Provider Newsletter Summer • 2022 CHANGE SERVICE REQUESTED PO Box 971100 El Paso, TX 79997-1100 Nonprofit Org. U.S. Postage PAID Walla Walla, WA Permit No. 44 Provider spotlight INNOVATOR Jorge Luis Sarmiento, MD, is a renowned, boardcertified radiologist and the owner of Professional Radiology. Dr. Sarmiento, originally from Colombia, is no stranger to innovation and loves to help patients. He studied at Universidad Nacional Autonoma de Mexico; worked at GE, where he patented several innovations; and worked with Texas Tech from 2006 to 2016, where he ser ved as a professor and Head of the Ultrasound Depar tment. One of his innovations is the Hitachi Oval Echelon 1.5T MRI. The wide-open machines allow patients to not feel claustrophobic. Dr. Sarmiento and his team at the Eastside Clinic location provide: ■Mammograms ■Advanced DEXA bone density scans ■Digital x-rays ■CT scans ■Ultrasounds ■Liver elastography ■Fibroscans ■Biopsies and aspirations ■Varicose vein treatments His new Westside Clinic provides: ■Wide-open MRI scans ■Ultrasounds ■Liver elastography ■Fine-needle aspiration biopsies (FNA) ■Digital x-rays ■Varicose vein treatments To learn more, please visit professionalradiologyep.com. El Paso Health is proud to introduce its two new CEOs El Paso Health’s mission requires a leader with passion and compassion, a sense of caring, and vast experience—and luckily, El Paso Health has two of the best. Carol G. Smallwood has been appointed President and Chief Executive Officer of El Paso Health, and Janel Lujan has been named Chief Executive Officer of El Paso Health Medicaid. Smallwood joined El Paso Health last year as Chief Organizational Development Officer. She has 30 years of experience in health-care administration and management, almost exclusively in Medicaid managed care. She also served as President and CEO of El Paso First Health Plans (now El Paso Health) from 2006 to 2013. Smallwood holds a bachelor’s degree in community health from New Mexico State University (NMSU) and a Master of Public Health degree from the University of Oklahoma. She is a decorated NMSU alumna and serves on several higher education boards. Lujan is a 15-year veteran of El Paso Health and previously served as the Interim Chief Executive Officer. Her broad health-care experience includes utilization management, population health, Provider reimbursement, Provider engagement, and pharmacy benefit implementation. She began her career with El Paso Health as a social work case manager and has held several positions since then, including Vice President of Operations and Chief Operating Officer. Lujan has both a bachelor’s degree in psychology and a Master of Social Work degree from Arizona State University. On behalf of El Paso Health’s 150-plus associates, the Board of Directors congratulates our new CEOs. We look forward to these two continuing our work as the largest health maintenance organization in the service delivery areas of El Paso and Hudspeth counties. Carol G. Smallwood President/CEO Janel Lujan CEO, Medicaid
2 Appointment accessibility statewide studies The Texas HHSC contracts with an external quality review organization (EQRO) to monitor all MCOs on appointment accessibility (i.e., how soon an appointment can be scheduled from the time of request). The 86th Legislative Session (SB 760), effective Sept. 1, 2019, mandates that the Texas HHSC monitor MCO networks and analyze compliance with appointment standards. MCOs are required to pay liquidated damages if performance thresholds are not met on these studies. The EQRO implements these studies for each MCO using secret shopper calls. The standards set by the HHSC and the Texas Department of Insurance for appointment accessibility are as follows: The necessity of self-audits We’ve all heard prevention is the best protection—but did you know that applies to audits as well? Here are 5 basic selfaudit tips from the Centers for Medicare & Medicaid Services to help your office reduce the chances of costly mistakes: 1. Develop and implement a solid medical record documentation policy if there is not one in place. If there is one in place, make sure the policy covers meeting federal and state Medicaid regulations. The policy should address what actually happens in everyday practice. 2. Develop or use one of the available standard medical audit tools. The tool should cover the documentation policy criteria and coding standards as part of the review. 3. Choose a staff member who understands documentation and coding principles to select a random sample of records for a specific time period. Decide how many records should be reviewed, then pull every “nth” chart for that time period. 4. Resist being the one to choose and audit your own charts. Most professionals can read their own writing and understand the meaning of records they wrote even if the documentation is not in the record. Removing bias is important. 5. Use the self-audit results for improving practice compliance. There is no real value in conducting a self-audit unless discovered issues are resolved. Review and analyze the audit findings. Identify the common documentation, coding, and billing problems, and solve the problems found. Then educate staff members and hold them accountable for making changes. If you suspect fraud, waste, or abuse, you can report it anonymously to the HHSC Office of Inspector General, toll-free, at 1-800-436-6184. resources Please note that all Providers designated as PCPs are also required to be available to our members 24 / 7. If you have any questions on the requirements, please contact the Provider Relations Department at 915-532-3778. Appointment type Standard (calendar days from time of request) Emergency ser vices Upon member presentation Urgent care Within 24 hours Routine primary care Within 14 days Specialty routine care Within 21 days Specialty therapy (PT / OT / ST) evaluations Within 21 days of signed referral Initial outpatient behavioral health Within 14 days Referrals for specialty care Within 5 days Prenatal care: low-risk pregnancy Within 14 days Prenatal care: high-risk pregnancy or new member in third trimester Within 5 days Preventive health: children (younger than 6 months) Within 14 days Preventive health: children (6 months to 20 years) Within 60 days Preventive health: adults (21 years and older) Within 90 days
3 El Paso Health continues to enhance the ABA Prior Authorization process. Our goal is to improve the turnaround time by continuing education with ABA Providers. Please keep in mind the following: ■For initial ABA evaluation requests, ABA Providers will submit a signed and dated referral from the prescribing Provider. They will also need a comprehensive diagnostic assessment with diagnosis of ASD signed and dated by the diagnosing physician within the last 3 years, including the DSM level of symptom severity. Finally, they need a completed Texas standard prior authorization (TSPA) form or a CCP prior authorization request signed and dated by the prescribing Provider. ■For initial 90-day ABA treatment, the ABA Provider will submit a completed ABA evaluation, the TSPA or CCP form, and a physician order outlining the therapy frequency and duration. ■For 90-day extension of initial ABA therapy requests, the ABA Provider must submit an attendance log for the member and parent or caregiver as well as a progress summary from the LBA signed and dated by the LBA and parent or caregiver. ■ For ABA 180-day recertification requests, the ABA Provider can begin to request recertification in 180-day increments following the initial 6 months of ABA therapy. The ABA Provider will submit an ABA re-evaluation, attendance log for the member and parent or caregiver, and a completed TSPA or CCP form signed and dated by the prescribing Provider. Requests must be submitted no earlier than 60 days from the current authorization’s expiration. If more than 180 days from previous ABA therapy occurs, then the ABA Provider will submit a new request as an initial request, and all documentation related to an initial request is required. Top claim denial reasons Claim denials can present a serious issue that affects the revenue cycle in health care. What is the root cause of your denials? Analyzing data allows you to see where the problems are occurring. Whether the issue is in patient registration, authorizations, eligibility, or coding or billing errors, claim denials can be very cumbersome. Regular analysis can help you resolve any potential issue before it becomes serious. Always stay on track with all health plan changes to ensure that your staff implements any system changes that affect claims. Below are the top denial reasons we frequently see: ■Benefit requires utilization management. It is important that you verify if a procedure code requires prior authorization. ■Claim is an exact duplicate claim to a previously submitted claim. It is important to keep up-to-date with posting claim payments in your practice management system to make sure you do not rebill claims that have been processed. ■Claim was not submitted in a timely manner (submission window exceeded). Timely filing is crucial. Remember, El Paso Health can assist you with any claim inquiry. Do not hesitate to contact us. stay informed If you have any questions, please feel free to reach out to the Prior Authorization Department. Applied behavior analysis services
Do your patients know their rights and responsibilities? The American Medical Association states that “the health and wellbeing of patients depends on a collaborative effort between patient and physician in a mutually respectful alliance.” This includes patients fulfilling their responsibilities. El Paso Health ensures that our members are aware of their rights and responsibilities, which include but are not limited to the following: Rights for Medicaid members ■The right to respect, dignity, privacy, confidentiality, and nondiscrimination. ■The right to a reasonable opportunity to choose a health-care plan and Primary Care Provider. ■The right to timely access to care that does not have any communication or physical address barriers. Rights for CHIP members ■The right to get accurate, easy-tounderstand information to help in making good choices about children’s health plans, hospitals, doctors, and other Providers. ■The right to know how the health plan decides whether a service is covered or medically necessary. ■The right of female members to see an OB-GYN without a referral from their PCP. Rights for CHIP Perinate members ■The right to get accurate, easy-tounderstand information to help in making good choices about an unborn child’s health plans, hospitals, doctors, and other Providers. ■The right to know the names and addresses of the hospitals and other Perinate Providers in the health plan and to pick from a list of health-care Providers to care for an unborn child. ■The right to emergency Perinate services if the unborn child’s life could be in danger or lack of care could have serious results. Responsibilities for Medicaid members ■Learn and understand each right under the Medicaid program. ■Abide by the health plan’s and Medicaid’s policies and procedures. ■Share information about their health with their Primary Care Provider and learn about service and treatment options. Responsibilities of CHIP and CHIP Perinate members ■Be involved in the doctor’s decisions about treatments and work together with the health plan, doctors, and other Providers to pick the best treatment options. ■Keep appointments with doctors and arrive on time. ■Pay any copays that are due at the time services are received (CHIP only). A full list of El Paso Health members’ rights and responsibilities can be found on our website at elpasohealth.com in the “Member Handbooks” section. If you have questions, feel free to contact our Member Services Department at 915532-3778 or toll-free at 1-877-532-3778. Provider Newsletter ABOUT YOUR HEALTH is published as a service for members of the EL PASO HEALTH Provider network. EL PASO HEALTH Executive Offices are located at 1145 Westmoreland Drive, El Paso, TX 79925, 915-532-3778 or 1-877-532-3778, elpasohealth.com. Information in ABOUT YOUR HEALTH comes from a wide range of medical experts. If you have any concerns or questions about specific content in this newsletter, call 1-877-532-3778. Models may be used in photos and illustrations. Member Services 1-877-532-3778 EPHP5372204-EPH-PR-SUMMER 2022 Provider Newsletter 2022 © Coffey Communications, Inc. All rights reserved. stay informed
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