A Message from Fulcrum’s New CEO; Organization Determinations; Patient Safety and Infection Prevention Assessment – Lessons Learned; Choosing Wisely Campaign Linked to Small Drop in Back Pain Imaging; June is National Men’s Health Month; ChiroCare Centers of Excellence Program Update; Non-Opioid Management Therapies Position Paper; Fulcrum’s Annual Meeting Notification; Moving or Retiring? Let us Know!
A Message from Fulcrum's New CEOIt is with great excitement and commitment that I welcomed the opportunity of serving as Fulcrum Health, Inc.’s (Fulcrum) Chief Executive Officer in May of 2017. It’s a privilege to work with our quality provider network, Board of Directors, partners, and staff team; and it’s an honor to be here.
We all know that health care is in a state of constant flux, and Fulcrum’s role in leveraging physical medicine to transform the industry away from a cost-per-transaction model to one based on outcomes has never been more important. That’s why, in the coming months, we will embark on key new initiatives to guide Fulcrum into an even stronger national model of success – all while staying true to our core values and supporting the patient through a personalized patient centered approach. I am confident we will provide meaningful new opportunities, and by focusing on the Triple Aim, we will continue walking the talk of Fulcrum’s Mission, Vision, and Values.
Organization DeterminationsThis article focuses on organization determinations – what they are and when to get one. As a reminder, Advance Beneficiary Notices (ABN) (Form CMS-R-131), are not used in the administration of Medicare Part C services. ABNs are used for Medicare Part A and B (original Medicare).
An organization determination, as defined by the Centers for Medicare and Medicaid Services (CMS), is:
Any decision made by a Medicare health plan regarding:
- Receipt of, or payment for, a managed care item or service;
- The amount a health plan requires an enrollee to pay for an item or service; or
- A limit on the quantity of items or services.
An organization determination, sometimes referred to as a coverage decision, is a decision a health plan or delegated entity makes about a patient’s benefits and coverage and whether the requested service(s) should be paid. Organization determinations are typically requested by a provider but a patient is also able to request a coverage decision BEFORE he/she receives certain medical services. A patient may choose to request a determination for a coverage decision beforehand when either the doctor or patient are unsure whether the health plan will cover a medical service.
After the appeal rights are provided, a written consent from the member agreeing to receive and be financially liable for the denied services PRIOR to the services being rendered is REQUIRED. After these steps are complete, then the provider may treat the member.
UCare members: If you would like to request an organizational determination, simply submit authorization request to eviCore and indicate whether the care is active care or maintenance care and the case manager will assist you in the organizational determination process.
HealthPartners members: If you or your patient would like to request an organizational determination, simply call the number on the back of the patient’s insurance card and a representative will assist you in the organizational determination process.
Upon receipt of your request for an organizational determination, the health plan has 14 calendar days for the physician or other health care professional to make a final decision. Once the decision has been made you and the patient will receive a letter indicating the outcome of the review. If the review was denied, you will be presented with appeal rights in the letter along with an explanation of the process you must complete to appeal the decision.
For more information on how a Medicare health plan processes organization determinations, please visit CMS Chapter 13 – Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals sections 30-50.
If you have any non-PHI related questions, please direct them to email@example.com. Additionally, if you know or suspect fraud, waste or abuse is occurring in your place of business please report it immediately to Fulcrum’s compliance hotline at 1-866-714-0526. Tips can be left on this voicemail 24/7 by anyone (provider, office support staff, patients, etc.).
Patient Safety and Infection Prevention Assessment - Lessons LearnedFulcrum would like to extend a thank you to the 30 clinics that volunteered to participate in the ChiroCare Infection Prevention Assessment in 2016. In addition to becoming more aware of patient safety best practices, participants saw an average improvement of 27 percent on their clinics’ pre and post infection prevention assessments.
Three universal infection prevention lessons learned include:
- Do not refill sanitizers or soap containers – replace empty containers with new ones instead
- Pay attention to contact time of disinfectant wipes – the time can vary from one to several minutes, depending on the brand of wipes
- Discard sanitizers with expired dates
Stay tuned for additional patient safety and infection prevention tips for your chiropractic clinic.
Choosing Wisely Campaign Linked to Small Drop in Back Pain ImagingAs a part of Fulcrum’s ongoing provider education campaign, we have highlighted several Choosing Wisely articles aimed at reducing potentially unnecessary “low-value” medical services – one of these being back pain imaging. Two and a half years following the launch of the campaign, researchers have found there was a four percent relative reduction in low-value back imaging.
“Our analysis suggests that Choosing Wisely recommendations combined with patient-level consumer incentives might be insufficient to reduce low-value medical care,” the authors write.
June is National Men's Health MonthIn the spring of 2017, the US Preventive Services Task Force (USPSTF) updated its recommendations for prostate cancer screening, saying that men age 55 to 69 years should consult their doctors to make individual decisions about whether to undergo this screening. The new recommendation takes into account current evidence of the screening’s potential benefits and harms.
To help keep you up-to-date on current recommendations and aid in this conversation with your patients, Fulcrum has partnered with the Institute for Clinical systems Improvement (ISCI) and USPSTF to develop two preventive screening guides – one for providers and the other for patients. See the Preventive Screening Guides on ChiroCare.com to identify patients who could benefit from talking to their primary care doctor about these services.
ChiroCare Centers of Excellence Program UpdateFulcrum would like to extend a thank you to the clinics who submitted an application for consideration in our ChiroCare Center of Excellence (CCoE) program. The application deadline expired on May 31, 2017, and all submissions are currently under review. An announcement with the CCoE designations for 2017 will be published in July; please stay tuned for more information. For general information about the program, visit our ChiroCare Centers of Excellence webpage.
Non-Opioid Management Therapies Position PaperThe Physical Medicine Management Alliance (PMMA) urges the use and coverage of non-opioid treatments as first-line therapy for individuals to manage pain. An estimated 126.6 million Americans are affected by a musculoskeletal disorder, costing an estimated $213 billion in annual treatment, care, and lost wages.
PMMA released a position statement titled, “Public Policy Position: Non-Opioid Pain Management Therapies” and focuses on conservative care and non-opioid therapies that are safe and effective for treating pain and musculoskeletal conditions. Check out this must read! You can find the Issue Brief here or read the full position paper here.
Fulcrum's Annual Meeting NotificationOn Thursday, July 27, 2017, Fulcrum will host a Q&A session regarding the 2016 Annual Report. This will be held via conference call in lieu of an in-person meeting. Please join the call by dialing (651) 219-4264 x4241. The Q&A session will begin at 5 p.m. and end no later than 6 p.m.
Moving or Retiring? Let Us Know!It is vital that your practice report any changes to ensure that we have your current address, phone, fax, and email address. Any changes or corrections to your TIN/name combination should be communicated immediately. The Provider Update tool within ChiroCare Connect offers a quick and electronic means to report changes. Simply select the “Billing Information Update” option within the Provider Update tool.
Please contact our Provider Services team at 877-886-4941 with any questions about submission of updates.
Posted under: Weekly News Flash