September 2024 - Home Hospital, adult preventive health resources

Home Hospital patients get inpatient care where they are most comfortable—in their homes.

There’s an old saying among doctors about patients recovering in hospitals, “The longer you stay, the longer you stay.”

Since 2016, Mass General Brigham’s Home Hospital has tackled this challenge with a set of innovations that bring acute inpatient care to the home, where the patient is most comfortable.

The success of the Mass General Brigham Home Hospital, one of the oldest and most established in the nation, is supported by research done by David Levine, MD, MPH, clinical director of research and development for Mass General Brigham Healthcare at Home, associate professor at Harvard Medical School, and a physician at Brigham and Women’s Hospital. Levine’s research, published in the Annals of Internal Medicine in January 2024, documents over 5,000 patients treated in hospital at home programs across the country. The results of his study reveal favorable outcomes.

On average, Home Hospital patients need less physical therapy, use less skilled nursing rehabilitation, report greater patient satisfaction, have an easier transition to life after discharge, and have better clinical outcomes. 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 needs. 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:

• ACO Spotlight: Adult preventive health resources
• Reimbursement for out-of-network urgent care centers
• Home Health Authorization Update
• Update to multiple procedure reduction rule on January 1, 2025
• Important information regarding Steward Health Care
• Mass General Brigham Health Plan’s fee schedules to be updated on October 1
• Help us keep directory information up to date
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• Formulary updates

ACO Spotlight: Adult preventive health resources

Mass General Brigham Health Plan endorses the preventive health guidelines established by Massachusetts Health Quality Partners (MHQP). These guidelines, created through a collaborative effort among Massachusetts healthcare organizations, offer comprehensive recommendations for delivering preventive care to the general population.

Preventive health recommendations that are required as part of PCP tiering and focus areas for the MassHealth ACO quality initiatives include:

Routine Social Determinants of Health screening and referrals to resources as needed

• • Incorporate health recommendations with social determinants in mind
  • Refer to SNAP or WIC as needed

• • Review and assess known cardiovascular risks, and counsel on mitigating any risks
  • Ask about access to safe, affordable, and accessible physical activity options  
  • Ask about access to healthy, affordable, and culturally appropriate food options   

• • Ask about access to preventive dentistry and encourage visiting a dentist at least yearly
  • Encourage use of fluoridated water and toothpaste
  • Advise twice daily tooth brushing and daily flossing
  • Share the MassHealth Find a Dentist tool

• • Obtain sexual history and ask about involvement in sexual behaviors with sensitivity to sexual orientation and gender identity
  • Discuss contraception with patients whose sexual practice might lead to pregnancy
  • Ask about use/motivation/access to use contraceptive methods to prevent STIs and unintended pregnancy
  • Offer PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis) if appropriate

• • Screen for depression annually and treat or refer as needed
  • Resource: Antidepressant Medication Screening & Management
  • Depression Treatment Guideposts: MDD-GPOCS.pdf

• • Assess history of unhealthy substance use, including marijuana/THC, prescription drugs, or over-the-counter drugs
  • Treat or refer for treatment if there is evidence of addiction
  • Massachusetts Consultation Service for treatment of Addiction and Pain
  • SUD - Initiation and Engagement in Treatment for Adults
  • AUD - Alcohol Use Disorder Care Pathway
  • OUD - Guideposts for the Treatment of Opioid Use Disorder
  • Substance Use Disorder is a treatable disease. And we’re here to help.

Reimbursement for out-of-network urgent care centers

Beginning on July 3, 2024, and ending on October 1, 2024, Mass General Brigham Health Plan is reimbursing out-of-network urgent care centers in Massachusetts as requested below. This is in support of the June 2024 directive from the Massachusetts Executive Office of Health and Human Services (EOHHS) and Assistant Secretary for MassHealth. Mass General Brigham Health Plan will reimburse urgent care centers in eastern Massachusetts* as follows:

• For Commercial members receiving services provided in urgent care centers with providers with whom Mass General Brigham Health Plan has a contract, but who do not participate in a member’s health plan, Mass General Brigham Health Plan will provide reimbursement for medically necessary urgent care services at the contracted rate for delivered services. Out-of-network providers are not allowed to balance bill members during this time.
  
  
• For Commercial members receiving services provided in urgent care centers with providers with whom Mass General Brigham Health Plan does not have any contract, Mass General Brigham Health Plan will reimburse medically necessary urgent care services at a rate equal to 135% percent of the rate paid by Medicare for medically necessary urgent care services. Out-of-network providers are not allowed to balance bill members during this time. 
  
  
• The MassHealth Program will reimburse at 100% of Medicaid.

Non-contracted providers in Massachusetts should submit claims directly to Mass General Brigham Health Plan (Payer ID: 04293). Please review our payment options and claims resource page before submitting claims using one of the following methods:

• Call Provider Service at 855-444-4647
• Mail paper claims to PO Box #323, Glen Burnie, MD 21060
• Submit a claim through the Provider Portal at MassGeneralBrighamHealthPlan.org
• Submit an electronic EDI claim to Payer ID 04293

For questions about reimbursement, please email HealthPlanProvRelations@mgb.org or visit the Provider Portal at Provider.MGBHP.org.

*Commercial is limited to these counties: Essex, Middlesex, Suffolk, Norfolk, Bristol, Plymouth, Barnstable, Dukes, and Nantucket

Home Health Authorization Update

Effective 12/1/2024, the way you enter your homecare authorizations through the provider portal will be updated.  This update will impact homecare authorization requests placed through the provider portal. Providers will have to submit a separate request for reach discipline: For example, Skilled Nursing and Physical Therapy being requested at the same time for the same period, would require 2 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 October and November newsletters, there will be instructions on how to access the training videos to help prepare for this 12/1/2024 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.

Important information regarding Steward Health Care

We are closely monitoring the situation with Steward Health Care, including its announcement about 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.

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).

Mass General Brigham Health Plan’s fee schedules to be updated on October 1

Mass General Brigham Health Plan reviews its drug fee schedules quarterly to ensure that they are current, comprehensive, and consistent with industry standards, to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes, to supplement the fees already on the fee schedule. 

The next update will occur on October 1, 2024. Changes may involve both new and existing CPT and HCPCS codes and will include the planned quarterly update to physician administered drugs, immune globulin, vaccine and toxoid fees.

The Plan will also be updating any Medicare Advantage fee schedules, on October, 1, 2024, if CMS has published any updates.

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

Genetic testing requests with eviCore Healthcare

Mass General Brigham Health Plan partners with eviCore Healthcare for genetic testing requests. Beginning 9/1/2024, all first-level appeal requests for denied genetic testing will also be handled by eviCore Healthcare, streamlining the process and maintaining expertise in reviews. Moving forward, all first-level appeals can be submitted directly through the eviCore Healthcare portal.

Medical policy updates

Seventeen (17) 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 September 2024 here. 

Formulary updates

View the formulary updates here.