistakes associated with their RA. Consider the following strategies:

Prescriptions: Emphasize the importance of taking a disease-modifying anti-rheumatic drug (DMARD) or a biologic early on, since these classes of drugs address the root cause of the immune system malfunction, often at the cellular level. The American College of Rheumatology (ACR) recommends that all RA patients be given a DMARD, regardless of how active or severe their RA is. Studies show that starting powerful drugs earlier may be more effective in reducing or preventing joint damage.

Medication Regimen: Patients may stop taking their medications or skip doses as they feel better. Therefore, it is critical to help them understand that failing to take their medication may cause pain or the arthritis to get worse. Patient education in this area is key to a successful treatment outcome.

Depression: Watch for depression in RA patients, since this chronic condition can negatively affect their psychosocial well-being. Some people with RA benefit from antidepressants in concert with help from a mental health professional.

As you deem beneficial, advise patients to utilize their mental health benefits by calling the number on the back of their Plan member ID card. In addition, encourage them to attend local support groups such as those offered by The Arthritis Foundation or local hospitals.

Exercise: It is recommended that RA patients take short rest breaks throughout the day, especially when the disease is active or exacerbated. This can help reduce joint inflammation, pain and fatigue. However, it is prudent to advise RA patients that too much rest will increase stiffness and decrease joint mobility. Teach gentle range-of-motion exercises and encourage exercising in water during flare-ups. When patients are feeling better, promote increased activity and resistance exercise to build muscle strength.

Referrals: Refer RA patients to follow up with a rheumatologist for ongoing monitoring, labs and medical treatment. Advise them to find a local rheumatologist through the Plan’s website at www.wellcare.com or by calling Customer Service.

WellCare also has specialized Disease Management nurses who speak to members with RA via telephone to provide education in conjunction with educational mailings. Please refer to your Quick Reference Guide at www.wellcare.com/Provider/QuickReferenceGuides for contact information to refer members to the Plan’s Disease Management program.

Sources: Arthritis Foundation, The American College of Rheumatology (ACR), http://www.arthritis.org

The Centers for Disease Control (CDC), http://www.cdc.gov/arthritis/media/quickstats.htm

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2013 Q2 PROVIDER FORMULARY UPDATEUpdates have been made to the Medicare formulary. The most current and complete formulary can be found at www.wellcare.com/medicare/medication_guide.

Please refer to your provider manual available at www.wellcare.com/provider/ProviderManuals to view more information regarding WellCare’s pharmacy utilization management policy/procedures.

2012 QUALITY IMPROVEMENT HIGHLIGHTSThe Medicare Quality Improvement (QI) program is an ongoing, comprehensive and integrated system. The QI program actively initiates, monitors and evaluates the standards of health care practice and infrastructures essential to the delivery of quality clinical care and service to our members.

HIGHLIGHTS FROM THE 2012 QI PROGRAM INCLUDE:• Conducted regular audits of utilization management, case management, appeals, human resource records,

contracting, complaint and grievance files to assess ongoing compliance and provide targeted feedback.

• Facilitated an initiative to connect members with their providers to complete an assessment and update documentation that yielded immediate benefits:

– Initiated member in-home health assessments.

– Initiated focused member and provider educational outreach mailings.

– Initiated focused member and provider educational outreach calls.

• Deployed a SOAP Note provider incentive. This incented providers for completed SOAP note documentation to improve closure of member care gaps.

• Educated medical groups and physicians on quality initiatives and HEDIS® measures.

• HEDIS Care Gap Customer Service Inbound Program continued in collaboration between Customer Service and Quality Improvement teams. Members who called WellCare’s Customer Service line for an issue were routed to a discussion regarding care gaps (after call resolution), if they are flagged with a medical care gap.

OUR GOALS FOR 2013 INCLUDE:• WellCare is focusing on improving members access to care by:

– Increasing the number of providers who are close to their members

– Increasing the number of primary care providers who have open panels to see new members

– Improving the member’s ability to get timely appointments

• Preparing for a successful National Committee for Quality Assurance (NCQA) health plan accreditation.

• Increasing efforts to work with community agencies to augment the care of our members.

• Developing specific interventions to improve HEDIS outcomes related to preventive and chronic care.

• A workgroup has been formed to review and analyze the 2012 Provider Satisfaction Survey results to identify areas of opportunity.

To receive a copy of our QI program description, please fax a request to the QI department at 1-813-262-2807.

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DESERT CANYON COMMUNITY CARE PLUS IS NOW WELLCARE OF ARIZONA Welcome to the WellCare family and our network of providers!

As you know, on January 1, 2013, Desert Canyon Community Care Plus (DCCCP) became WellCare of Arizona. More than 4,000 members in Mohave and Yavapai counties will be covered under our benefit plans, and continue to be cared for by you. WellCare of Arizona is committed to providing your practice impeccable service through our local leadership and field network management representatives.

We’re very pleased to announce that all of the associates in our Prescott office that you’ve come to know over the years – Adrianna Burnett, Leanne Bryan, Bea Richardson and Cheryl Boik – have been retained by WellCare.

We’re eager to resume our great partnership. In fact, we’ll be calling to introduce ourselves as WellCare associates. And we’ll be visiting your office very soon.

Please note that our office address, telephone and fax numbers remain the same, however, our extensions have changed. Please note our telephone numbers and email addresses below. If you need help, please give us a call. We’re ready to help!

ARIZONA

Telephone: 1-800-657-2193

Local Telephone: 1-928-777-9226

Fax: 1-928-777-9243

Adrianna Burnett Ext. 6644 adrianna.burnett@wellcare.com

Leanne Bryan Ext. 6642 leanne.bryan@wellcare.com

Bea Richardson Ext. 6648 bea.richardson@wellcare.com

Cheryl Boik Ext. 6641 cheryl.boik@wellcare.com

Roy Dickerson Ext. 6645 roy.dickerson@wellcare.com

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WELLCARE OF CONNECTICUT ADDS URGENT CARE CENTERS, AMBULATORY SURGERY CENTERS TO NETWORKWellCare of Connecticut is pleased to announce the addition of these Urgent Care Centers to our Provider Network. The facilities will provide additional access to care for urgent medical needs after hours and on weekends, without an appointment.

CONNECTICUT

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NORTH HAVEN URGENT CARE GROUP

163 Universal DriveNorth Haven, CT 06473

109 Boston Post RoadOrange, CT 06477

667 Connecticut AvenueNorwalk, CT 06854

Hours of Operation:

Monday–Friday: 8 a.m. to 8 p.m.

MEDICAL WALK-IN CARE OF WESTVILLE

1351 Whalley Avenue New Haven, CT 06515

Hours of Operation:

Monday–Friday: 8:30 a.m. to 5 p.m.Saturday and Sunday: 8 a.m. to 1 p.m.

URGENT CARE OF CONNECTICUT

346 Main AvenueNorwalk, CT 06851

10 South Street Suite 101Ridgefield, CT 06877

31 Old Route 7Brookfield, CT 06804

Hours of Operation:

Monday–Friday: 8 a.m. to 8 p.m.Saturdays, Sundays and Holidays: 9 a.m. to 5 p.m.

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ENFIELD AMBULATORY CARE CENTER

15 Palomba Drive Suite 9 Enfield, CT 06082

Hours of Operation:

Monday–Friday: 9 a.m. to 7 p.m.Saturday: 9 a.m. to 5 p.m.Sunday: 9 a.m. to 2 p.m.

WellCare of Connecticut is also pleased to announce the addition of these Ambulatory Surgery Centers to our Provider Network. These surgery centers will provide a lower cost option for our members for Outpatient Surgery Services and do not require prior authorizations when performed in this setting.

NORTH HAVEN SURGICAL CENTER

52 Washington Avenue Suite 1North Haven, CT 06473

NEW ENGLAND SLEEP THERAPY, LLC

1291 Boston Post Road Suite 202Madison, CT 06443

RESOURCES FOR SMOKING CESSATIONWith millions of Americans still smoking; providers will inevitably encounter many patients with nicotine addiction. You can develop systems within your workplace that identify smokers and offer them treatment options. Alternatively, you or your staff can identify patients who smoke, advise them to quit and refer them to a Quitline.

Quitlines are a great resource to assist with smoking cessation. They are staffed by coaches trained specifically to help smokers quit and deliver information, advice, support, and referrals through 1-800-QUIT-NOW in all U.S. states. In essence, the Quitline coach will offer the benefit of a personalized plan and counseling to help the patient kick smoking to the curb. Any information patients provide or discuss with a Quitline coach during the call is completely confidential.

Patients can talk to counselors by instant message online through LiveHelp at www.smokefree.gov/expert.aspx. LiveHelp Information Specialists can answer questions about cancer, clinical trials and quitting smoking. LiveHelp is confidential, however LiveHelp does not provide medical advice.

Additional resources for smokers, such as a step-by-step guide, tools to help smokers quit and topics related to quitting are also available at www.smokefree.gov. The step-by-step guide providers the basic “START” steps for quitting:

S= Set a quit date

T= Tell family, friends and co-workers that you plan to quit

A= Anticipate and plan for the challenges you’ll face while quitting

R= Remove cigarettes and other tobacco products from your home, car and work

T= Talk to your doctor about getting help to quit

Talk to your patients today about the dangers of smoking and the information available to help them quit.

Source: www.smokefree.gov

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WellCare Health Plans8735 Henderson RoadRen 1Tampa, FL 33634

NA021449_PRO_NEW_ENG©WellCare 2013 NA_02_13

50938

To contact WellCare, please call the following:

WellCare of Arizona: 1-877-560-3213

WellCare of Connecticut: 1-866-579-8006

WellCare of Louisiana: 1-866-804-5926

WellCare of Missouri: 1-866-687-8994

WellCare of New Jersey: 1-866-687-8570

WellCare of Texas: 1-866-687-8878

Or visit www.wellcare.com.

IN THIS ISSUE

• Provider Satisfaction Survey

• 2012 Quality Improvement Highlights

• CMS Medicare Quality and Performance Star Ratings - Pharmacy Quality Measures

• WellCare is now CORE Phase I and II Compliant

• WellCare of Connecticut Adds Urgent Care Centers, Ambulatory Surgery Centers to Network

• How Case Management Can Help You

• Disease Management - Improving Members’ Health

• Assess Potential Health Concerns for Your Older Patients

• Helping Patients with Rheumatoid Arthritis

• Ways to Reduce Your Patients’ Risk of Complications from Diabetes Mellitus

• Desert Canyon Community Care Plus is Now WellCare of Arizona