Menu

Healthy Practices Archive

Interested in reading previously published information from MVP? Review our online archive of Featured Stories, Additional Information, Quality Corner, Pharmacy Policy & Formulary Updates, Medical Policy Updates, and MVP in the Community – organized by the quarter and year it was published.

Featured Stories

  • Fall 2021

    The Fall of Flu and COVID

    A Discussion with Daren Wu, MD, Chief Medical Officer at Open Door Family Medical Center

    The recent resurgence of COVID outbreaks fueled by variants, combined with the return to the office and school and relaxed preventive protocols, has led many to predict higher volumes of sick patients through the fall and winter. With these factors in mind, we want to understand how Open Door is preparing to handle these potential challenges while caring for their patient’s physical and mental health needs.

    Dr. Wu, how are you preparing differently today for the cold and flu season in combination with COVID than you have in previous years?

    Throughout the pandemic, we have continued to be flexible and are able to pivot to change our procedures to help our patients with ever changing needs. We have been very successful in utilizing telemedicine as a way of identifying symptoms before a patient would come into our facility. We also have strict check-in procedures that helped us to quickly identify well patients from sick patients, allowing us to separate them into distinct designated areas to mitigate the risk of spreading infections.

    How have you been proactively encouraging patients to get the flu vaccine?

    Our organizational culture emphasizes wellness and preventive care. As such, we have a long history of broadly encouraging our patients to get vaccinated whenever possible, and that includes against flu.

    We continually have conversations with our patients regarding recommended vaccinations, even during medical visits in which they present for something entirely different than an interest in vaccinations. We provide them with education on the important role of vaccinations and are comfortable working and coaching those patients who may be vaccine hesitant. We cannot change everyone’s minds, of course, but we certainly do try!

    We are very ready to give lots of flu shots this season, with flu shots from many manufacturers, encompassing all age groups, and even a non-injectable nasal spray formulation, for those who really do not want a shot.

    How are you identifying at-risk patients and how are you communicating to them about scheduling their vaccinations?

    Even prior to the pandemic, we’ve relied on having robust data-aggregation to identify high risk patients and encouraging them to get the flu shot. The data informs and supports our “flu shot campaigns” that include sending text message reminders to patients. These campaigns had built in mechanisms to not only remind them, but to give them the opportunity to request an appointment right away. When COVID shots became available earlier this year, we used the same mechanisms to identify eligible patient populations, such as older adults and those with high-risk conditions, and we used these processes to great success. To date, this organization has administered more than 45,000 vaccinations against COVID, which is a very large number for an organization our size.

    Do you have the capacity to provide COVID vaccine boosters at high volumes once they are available?

    Yes, once they are available, we will use the same mechanisms to identify and reach out to high risks patients and book appointments. Due to our capabilities to provide mass vaccinations, we were one of only 25 federal health centers in the country that initially were selected to help with COVID vaccinations, and that was because we have a track record of success when it comes to many clinical processes. During that time, we are administering 2,000 shots per week. We learned a lot from the NYS DOH vaccination sites about how to provide such a large volume of vaccines, including creating an “assembly line” where each individual had a single task and moved patients along quickly with a single point of entry and exit. We were also lucky to have a large number of volunteers at our disposal. We credentialed individuals with Open Door who had professional experience giving shots to patients which has resulted in a group of volunteers ready to assist. Even with flu vaccines and possible COVID booster vaccines, we don’t expect the volume of 2,000 shots per week, but the process remains flexible and scalable, so we’ll be ready for whatever comes.

    How are you preparing to provide COVID vaccines to kids under 12?

    We are preparing messaging to parents, with scripts in both English and Spanish. We have a strong IT infrastructure, and good data capabilities, so once the vaccines are approved, we can start disseminating the messaging to parents and start vaccinating children the next day.

    How have you addressed the mental health of your doctors, office staff, and their families?

    We recognize the need to provide the best support possible to our staff, as we are fully aware of a spike in turnover at all levels – Medical Assistants, Dental Assistants, Medical Directors, it has been a serious concern for us, and many practices in our area and across the country. A particular problem is that practices cannot hire as many Behavioral Health Providers as are leaving. All health systems are dealing with this. To stay ahead of it, we have in some cases reduced in-person hours for our clinicians, adjusting schedules 5 days a week to 4. Providers want more flexibility, as the pandemic has put a spotlight on enjoying the time you have. Something we have implemented is to allow providers to work from home virtually. More than 40% of our clinical encounters were in the form of Telehealth during the height of the pandemic and we intend to continue with Telehealth – due to its popularity with both patients and staff, in perpetuity. At this time, with many more patients choosing to come in-person, we still maintain Telehealth at over 20% of our visits, and many of our clinicians are able to continue working one day per week from home This has been a good transformation and an effective way to both provide care for patients and support our staff.

    New D-SNP Plan Provider Training

    Effective January 1, 2022, MVP will offer a new D-SNP plan for enrolled individuals dually eligible for Medicare and Medicaid in the Capital District (Albany, Columbia, Greene, Rensselaer, Saratoga, and Schenectady counties), and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester counties). Special Needs Plans (SNPs) are a type of Medicare Advantage (MA) plan designed for individuals with special needs focusing on intensive care coordination.

    The Centers for Medicare and Medicaid Services (CMS) require Providers who care for patients in D-SNP plans to complete a training. All Providers in the Medicare network in the counties listed above must complete this training, which will take approximately 15-30 minutes. MVP understands your time is valuable, so as a thank you, we will email all Providers who complete the training by November 30, 2021, a $25 Amazon gift card.

    To access the training, visit mvphealthcare.com/DSNPeducation. Once you have taken the training, complete the form below it to verify completion. Upon submission, an email will be sent with instructions for how to claim your gift card.

    If you have any questions about this training requirement, please contact your MVP Professional Relations Representative.

    MVP to Launch new Pharmacy Electronic Prior Authorization Process in November

    In November MVP will launch a new tool to manage electronic prior authorizations (PA) for pharmacy and medical drug claims for Members in all plans*. Providers will be able to access the new tool, powered by Novologix, via a link in their online provider account. Providers may request access to their online account at mvphealthcare.com/ProviderRegister.

    Once logged in to their account, providers will be able to initiate a PA, which will run a test claim to determine if a PA is needed. If a PA is required, additional information will be collected, if necessary, and the request will be submitted to an MVP medical director for approval or denial. Providers will now know immediately if a PA is not required, and if it is, they will know within a few minutes to hours if it is approved or denied, instead of potentially waiting days.

    Additional information will be sent to providers in October for how to access the new tool and accompanying training documents.

    *This new tool will be usable for Members in all plans except ASO plans with pharmacy carved out. Providers will be immediately notified if they submit a request for a member who does not have pharmacy benefits with MVP.


Additional Information This Quarter

  • Fall 2021

    New EyeMed Network

    MVP Health Care® (MVP) is excited to announce a new relationship with EyeMed Vision Care® (EyeMed) to manage routine vision care for Members in several MVP plans. We’ve chosen EyeMed because they can provide more robust benefits for our Members’ routine vision care than what are currently available to them.

    Starting January 1, 2022, Members in all plans except Medicaid, Essential Plan, and a few other plans, such as those that have ACA pediatric benefits, will begin to utilize the EyeMed network for routine vision care. Providers will be able to determine which network Members utilize based on their MVP Member vision ID card. The network of MVP Participating eye care Providers will still be used for medical and diagnostic services for Members in all MVP plans.

    Navigating Diabetes Series

    MVP is launching a new member education series, Navigating Diabetes in November. This four-part series will offer clinical guidance plus practical tips to help manage diabetes. If you have patients that may benefit from attending, encourage them to register at mvphealthcare.com/calendar.

    Receive Important Updates by Email

    MVP is working to improve how we communicate with you. To assure that general notifications, regulatory and MVP policy updates, Professional Relations updates, tips for closing gaps in care, and other valuable information gets to the right point of contact within your practice, please visit mvphealthcare.com/provideremail and enter the main group contact information to opt in to receive emails from MVP.


Quality Corner

  • Fall 2021

    New Star Measures: PCR, FMC, TRC

    Effective January 22

    Plan All-Cause Readmissions (PCR) captures the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days after discharge, for Medicare Members who are 18 years of age or older.

    Exclusions:

    • Principal diagnosis of pregnancy or condition originating in the perinatal period on the discharge claim
    • Planned admission using any of the following:
      • Principal diagnosis of maintenance chemotherapy
      • Principal diagnosis of rehabilitation
    • Organ transplant
    • Potentially planned procedure without a principal acute diagnosis
    • Enrolled in hospice at any time in the measurement year
    • The Member expired during the stay

    Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) reports on Medicare Members who are 18 years of age or older with multiple high-risk chronic conditions who had an emergency department (ED) visit and a follow-up service within seven days of that ED visit.

    Note: The denominator for this measure is based on ED visits, not on Members. If a Member has more than one ED visit, identify all ED visits between January 1 and December 24 of the measurement year.

    For more detailed information including exclusion, chronic condition diagnosis, and follow up visit criteria and best practices, visit mvphealthcare.com/providers, select Reference Library, then select 2021 HEDIS Provider Guides, and then select Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC)(PDF).

    Transitions of Care (TRC) assesses the percentage of inpatient discharges from acute and/or non-acute facilities for Medicare Members who are 18 years of age or older, and who had each of the following indicators reported:

    • Notification of Inpatient Admission: Documentation that shows receipt of notification of an inpatient admission either on the day of admission or two days after admission (three total days).
    • Receipt of Discharge Information: Documentation of receipt of discharge information on the day of discharge through two days after the discharge (three total days).
    • Patient Engagement after an Inpatient Discharge: Documentation that supports office visits, visits to the home, or telemedicine visits within 30 days after discharge (day of discharge not included).
    • Medication Reconciliation Post-Discharge: Documentation supporting that medication reconciliation occurred on the date of the discharge through 30 days after discharge (31 total days).

    This medication reconciliation is conducted by a prescribing Provider, clinical pharmacist, or registered nurse on the date of discharge through the 30 days following the discharge.

    Note: Members may be in the measure more than once if there are multiple admissions.

    For more detailed information and best practices visit mvphealthcare.com/providers,, select Reference Library, then select 2021 HEDIS Provider Guides, and then select Transitions of Care (TRC)(PDF).

    Why It Matters

    A high rate of unplanned readmissions may indicate inadequate post-discharge planning and care coordination. Preventing unplanned readmissions by standardizing coordination of care after discharge and increasing support for patient self-management will help improve both your quality performance scores and patient satisfaction.

    HEDIS Updates for Measurement Year (MY) 2022

    For MY 2022, HEDIS added three new measures, modified seven existing measures, and retired three measures/indicators.

    New Measures

    Advance Care Planning: Medicare Members 65-80 years of age with advanced illness, indication of frailty, or receiving palliative care who had advance care planning during the MY. Members 81 years of age and older who had advance care planning during the MY.

    Antibiotic Utilization for Respiratory Conditions: Members three months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event.

    Deprescribing of Benzodiazepines in Older Adults: Medicare Members 65 years of age and older who were dispensed benzodiazepines and achieved a 20% decrease or greater in benzodiazepine dose during the MY. 

    Changes to Existing Measures

    Acute Hospital Utilization: Revised to exclude planned hospitalizations and removed separate Medical and Surgical reporting categories, retaining the total rate (which includes medical and surgical admissions).

    Identification of Alcohol and Other Drug Services/Diagnosed Substance Use Disorders

    • Modified from “utilization” to “diagnosed-prevalence” of substance use
    • Revised name to Diagnosed Substance Use Disorders
    • Revised the denominator to reflect the number of Members, rather than Member years, and to include substance use disorder (SUD) codes.
    • Modified the age groups for reporting to 13–17, 18–64, and 65+

    Mental Health Utilization/Diagnosed Mental Health Disorders

    • Modified from “utilization” to “diagnosed-prevalence” mental health disorders
    • Revised name to Diagnosed Mental Health Disorders
    • Revised the denominator to reflect the number of Members, rather than Member years, and to include mental health disorder codes in “any position” rather than by “principal diagnosis”
    • Removed the “mental health practitioner” requirement from the numerator
    • Modified the child and adolescent age groups for reporting to 1–17

    Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence

    • Revised name to Initiation and Engagement of Substance Use Disorder Treatment
    • Modified from “Member-based” to “episode-based”
    • Changed the denominator to lengthen the negative SUD history period from 60 days to 194 days and remove ED visits and medically managed withdrawal from the negative SUD history period
    • Removed the numerator requirement that psychosocial treatment accompany pharmacotherapy
    • Modified the age groups to ages 18–64 years and 65+ years

    Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence / Follow-Up After ED Visit for Substance Abuse

    • Revised name to Follow-Up After ED Visit for Substance Use
    • Changed the denominator to include ED visits for unintentional or undetermined overdose for commonly used drugs with addiction potential in “any” diagnosis position
    • Changed the numerator to:
      • Allow follow-up visits with SUD indicated in “any” diagnosis position
      • Add pharmacotherapy for alcohol or opioid use disorder
      • Incorporate outpatient or telehealth visits, for
        • Diagnosis of drug “use” or overdose
        • Services defined as addressing substance use (per CPT code description), without a diagnosis requirement
        • Visits where a behavioral health assessment or screening is performed
        • Visits with a mental health provider
        • Substance use services provided by a peer recovery support specialist

    Use of Imaging Studies for Low Back Pain

    • Expanded the upper age limit from 50 to 75
    • Added reporting for the Medicare product line
    • Added four clinical exclusions: osteoporosis (any history), lumbar surgery (any history), spondylopathy (any history), and fragility fracture (within 90 days prior to the index episode start date)
    • Added two cross-cutting exclusions: palliative care and advanced illness/frailty

    Comprehensive Diabetes Care/Hemoglobin A1c Control for Patients with Diabetes, Eye Exam Performed for Patients with Diabetes, Blood Pressure for Patients with Diabetes

    • Separated each indicator into three standalone measures:
      1. Hemoglobin A1c Control for Patients with Diabetes with indictors for HbA1c Control <8 and Poor Control HbA1c >9
      2. Eye Exam Performed for Patients with Diabetes
      3. Blood Pressure Control for Patients with Diabetes

    Retired Measures/Indicators

    • Care for Older Adults—Advance Care Planning Indicator
    • Comprehensive Diabetes Care—HbA1c Testing indicator
    • Antibiotic Utilization

    For more information about MY 2022 HEDIS updates, visit blog.ncqa.org and select the HEDIS Quick Link.

    Follow-Up After Hospitalization for Mental Illness (FUH) measures the rate of MVP Members six years of age and older who are discharged after an acute in-patient hospitalization for treatment of selected mental illness or intentional self-harm diagnoses and had a follow up visit with a behavioral health provider within seven days or 30 days following that hospital discharge.

    Why it matters. Timely follow-up care after your patient has been discharged from the hospital for mental illness or intentional self-harm may reduce repeat hospital readmissions and improve health outcomes. Closing this measure for your patient will also help to improve your HEDIS quality performance scores. Behavioral health providers can utilize telehealth visits, e-visits, and virtual check-ins for both the seven- and 30-day follow-up visit.

    Not a behavioral health provider? While FUH does require that the Member follows up with a behavioral health provider (psychiatrist, psychologist, clinical social worker, or other therapist), as their PCP, there are strategies your practice can implement to establish continuity of care:

    • If the hospital discharge planner calls your practice to schedule a follow up visit, and the hospitalization was for mental health, coordinate with the discharge planner to make the appointment with the Member’s behavioral health provider.
    • If the Member calls your practice after discharge from a hospitalization for mental illness, implement office procedures to assist them to schedule a follow up visit with their behavioral health provider.
    • If the Member does not have a behavioral health provider, refer them to com/FindaDoctor and use the Doctors by Specialty or Places by Type search options.
    • Develop a referral relationship with behavioral health and substance use disorder providers close to your office.

    For additional information on FUH, visit mvphealthcare.com/providers, select Reference Library, then 2021 HEDIS Providers Guides, and then Follow-Up After Hospitalization for Mental Illness (FUH). 

    Important Reminders

    New York State 2019-2021 Kids Quality Agenda Performance Improvement Project Developmental and Autism Screenings

    • Developmental screenings should be performed with a multi-domain screening tool at nine-months, 18-months, and 30-months during well-child visits.
    • An Autism Spectrum Disorder (ASD) specific screening tool must be completed during the 18-month and 24-month well-child visits.
    • Developmental surveillance should be performed at all other well-child visits.

    Coding Changes for Developmental and Autism Screening

    Description

    Billable Diagnosis Codes

    Developmental screening with a multi-domain screening tool

    CPT Code: 96110

    Autism screening with a standardized screening tool

    CPT Code: 96110 with CG Modifier

    ICD-10 Code: Z13.41

    REMEMBER! Both a CPT and E/M code need to be included on all claims to receive additional reimbursement for the screening and the reporting of screening completion to NYS DOH.

    Blood Lead Screening and Follow-up

    All Medicaid and Child Health Plus Plan Members are required to have a blood lead screening around age one and again around age two, regardless of the initial value. A confirmatory or follow-up venous blood test is required if blood lead levels are greater than or equal to 5mcg/dl.

    For more information, visit mvphealthcare.com/providers and select Quality Programs, then select NYS Kids Quality Agenda Performance Improvement Program.

    2021 HEDIS Reference Guide for Primary Care

    Statin Therapy for Patients with Cardiovascular Disease (SPC)

    Check out our latest Provider tip sheet that gives useful information regarding patients you identify as having clinical atherosclerotic cardiovascular disease (ASCVD) and were dispensed at least one high or moderate-intensity statin medication and adhered to statin therapy for at least 80 percent of the treatment period. This information can be found at mvphealthcare.com/providers, then select Reference Library, then 2021 HEDIS Provider Reference Guides, then Adult Medical Conditions & Preventive Care.


Pharmacy Policy & Formulary Updates

  • Fall 2021

    To review the most recent Pharmacy Policy updates, Sign In to your MVP online account, then go to Resources, then Other Resources and select the Healthy Practices Newsletter – Fall 2021 issue.

    Don’t have an MVP online account? Register here.

    FORMULARY UPDATES FOR COMMERCIAL, MARKETPLACE, AND MEDICAID FORMULARIES

    New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid)

    DRUG

    INDICATION

    Margenza (medical)

    Breast Cancer

    Amondys 45 (medical)

    Duchenne Muscular Dystrophy

    Nulibry (medical)

    Molybdenum Cofactor Deficiency Type A

    Pepaxto (medical)

    Relapsed or Refractory Multiple Myeloma

    Ponvory

    Relapsed or Refractory Multiple Sclerosis

    Barhemsys (medical)

    Prevention of Post-Operative Nausea and Vomiting (PONV)

    Fotivda

    Relapsed or Refractory Advanced Renal Cell Carcinoma

    Abecma (medical)

    Relapsed or Refractory Multiple Myeloma

    Qelbree

    Attention Deficit Hyperactivity Disorder

    Zegalogue

    Hypoglycemia in Diabetes

    Elepsia XR

    Partial-Onset Seizures

    Roszet

    Primary Non-Familial Hyperlipidemia and Homozygous Familial Hypercholesterolemia (HoFH)

    Jemperli (medical)

    Endometrial Cancer

    Zynlonta (medical)

    Relapsed or Refractory Large B-Cell Lymphoma

    Accrufer

    Iron Deficiency Anemia

    Empaveli

    Paroxysmal Nocturnal Hemoglobinuria

    Rybrevant (medical)

    Non-Small Cell Lung Cancer

    Nextstellis

    Contraception

    Exservan

    Amyotrophic Lateral Sclerosis (ALS)

    Kimyrsa (medical)

    Acute Bacterial Skin and Skin Structure Infections

    Myfembree

    Heavy Menstrual Bleeding Due to Uterine Leiomyoma (Fibroids)

    Truseltiq

    Cholangiocarcinoma

    Lumakras

    Non-Small Cell Lung Cancer

    Wegovy (excluded for Medicaid)

    Weight Loss

    Aduhelm (excluded for all lines of business)

    Alzheimer’s Disease

    Drugs removed from prior authorization- Commercial and Exchange

    Ongentys

    Winlevi

    Monoferric (medical)

    Gavreto

    Olinvyk (medical)

    Sevenfact (medical)

    Eysuvis

    Nyvepria (pharmacy benefit)

    Nyvepria (medical benefit)

    -Subject to retrospective review per the Colony Stimulating Factor Policy


Medical Policy Updates

  • Fall 2021

    To review the most recent updates, Sign In to your MVP online account, then go to Resources, then Other Resources and select the Healthy Practices Newsletter – Fall 2021 issue.

    Don’t have an MVP online account? Register here.


MVP In The Community

  • Fall 2021

    George Eastman Museum

    With 48 volunteers in attendance, MVP had a strong presence at the George Eastman Museum in Rochester. Volunteers were on hand to help maintain the historic gardens at the museum which included weeding, trimming, pruning, and raking.