October 2024 - Register for the regional provider meeting; Flexible Services changing to HRSN framework

Program expands access to Down syndrome specialty care

More than 95% of people in the U.S. with Down syndrome live over two hours away from a Down syndrome specialty clinic. That’s why providers like Dr. Brian Skotko, M.D., MPP, and the team at Mass General Hospital are expanding access to care.

Inspired by his own family’s experience, Dr. Skotko and his team of multi-disciplinary experts collaborated to create the DSC2U.org platform. The program brings the best health and wellness information about Down syndrome to caregivers and primary care physicians around the globe.

In recognition of Down Syndrome Awareness Month, we sat down with Dr. Skotko to learn how this first-of-its-kind technology meets the needs of this underserved population. Read the full article.

Contact

MGBHP Provider Service Team assists our Provider Community with the following inquiries:
•    General questions around provider participation status
•    Member benefits
•    Claim request for review/appeals
•    Authorization requirements/escalations
•    Medical drug specialties 
•    Other inquiries related to MGBHP policies and procedures  
Phone:  855-444-4647
Email: HealthPlanProvidersService@mgb.org 

MGBHP Provider Relations works in partnership with provider offices to build and maintain positive working relationships and respond to the needs of contracted providers and assist with any training and education. Provider Relations can also assist with escalations. 
Email: HealthPlanProvRelations@mgb.org 

Provider Portal: Register for the portal to complete the following tasks:

•   Benefits and cost sharing 
•   Claims status
•   Member eligibility
•   PCP changes
•   Authorization submission
•   EOP
•   And more

Register and access the portal here: https://Provider.MGBHP.org/ 

In this issue:

• Join us for the next Regional Provider Meeting on November 11, 2024
• Mass General Brigham Health Plan launches new pelvic health initiative
• New for 2025: The Medicare Prescription Payment Plan helps members manage monthly drug costs
• Mass General Brigham Health Plan names new SVP of State Programs
• Flexible Services transitioning to Health-Related Social Needs (HRSN) framework
• Join our Quality Program Committee to help improve care quality and effectiveness
• Watch: Medicaid ACO Behavioral Health Supports webinar
• Win a $100 gift card - Confirm your directory info and next available appointments
• Improving call wait times
• Optum Financial, Inc. & ECHO Health Inc. partnership
• ACO Spotlight: 2024 quality measures and resources
• Claim timely filing best practices
• Provider portal roster enhancements
• Home health authorization update
• Update to multiple procedure reduction rule on January 1, 2025
• Hospital inpatient utilization report
• Fraud waste abuse prevention
• Prior auth flexibilities for Steward-impacted members in effect until October 15
• Help us keep directory information up to date
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• Formulary updates

Join us for the next Regional Provider Meeting on November 11, 2024

We will be hosting the next Regional Provider Meeting at Assembly Row in Somerville, MA on November 11. Join us to learn more about doing business with Mass General Brigham Health Plan, get to know your dedicated Provider Network Account Executive as well as other members of our Provider Relations team, hear from members of the Mass General Brigham Health Plan leadership on products and new company initiatives, and network with your peers from around the region. Lunch will be served.

Date: Monday, November 11, 2024
Time: Doors open 12:30 p.m., Presentation from 1:00 - 2:00 p.m.
Address: Mass General Brigham, 399 Revolution Dr, Somerville, MA, 02145
Meeting location: Markell Conference Room, West Building, 1st Floor
Parking: FREE on-site parking available
Registration: Save your seat

Mass General Brigham Health Plan launches new pelvic health initiative

Last month, Mass General Brigham Health Plan announced a new, customized pelvic health offering that expands its women’s health portfolio. The new program enhances coverage of pelvic health services and deepens support for underrepresented areas of women’s healthcare.

“Increasing access to convenient pelvic health support builds on our commitment to meeting members where they are in any stage of life, particularly with stigmatized health experiences,” said Lisa Scarfo, M.D., Senior Medical Director, Mass General Brigham Health Plan. “We are thoughtfully growing our women’s health portfolio to respond to our members’ needs, support inclusive approaches, and raise awareness to normalize these conversations. Read the full announcement.

New for 2025: The Medicare Prescription Payment Plan helps members manage monthly drug costs

Starting January 1, 2025, members can choose to spread out their covered Part D out-of-pocket prescription drug costs over the calendar year. The Inflation Reduction Act requires all Medicare prescription drug plans, including standalone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage, to offer members the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy. This new payment option is known as the Medicare Prescription Payment Plan (M3P).

The M3P doesn’t lower members covered Part D drug costs or save money. However, it may be helpful for members to spread their payments for covered Part D drug costs across the remaining months of the calendar year. There’s no cost to members to participate in the M3P and participation is voluntary. Members must voluntarily opt into the M3P to participate. To maximize this payment option, members should opt-in to this payment option prior to filling their prescriptions.

Members who may benefit from the M3P if:

• They have high covered Part D drug costs early in the plan year.
• They will exceed the $2,000 annual out-of-pocket maximum Medicare Part D drug cost amount for 2025 before September.
• They want to spread their covered Part D drug costs throughout the rest of the year.

Members who may not benefit from the M3P.

• Low yearly out-of-pocket covered Part D drug costs (<$2,000 per year).
• Members receiving or eligible for Extra Help from Medicare.
• Members receiving or eligible for a Medicare Savings Program.
• Members receiving help paying for drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.

Members must voluntarily renew their participation or opt into the M3P each year. Members may opt in during the annual election period beginning in October or may wait until the plan year to opt into the M3P. However, if they would like the M3P to be active January 1, they must opt into the program during the annual election period.

Members may opt out or leave the M3P at any time by contacting the health or drug plan. Leaving the M3P will affect their Medicare drug coverage and other Medicare benefits.

If a member does not pay their Medicare Prescription Payment Plan bill, they’ll be removed from the M3P. Members are required to pay the amount owed but will not pay any interest or fees, even if the payment is late. If a member is removed from the M3P, they are still enrolled in their Medicare health or drug plan.

For more information about the program, please see the following resources:

• https://www.medicare.gov/prescription-payment-plan
• https://www.medicare.gov/publications/12211-whats-the-medicare-prescription-payment-plan.pdf

Mass General Brigham Health Plan names new SVP of State Programs

Mass General Brigham Health Plan announced that Ashley Hague has joined the organization as Senior Vice President of State Programs.

In this role, Hague will lead government programs to ensure high-quality, affordable care, including Medicaid and preparations to serve Massachusetts residents who are dually eligible for Medicaid and Medicare as part of the state’s process to provide Dual Eligible Special Needs Plans (D-SNP) in 2026.

“As part of an integrated healthcare system, we are building a foundation within Mass General Brigham to serve a broader range of populations,” said Steve Tringale, President, Mass General Brigham Health Plan. “We are pleased that Ashley has joined our organization, and her breadth of experience and commitment will support our mission to ensure equitable healthcare access for communities across the Commonwealth.” Read the full announcement.

Flexible Services transitioning to Health-Related Social Needs (HRSN) framework

Effective January 1, 2025, the Flexible Services Program will transition into a Health-Related Social Needs (HRSN) framework and will be eligible for MassHealth members enrolled in the Mass General Brigham ACO who meet specific eligibility criteria.

Similar to the Flexible Services Program, the HRSN framework will be designed to address HRSN and will provide non-medical services aimed at improving health outcomes by addressing non-medical factors that can influence a person’s overall well-being, such as housing and nutrition.

This new framework will provide an array of housing and nutrition services to better cater to a wide range of our Mass General Brigham ACO members.

Additional information will be provided in future communications.

Join our Quality Program Committee to help improve care quality and effectiveness

Mass General Brigham Health Plan is seeking provider membership (including all MD specialties, NPs, and PAs) for its Quality Program Committee (QPC) to share expertise on topics that will ensure the quality and effectiveness of the care delivered to its members including all lines of business. Committee members have the opportunity to weigh in on a variety of health plan topics including:

• Network adequacy;
• Utilization Management and Medical Necessity Procedures;
• Member experience and satisfaction;
• Identifying and addressing potential health care disparities and inequities.

The QPC meets virtually on the third Wednesday every other month for 90 minutes. 

The meeting dates for the rest of 2024 are:

• Wednesday, October 16, 7:30 - 9:00 a.m.
• Wednesday, December 18, 7:30 - 9:00 a.m.

If you are interested in joining the QPC, please contact Elaine Alden at ealden@mgb.org indicating your interest and we will reach out with information on the next steps regarding your participation. Some providers may qualify to earn $300 per meeting. Please feel free to contact us with any questions regarding your eligibility for this and/or any other questions that you may have about the committee.

We appreciate the opportunity to collaborate with our provider network and thank you for the care you provide our members.

Watch: Medicaid ACO Behavioral Health Supports webinar

The recording of last month's Behavioral Health Supports webinar is now available. Hear from leading experts in population health management as they share key strategies on community partnerships, collaborative care models, and diverse behavioral health solutions, along with essential guidance on accessing these vital services. Watch the webinar.

Win a $100 gift card - Confirm your directory info and next available appointments

Please take a few minutes to complete both of the following brief forms by the end of November and you'll be automatically entered into our drawing to win a $100 gift card. 

1. Provider Directory Accuracy: Let us know if your information is accurate by completing this form.  
2. Future Appointment Access: Let us know about your next available appointments by completing this form.

Improving call wait times

We understand there are longer than normal wait times when contacting the Provider Call Center. Our leadership team is working diligently to recruit and train additional staff to keep up with the demands in volume. We appreciate your understanding and cooperation. Please use our Provider Portal to answer routine inquiries such as benefits and cost sharing, claims status, eligibility, explanation of payments, authorization, outpatient code checker tool, and much more.  Our provider call center hours of operation are 8:00 a.m. to 4:30 p.m. Monday- Friday (closed daily from 12:00 - 12:45 p.m. and Wednesdays from 9:30 - 10:30 a.m.). You can also contact us via email at HealthPlanProvidersService@mgb.org.

Optum Financial, Inc. & ECHO Health Inc. partnership

Mass General Brigham Health Plan is expanding our partnership with Optum Financial, Inc. and ECHO Health Inc. Currently, they manage our fee-for-service payments.

Beginning October 2024, Optum Financial, Inc. and ECHO Health, Inc. will begin managing capitation/sub-capitation payments to participating providers. In addition, the method in which payment backup is provided will be transitioning from excel to PDF.

Please note that capitation payments will continue to be sent monthly separate from fee-for-service payments.

If you currently receive your Fee for Service (FFS) payments for Mass General Brigham by ACH today, you will receive your Capitation payments via ACH as well. If you are not yet set up to receive ACH payments for FFS payments for Mass General Brigham, the default payment method will be virtual credit card. 

Please visit MGBHP.org/providers/payment-options to learn about all your payment options, including how to sign up for electronic funds transfer (EFT) payments. 

Questions about e-payments?

To reach our e-payment partner, ECHO Health, with questions about payment & status, EDI connectivity, or virtual credit cards, please call 800-895-0710 or email edi@echohealthinc.com.

ACO Spotlight: 2024 quality measures and resources

MassHealth’s Accountable Care Organizations (ACOs) are incentivized through the Quality and Equity Incentive Program (AQEIP) to pursue performance improvements in three domains: demographic and health-related social needs data, equitable quality and access, and capacity and collaboration.

At MGBHP, the Quality Department has spearheaded performance improvement in collaboration with provider partners in all three domains and is pursuing NCQA Health Equity accreditation by January 2026.

The ACO Quality Measures that are part of MassHealth AQEIP include claims-based measures, clinical quality measures, and member experience surveys. For calendar year 2024, MGBHP has identified the following measures for opportunity for improvement: Prenatal and Post-partum Care (PPC), and HbA1c Poor Control (HBD).

As a provider there are many opportunities to impact HEDIS® measures. This includes scheduling follow-up appointments, coordinating care, using correct diagnosis and procedure codes, documenting medical and surgical history in the medical record, including dates and submitting claims and encounter data in a timely manner.

Click on the links below to see provider tips on how you can help improve the ACO Quality Measures.

Claims timely filing best practices

Want a refresher on timely filing guidelines? We've put together a handy resource with the best practices for submitting original and adjusted claims. Plus, it includes tips on what documents you’ll need if you ever need to contest an untimely filing denial. View the resource here and on our claims page under Additional claims resources. 

Provider portal roster enhancements

Providers can now easily run rosters based on program (line of business) in the provider portal. We've also made updates to the panel status to clearly show if a provider has a panel and whether it's open or closed. See screenshots of the enhancements below and try them out in the provider portal. 

Home health authorization update

Effective December 1, 2024, the way you enter homecare authorizations through the provider portal will be updated.  This will impact homecare authorization requests placed through the provider portal. Providers will have to submit a separate request for each discipline: For example, skilled nursing and physical therapy being requested at the same time for the same period, would require two separate entries through the provider portal.

Inputting a separate homecare authorization for each service being requested will help enhance the current provider claim and authorization process. In the November newsletter, there will be instructions on how to access the training videos to help prepare for this enhancement.

Update to multiple procedure reduction rule on January 1, 2025

Beginning January 1, 2025, Mass General Brigham Health Plan is updating its multiple procedure reduction rule to more appropriately align with CMS and industry standards. When multiple surgical services are performed in the same operative session, the procedure with the highest RVU will be reimbursed at 100% of the allowed amount and all subsequent, lower-RVU valued procedures, will be reduced per the Plan’s Modifiers Provider Payment Guidelines, unless otherwise specified in the provider’s contract.

Hospital inpatient utilization report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register here.

Fraud waste abuse prevention

Mass General Brigham Health Plan expects providers to comply with all federal and state regulations that prohibit fraudulent behavior, including but not limited to:

• Recording clear and accurate documentation of all services rendered in a timely manner as close as possible to the date of service
• Not signing blank certification forms that are used by suppliers to justify payment for home oxygen, wheelchairs, and other medical equipment
• Being suspicious of any vendor offering discounts, free services, or cash in exchange for referrals
• Refusing to certify the need for medical supplies for patients not seen and/or examined. Mass General Brigham Health Plan—Provider Manual 3 –Provider Management 3-14 2024-05-01
• Specifying the diagnosis when ordering a particular service (e.g., lab test)
• Knowing and adhering to the practice’s billing policies and procedures
• Verifying the identity of patients since insurance cards can be borrowed, stolen, and fabricated
• Carefully scrutinizing requests for controlled substances, particularly with new patients.

Reporting health care fraud

Providers who suspect health care fraud should report any suspicions to their organization’s compliance office or executive director.

Suspicions or concerns involving a Mass General Brigham Health Plan member or clinician can be reported to Mass General Brigham Health Plan’s Compliance Office in writing or by email. These concerns can also be reported anonymously to the Mass General Brigham Health Plan Compliance Hotline 24 hours a day, seven days a week. The hotline is operated by an independent company and is not staffed by Mass General Brigham Health Plan employees.

Fraudulent acts or suspicions may be reported as follows:

Mail:

Mass General Brigham Health Plan Legal, Regulatory and Compliance Department

399 Revolution Drive

Suite 810

Boston, MA 02210

Phone:

• Mass General Brigham Health Plan Legal, Regulatory & Compliance Department
  800-433-5556 (then dial 0 to have your call directed)
  
  
• Mass General Brigham Health Plan Compliance Hotline (anonymous)
  844-556-2925

Website:

• Submit a report through our Compliance website using this link: EthicsPoint - Mass General Brigham Health Plan

Prior auth flexibilities for Steward-impacted members in effect until October 15

We are closely monitoring the situation with Steward Health Care, including the closures of Carney Hospital and Nashoba Valley Medical Center on August 31, 2024.

Our team is reaching out to our members who were in active care at Carney Hospital and Nashoba Valley Medical Center to ensure continuity of care. We are also allowing flexibilities in prior authorization and referral requirements for services previously approved at Carney Hospital or Nashoba Valley Medical Center which need to be transferred to another facility. These flexibilities will be in effect through October 15, 2024 in alignment with guidance from the Division of Insurance. 

If a member has any questions or needs help accessing care, please direct them to contact us at the customer service number on the back of their ID card.

For updates about Steward Health Care facilities in Massachusetts, visit the state’s website and frequently asked questions at mass.gov/stewardresources and hotline at 617-468-2189 (local) or 833-305-2070 (toll-free).

Help us keep directory information up to date

The Centers for Medicare & Medicaid Services and other regulatory bodies, as well as the federal No Surprises Act of 2021, require health plans to maintain and update data in provider directories. We rely on providers to review their data and notify us of changes as they happen, this ensures members have access to accurate information.

Provider demographic information in our Provider Directory must reflect accurate data at all times and should mirror the information members may receive directly from the practice or via patient appointment call centers.

On at least a quarterly basis, providers should review and verify the accuracy of their demographic data displayed in our Provider Directory. To report any changes to demographic data or to your address, panel status (open or closed) for each individual provider, institutional affiliations, phone number, or other practice data requests should be reported via the Mass General Brigham Health Plan Provider Portal provider.massgeneralbrighamhealthplan.org or by submitting a Provider Change via the Provider-Enrollment-Form to Mass General Brigham Health Plans Provider Enrollment Team by email at HealthPlanPEC@mgb.org.

Consistent with provisions related to the federal No Surprises Act of 2021, failure to review and update demographic information at least quarterly may result in suppression from Mass General Brigham Health Plan Provider Directory until the information is validated. In addition, if Mass General Brigham Health Plan identifies potentially inaccurate provider information in the directory, we may outreach to your practice to validate or obtain accurate information. If we are unable to obtain a timely response, the provider’s applicable location may be subject to suppression in the directory until up-to-date information is received.

In addition, please keep the following in mind:

• Practice location — As new providers join your practice, it is important that only practice locations where the provider regularly administers direct patient care are submitted for inclusion in the Mass General Brigham Health Plan provider directory. Locations in which a provider may occasionally render indirect care — such as interpretation of tests or inpatient-only care — should be specified to ensure the location information is included in the provider’s demographic profile, but not in the provider directory.
• Timely notice — As a reminder, notification of address, acceptance of new patients, provider terminations, and other demographic information changes should be submitted at least 30 days in advance.

For questions, contact our Provider Service Center at 855-444-4647 or Provider.MGBHP.org

Medical policy updates

Twelve (12) medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. These policies are now posted to MassGeneralBrighamHealthPlan.org. The table below is a summary.

For more information or to download our medical policies, go to https://www.massgeneralbrighamhealthplan.org/providers/medical-policies and select the policy under the medical policy listings.

Drug code and code updates

View code updates for October 2024 here. 

Formulary updates

View the formulary updates here.