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Winter 2018
The Oklahoma Health Care Authority (OHCA) board met in special
session on Dec. 29, 2017, and voted to reverse provider rate reductions which were
approved on December 1 and scheduled to go into effect January 1.
During the second special session, the Oklahoma legislature passed
an additional appropriation providing the agency with $17.7 million. These
funds coupled with the $22.8 million that was provided when Governor Mary
Fallin approved sections of the appropriations bill on November 17 give the
agency enough funds to operate at current levels until April.
The
OHCA had already taken several budget balancing actions preparing for the agency’s
$70 million reduction to its appropriation due to the loss of the smoking
cessation fee and in order to submit a balanced budget. Several program changes
have been implemented in state fiscal year (SFY) 2018 that produce savings of approximately $3.2
million for SFY18. In addition, $4.65 million in 2017 general revenue was returned
to the agency in SFY18 and the agency had $12 million in carryover from SFY17.
On December 1, the OHCA board approved across-the-board provider rate reductions of 6
percent and 1 percent for nursing facilities as well as eliminating Medicare
crossover coinsurance and deductible payments for nursing facilities to be
effective Jan.1, 2018. Read more.
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Although federal
funding of the Children’s Health Insurance Program (CHIP) expired Sept. 30,
2017, Congress provided $2.85 billion in temporary funding allotments for CHIP
programs nationwide through the Continuing Appropriations Act 2018 passed on
Dec. 21, 2017. Oklahoma received notice on December 22 of its temporary funding
allotment of approximately $44.4 million for the period October 2017 – March
2018.
In Oklahoma,
CHIP and Medicaid operate as the combined program SoonerCare under our state
plan. In addition, Soon-To-Be-Sooners* and Insure Oklahoma Employer Sponsored
Insurance (ESI) – Child are stand-alone programs funded by CHIP.
Congress has
yet to agree on long-term plans for CHIP. Therefore, the OHCA is preparing for
the possibility of terminating coverage for CHIP stand-alone programs. If
Congress does not reauthorize CHIP, then terminating these programs may be
necessary to balance the agency’s budget as required by state law.
The requested
effective date for the end of member eligibility into these programs is Feb. 28,
2018.
Members may
continue using their benefits through February but are encouraged to start
learning about other options and making plans for possible changes.
The OHCA will
post updates as more information becomes available at www.okhca.org/chip.
*Soon-to-be-Sooners are pregnancy-only benefits for women
at 133-185 percent of the federal poverty level (FPL).
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 The OHCA invited approximately 100 key stakeholders to provide input for its five-year Strategic Plan (2018-2022) during an on-site forum at the agency. The October 11-12 session focused on developing action plans for the OHCA and creating outcome measurements for goals and objectives. Focus areas for this strategic plan include:
- Access to health care in rural areas;
- Economic and racial disparities in health status and outcomes;
- Effectively changing individual health-related behaviors;
- Quality improvement in OHCA’s programs and processes; and
- Budget effectiveness, including revenue implications of any new state or federal action.
Vision of Success
The group developed a vision of success in response to this question: “Assuming the agency had necessary resources and made significant progress towards its goals, what would Oklahoma’s health care environment be like at the end of 2022?” The vision included culture and behavior changes resulting in healthier Oklahomans, a stable and coordinated provider network, a focus on preventive care and care coordination, and an outstanding agency fully funded because of its administrative excellence and clear contribution to health outcomes.
Employee Engagement and More Critical Components
Using all this input, as well as feedback from the October 2017 OHCA Annual Tribal Consultation, the agency held three employee planning sessions in November; more than 60 people participated.
Staff reviewed and enhanced the ideas developed during the Strategy Forum and added some of their own. In addition, these small groups of employees further developed specific action plans including implementation milestones, risk analysis and contingency planning.
The OHCA also invited SoonerCare/Insure Oklahoma members and additional stakeholders to provide input through online surveys held in September and December, respectively.
Next Steps
The OHCA is on schedule to have a draft strategic plan in February 2018. The Provider Checkup will bring you more details as they become available.
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 The following provider types have contracts set to expire on March 31, 2018:
- Ambulance service
- Dietitian
- Audiologist
- Occupational therapist
- Physical therapist
- Podiatrist
- Speech pathologist
To avoid a disruption in service to our members, the OHCA encourages providers to renew early. The provider types listed above can log on to the secure OHCA Provider Portal to start renewing their contracts as early as Jan. 15, 2018.
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Don't forget! DME contracts extended
The OHCA has amended its durable medical equipment and/or medical supplies (DME) contracts. This change allows DME providers who also have pharmacy contracts to have both contracts expire on the same date - June 30, 2018.
Please have your signatory authority sign the required amendment and return it to OHCA Provider Enrollment as soon as possible. You can fax your amendment to 405-530-3224 or email it to ProviderEnrollment@okhca.org.
The OHCA will send you a fully-executed copy of the amended contract after it is received and signed by our agency representative.
If you have any questions regarding this change, please contact us at 800-522-0114, option 5.
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Permanent rulemaking process in effect
OHCA’s permanent rulemaking process is underway.
The first set of proposed rules were made available for comment at www.okhca.org/rule-changes on Dec. 15, 2017.
The second round of proposed rules will post Jan. 17, 2018.
The public, SoonerCare members and providers, other state agencies and OHCA
staff and leadership may request changes in policy. Proposed permanent rules
may include proposals for new programs and/or policies or amendments to current
policies. They also include rules previously promulgated on an emergency basis.
As required by state statute, OHCA provides a Rule Impact Statement for each
proposed rule. This includes the legal authority, possible impact to providers
and/or members, projected budget impact and reason for the proposed changes. We
also highlight all text changes.
Permanent rule recommendations go to the
Legislature and governor for action in the spring. We encourage you to review
the proposed rules and give your input.
Click the flow chart image below for more details on our rulemaking process.
OHCA permanent rulemaking process flow chart
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Save-the-date! Spring 2018 Provider Training Workshops
You and your
staff are invited to attend one of the spring 2018 SoonerCare Provider Training
Workshops hosted by OHCA and DXC Technology (formerly Hewlett Packard Enterprise).
- Durant - May
1
- Tulsa - May 9
and 10
- Lawton - May
17
- OKC - May 23
and 24
- Guymon - June
20
OHCA and DXC highly recommend that all providers
attend a workshop in their area. Be sure to mark your calendar!
Watch for class
descriptions, recommended audiences and registration details in the next
Provider Checkup (March). Updates will also post to the provider training page of our website.
The OHCA is charged with
determining the medical necessity for requested services. Recent reviews of
prior authorization (PA) requests for MRI and CT imaging have resulted in denials
due to insufficient information to evaluate medical necessity.
Medical evaluators frequently encounter a chief complaint of
“back pain” or “decreased ROM in R shoulder,” for example, and then an imaging order
for the back or shoulder. The request contains no supportive documentation in the
history of present illness (HPI), review of systems (ROS), or the physical exam
(PE).
In practice, we all proceed from the chief complaints to
developing HPI for each complaint, and then using ROS to identify any other
related signs and symptoms. A physical exam is directed at each chief complaint
or identified in HPI and/or ROS. Resultant assessments are listed with a plan statement for each assessment.
If the medical record submitted with the PA does not contain this progression
of information leading to an assessment and plan that justifies the requested
imaging, the medical evaluator cannot determine the medical necessity of the
request. If the medical record only
states “decreased ROM of shoulder” and “MRI shoulder,” then the evaluation is
incomplete and results in a denial.
Ensuring that the medical records submitted with the PA
request include supporting information for the imaging request allows
evaluation for medical necessity. Absence of this information results in denial.
MD-DDS.Inquiries@okhca.org
is available for questions addressed to OHCA medical directors regarding PA
approvals and denials. As a reminder,
this email address is available only to contracted M.D., D.O. and D.D.S.
providers, as well as advanced practice registered nurses and physician
assistants.
The agency wishes to thank all providers who provide health care
to our members.
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SoonerCare recognizes the critical role of immunizations in protecting the health of pregnant women and their newborns. Providers are encouraged to administer immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP). ACIP recommends the following vaccinations for pregnant women:
- Inactivated influenza vaccines, quadrivalent (IIV4’s), standard-dose;
- Tetanus/diphtheria/acellular pertussis (Tdap) (vaccine should be given between 27 to 36 weeks of pregnancy); and
- Vaccines for hepatitis A virus, hepatitis B virus, pneumococcus, and meningococcus (may be administered in the third trimester if the member is at risk for these diseases by virtue of lifestyle, travel, or occupation).
 Providers administering vaccines to pregnant SoonerCare members will be reimbursed for the vaccine according to the fee schedule.
Pregnant women can receive the vaccination from their obstetrician/gynecologist or primary care provider. SoonerCare encourages obstetricians to coordinate with the member’s primary care provider to ensure that appropriate vaccinations are given to pregnant members.
Further information on vaccination recommendations during pregnancy can be obtained by visiting the Centers for Disease Control and Prevention.
If you have any questions, please call the OHCA Provider Helpline at 800-522-0114.
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The OHCA is implementing InterQual® guidelines in our prior authorization (PA) request process. InterQual® evidence-based questions and answers will be embedded into the SoonerCare Provider Portal PA function. Over time, the OHCA anticipates the InterQual® implementation will help to automate the PA processing further, thereby shortening the average review time.
The OHCA is rolling out the implementation in phases. Total knee and hip arthroplasty surgeries, American Medical Association Current Procedural Terminology codes 27447, 27130, and 27132, are the first codes routed to InterQual®. All SoonerCare providers who request these codes will be part of this initial implementation phase.
Below is information for Phase I implementation:
- Phase I began on Jan. 8, 2018, and will run approximately two months.
- Provider training webinars will be available. Please check www.okhca.org/provider-training to view dates and register to participate.
- Supporting documentation must continue to accompany the PA request. The new question-and-answer format will help clarify which documentation is needed, potentially streamlining your efforts as well as ours.
- Your internet browser must meet encryption standards to successfully use InterQual® through the SoonerCare Provider Portal. A Global Message from Oct. 10, 2017 (Upcoming Change to the Medical Prior Authorization Request Process), offers more information regarding these requirements at www.okhca.org/global.
- The OHCA is always interested in your comments. They are especially welcome during this effort.
- The OHCA contact during this implementation phase is Natasha Kester. Should you have any questions or comments, please email her at Natasha.Kester@okhca.org.
If you have any additional questions, please contact the OHCA Medical Authorization Unit at 800-522-0114.
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Keep it SIMPLE
Former United States Surgeon General C.
Everett Koop, M.D., once said, “Drugs don’t work in patients who don’t take
them.”(1) While he said those words in 1985, they still hold true
today.
A recent study presented at the American
College of Medicine Annual Meeting highlighted the importance of medication
adherence. Researchers found patients who understand their medication is “very
important” take their medication 95 percent of the time. Adherence drops to 55
percent if the medication is seen as “not important.” The Centers for Disease
Control and Prevention (CDC) summarizes national adherence rates with the
following graphic: (2)
 So, how can we move the needle on
patient adherence?
The American
College of Preventive Medicine (ACPM) has created the SIMPLE tool to help
providers improve adherence rates. This tool, which is available on the ACPM
website, addresses both intentional and unintentional adherence in order to decrease
treatment failures, reduce hospitalizations and improve patient outcomes. A few
brief examples of SIMPLE in action are as follows:
When tools like SIMPLE become part of practice culture, we
can start to reduce adherence barriers and see significant improvement in
disease management.
References
- Lindenfield J, Jessup M. Drugs don’t work in
patients who don’t take them. Eurpoean
Journal of Heart Failure. Available at: http://onlinelibrary.wiley.com/doi/10.1002/ejhf.920/full. Accessed November 16, 2017.
- Overcoming Barriers to Medication
Adherence for Chronic Diseases. CDC Public Health Grand Rounds. Available at: https://www.cdc.gov/cdcgrandrounds/pdf/archives/2017/GR_02-21-2017.pdf. Accessed November 16, 2017.
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 National Children’s Dental Health Month
February is National Children’s Dental Health Month (NCDHM) – a time for dental professionals, health care providers, parents and other caregivers to promote healthy oral habits to the children in their lives.
The American Dental Association’s 2018 campaign focuses on creating sensational smiles and its NCDHM Program Planning Guide offers free resources and easy-to-do activities to help achieve them. Posters, available in both English and Spanish, are also available for ordering online. Visit the NCDHM website at www.ADA.org/ncdhm to download materials.
SoonerCare also has online resources to help your patients keep their teeth in tip top shape. Check them out at www.okhca.org/dental.
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The EHR
Incentive Program is now for any returning eligible
professionals (EPs). EPs who have not participated in the program
prior to 2016 are no longer able to participate in the program.
Participation
year 2017 is 90-day reporting period with the deadline of March 31, 2018.
Any eligible hospital participating in the
EHR Incentive Program must attest consecutive years. They are no longer able to
skip a year.
If you have
any questions or concerns regarding this program, please contact the EHR
Incentive Team at EHRIncentive@okhca.org or by phone at 405-522-7347. You can
also visit us online at www.okhca.org/ehr.
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 Speaker of the House Charles McCall appointed Alex Yaffe, of Oklahoma City, to the OHCA Board on Dec. 19, 2017.
Yaffe is an attorney with Foshee & Yaffe concentrating on all areas of litigation. He has been selected as a Rising Star or Super Lawyer since 2011. Yaffe also serves as the CEO of Just Kids Pediatrics, a multi-site pediatric practice.
Read more.
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OHCA Provider Helpline: 800-522-0114
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