Peach State Health Plan Blog

Great News!! Peach State  is proud to  announce a new web enhancement to the Provider Secure Portal.  An Office Manager function has been added. This role allows a user who is designated as the Office Manager during the Secure Portal registration process to manage the other users associated with the Provider’s Tax Id Number.

The user designated as the Office Manager will have the ability to create new user logins, disable user logins, and reset passwords for other office staff associated with the same TIN. At least one user for the provider site should be designated as Office Manager. 

Provider offices that have not previously designated an Office Manager during the registration process must create one by registering at www.PSHP.com. During the  registration process, please select the Office Manager Role.

Provider offices in which multiple users have been designated as the Office Manager during registration, we recommend that you review the users registered for your TIN and adjust the roles of any user flagged incorrectly as Office Manager.

Peach State will be offering Webinar sessions to demonstrate the functions available with this new Office Manager Role.  The webinar sessions will be offered March 8, 2010 through March 12, 2010 at 12:00 PM and 2:00 PM.  Please register for these sessions by accessing https:centene.webex.com. Click on the Meeting Center tab and then Browse the Meetings available on the Monthly tab to register for one of the Peach State Secure Portal Office Manager Training sessions.

This entry is filed under Blog, News.

Requests for Hospital Statistical Reports (HS&R)

Dear Georgia Hospital Provider:

Peach State Health Plan (Peach State) is pleased to announce a new and more efficient process for responding to your requests for HS&R reports. The new process allows Peach State to track report request through a single entry point and increase the turnaround time for production and delivery of your reports. We will also provide you with an acknowledgement notice that confirms the receipt and processing of your request.

Effective immediately, you must adhere to the process outlined below when requesting HS&R reports. 

• All requests for production of HS&R reports must be submitted via e-mail to the designated e-mail box or via certified mail to the address identified below.
• Please note: Any request submitted directly to an individual’s attention will be returned to the requestor via email with instructions on how to submit the request via one of the methods identified below.
• Acknowledgement notices will be provided via email within three (3) calendars days of receipt of your email request.
• Acknowledgement notices will be provided in writing within five (5) calendar days of your written request.
• Submit your e-mail request to:   
  • HSRRequest@pshp.com
  • SUBJECT: Request for HS&R Report

Submit your written request via Certified mail to:

Peach State Health Plan
VP of Compliance
3200 Highlands Parkway SE
Suite 300
Smyrna, GA 30082
ATTN:  Request for HS&R Report

Reminder: 

In order to generate your reports, you must provide the following information:    

a. Hospital Name
b. Hospital Tax ID Number
c. Provider Medicaid ID Number
d. Hospital fiscal year or period service dates
e. Hospital fiscal year or period for paid through dates
f. Contact Information – including email

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Background

Peach State Health Plan (Peach State) is contractually obligated to have procedures in place to detect waste, fraud, and abuse. This is achieved through:

• Claims editing
• Post-processing review of claims
• Provider profiling and credentialing
• Quality control
• Utilization management

As accountable and fiscally responsible stewards of public funds, we take the prevention and detection of waste, fraud, and abuse very seriously.  Peach State has a management contract with its parent organization, Centene Corporation (Centene) in which Centene conducts routine post-processing claims audits on behalf of Peach State.  These audits are designed to ensure that billing codes and practices are correct and that Peach State has paid health care providers appropriately.  In addition to provider reviews, Centene also investigates members who appear to be abusing the Medicaid and PeachCare for Kids programs.

Post Processing Claims Audit

A post-processing claims audit consists of a review of clinical documentation and claims submissions to determine whether the payment made was consistent with the services rendered. To start the audit, Centene Auditors request medical records for a defined review period.  Providers have two weeks to respond to the request; if no response is received, a second and final request for medical records is forwarded to the provider.  If the provider fails to respond to the second and final request for medical records, or if services for which claims have been paid are not documented in the medical record, Peach State will recover all amounts paid for the services in question. 

Centene Auditors review cases for potential unbundling, upcoding, mutually exclusive procedures, incorrect procedures and/or diagnosis for member’s age, duplicates, incorrect modifier usage, and other billing irregularities. They consider state and federal laws and regulations, provider contracts, billing histories, and fee schedules in making determinations of claims payment appropriateness. If necessary, a clinician of like specialty may also review specific cases to determine if billing is appropriate. Auditors issue an audit results letter to each provider upon completion of the audit, which includes a claims report which identifies all records reviewed during the audit. If the Auditor determines that clinical documentation does not support the claims payment in some or all circumstances, Peach State will seek recovery of all overpayments.  

Depending on the number of services provided during the review period, Peach State may calculate the overpayment using an extrapolation methodology.  Extrapolation is the use of statistical sampling to calculate and project overpayment amounts.  It is used by Medicare Program Safeguard Contractors, CMS Recovery Audit Contractors, and Medicaid Fraud Control Units in calculating overpayments, and is recommended by the OIG in its Provider Self-Disclosure Protocol (63 Fed. Reg. 58,399; Oct. 30, 1998).  To ensure accurate application of the extrapolated methodology, Centene uses RAT-STATS 2007 Version 2, the OIG’s statistical software tool, to select random samples, assist in evaluating audit results, and calculate projected overpayments.  

Providers who contest the overpayment methodology or wish to calculate an exact overpayment figure may request a full, on-site chart audit of all services rendered during the review period.  A full chart audit may take four to eight weeks to complete.  On-site audits are performed by Peach State’s contracted vendor, HMS.  Per the terms of your contract, you may be liable for the cost of an on-site audit.       

Audit findings are reported to the Department of Community Health and may also be reported to the Georgia Healthcare Fraud Control Unit. 

Additional information regarding Peach State’s Waste, Fraud, and Abuse program may be found in the Provider Manual.  To report wasteful, abusive, or fraudulent activity, please contact Peach State’s Confidential Hotline at 1-866-685-8664.

This entry is filed under Blog, News.

N E W S   R E L E A S E                                

Media Contact: Deanne Lane

Senior Director, Media Affairs

(314) 725-4477

WASHINGTON, D.C. (February 11, 2010) — The Centene Foundation for Quality Healthcare announced today that it has awarded a $35,000 grant to Fragile Kids Foundation, Inc. (FKF), a nonprofit organization based in Atlanta, Ga. The grant award will launch the Fragile Kids Partner Program, an effort to better reach underserved, rural Georgia families caring for medically fragile children with a range of diagnoses, including cerebral palsy, spina bifida, muscular dystrophy, mitochondrial disorder and other genetic/trauma disorders.  The goal of the program is to provide medical equipment and therapy tools to those children in Georgia who are not covered by insurance or any other healthcare option by collaborating with partners in the state that are established social, educational and therapy “homes.”   

“For many medically fragile children, durable medical products represent the sort of crucial equipment needed for them to grow and thrive,” said Kathy Bradley-Wells, President, Centene Foundation for Quality Healthcare. “The Fragile Kids Partners Program strengthens FKF’s capacity to serve children and families who experience healthcare disparities throughout Georgia.

“In a grassroots effort to reach out to rural caregivers of special-needs and chronically ill children, we learned that we share so many of the same families in our equipment grants program with other smaller organizations,” said Carolyn Polakowski, Executive Director, Fragile Kids Foundation. “We discovered that these small, struggling community resource initiatives rarely have the appropriate medical equipment for children in attendance to share.  Joining forces with these smaller partners is a natural progression of our mission to fill the gaps for all children with a medically fragile diagnosis.  This grant from the Centene Foundation will empower us to launch the program statewide and deepen our network of community advocates and therapists.”

About Fragile Kids Foundation, Inc.

The Fragile Kids Foundation, a twenty-year-old charitable organization serving the entire state of Georgia, provides medical equipment and durable medical goods to medically fragile children that are not covered by government (Medicaid) or private insurance programs.  76% of the children benefitting from the programs of FKF have incomes hovering at the poverty line; 50% of the children are cared for by single mothers and grandmothers.  The Foundation provides wheelchair lifts, specialized car seats, communication aids, toileting and bathing systems and other prescribed equipment for children that cannot be secured through other means.  Children from birth to 21 who reside in Georgia and have a medically fragile diagnosis—Cerebral Palsy, Spina Bifida, Muscular Dystrophy, Mitochondrial disorder and other genetic and traumatic disorders are eligible for support.  The Foundation provides equipment through the “Healthcare Grants” and “Loaned Equipment programs.”  The new Partners Program sponsored by Centene Foundation will launch in 2010. For additional information, please visit www.fragilekids.org.

About The Centene Foundation for Quality Healthcare

The Centene Foundation for Quality Healthcare is a non-profit private foundation dedicated to improving the quality of healthcare in the United States. The Foundation serves as a resource to identify and support innovative approaches to improving and increasing the quality of and access to healthcare for low-income individuals and families. This is accomplished through an inspired philanthropic giving plan that seeks to promote efforts and activities that identify and address core causes of unequal access and treatment in healthcare.  For additional information, please visit www.centenefoundation.org.

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The 2010 HEDIS measure for acute myocardial infarction (AMI) assesses the percentage of members age 18 and older with a diagnosis of AMI who were hospitalized and discharged during the period of July 1, 2009, to June 30, 2010, and who were taking a beta blocker for at least 180 days after discharge.

Use of beta blockers after AMI has been shown to reduce the risk of rehospitalization and death from subsequent attacks within the first two years. But despite these potentially lifesaving benefits, compliance is a problem. In a study of Medicaid patients, only 32 percent of AMI patients continually filled their beta-blocker prescriptions for six months after discharge. Within 30 days of hospital discharge, just over half of patients had filled their initial ambulatory prescription.

Steps You Can Take

Impart a strong message to your AMI patients about the value of long-term, persistent use of beta blockers. Do this at every appointment. Ask about side effects. If possible, coordinate with pharmacies to remind patients to fill or refill prescriptions.

Keep an Eye on LDL Levels

The higher the level of low-density lipoprotein cholesterol (LDL-C), the greater the risk of plaque buildup on artery walls, where hemorrhaging or clot formation can block arteries and cause heart attack and stroke. For patients with cardiovascular disease, an LDL level of less than 100 mg/dL is a desirable target. 2010 HEDIS cholesterol management measures assess the percentage of patients age 18 to 75 years old with cardiovascular conditions who had an LDL-C screening performed during the year and the percentage of those patients with an LDL level less than 100 mg/dL.

People at risk of a major coronary event are most likely to benefit from statin therapy to lower LDL levels, as are those with elevated LDL levels and any cardiac risk factors (smoking, high blood pressure, obesity or family history of heart disease). But supplement it with lifestyle counseling. Changes in diet and exercise can have dramatic effects in a relatively short time and may be the most important recourse for CVD patients unable to tolerate the side effects, like muscle pain or liver damage, produced by statins.

Where there’s heart trouble, depression also may occur. Depression, in turn, can increase cardiac risks, so screen promptly and periodically.

This entry is filed under Blog.