Federal Employees Health Benefits Program

HMO Blue Texas Patient Safety Initiatives

The HMO Blue® Texas (HBT) program to improve patient safety involves fostering a supportive environment to assist physician and providers in maintaining a safe practice. Several initiatives are incorporated into this program.

Mental Health and Substance Abuse Benefits

Coverage for Mental Health and Substance Abuse Parity will continue with no changes for 2005.

Patient Safety Programs

Utilization Management
The focus of the Utilization Management (UM) program is on providing our members with access to appropriate care and monitoring the appropriate level of coverage for members' utilization of services. The UM program defines appropriate care as treatment that:

• Promotes health and early treatment
• Involves patients in decision making
• Is based on accepted medical principles
• Uses technology and other resources effectively
• Is accessible to members in a timely fashion
• Is sufficiently documented in medical records

The goals of the UM program are to:

• Enhance the efficiency of resources utilization
• Provide consistency throughout the health plan, throughout products and decision making
• Maximize the administrative efficiencies to enhance access to care
• Provide consistent identification and follow-up of potential quality assessment concerns

Utilization Management Program patient safety initiatives are:

• Evaluation of safety issues during the case management (CM) process with intervention designed to reduce risk when issues are identified.
• Identification of potential quality of care issues through assignment of quality indicator codes
• Provision of Disease Management Programs for asthma and diabetes to assist in improving health outcomes
• Development of clinical practice guidelines which providers may utilize as a resource to assist in improving health outcomes.
• Provision of Preauthorization and concurrent review processes to assist in ensuring appropriate and accessible health care
• Provision of a CM Program to assist in improving health outcomes
• Evaluation of complaints related to the UM/CM process

The components of the HBT UM program include the following:

Inpatient Services

• notification of select inpatient services
• Preauthorization of select inpatient services
• concurrent review
• discharge planning
• retrospective review

Outpatient Services

• Preauthorization of select ambulatory services

Other Utilization Process Components

• non-participating referral process
• appeals process

Quality Management Indicators

• quality indicator codes
• service indicators

Special Programs*

• Disease management programs
  • FEP Pilot Navigator

    This program ties Blue Health Connection, the 24 hour nurse line, to the McKesson asthma and diabetes disease management programs and process in place to secure FEP approval for the vended CHF program provided by Alere, Inc (CHF). Another feature is a one touch call for the following newly diagnosed members by the HBT Case Management Department.

    • Cancer
    • Chronic Obstructive Pulmonary Disease
    • AIDS/HIV
    • End Stage Renal Disease
    • Stroke
    • Brain/Spinal Cord Injury
    • Heart Disease
• Case management program

  *Note: Not all programs are available to all members. Programs are subject to change (deletion or addition or new programs) without notice.

  Clinical Pharmacy Program

  As a part of the patient safety initiatives, a program to decrease the abuse of Controlled Drug Substance (CDS) is performed. HBT utilizes a drug utilization review (DUR) program to monitor the frequency and usage of prescription drugs. Retrospective DUR, performed using paid claims data, is used to identify situations in which it appears that prescription drugs are potentially used in dangerous combinations or quantities and to identify situations of potential abuse or misuse of prescription drugs.

Our Quality Management staff, in cooperation with the Pharmacy and Therapeutics Committee, which is comprised of practicing physicians and pharmacists, as well as Plan representatives, are responsible for ongoing DUR monitoring.

The DUR service includes the following review components:

Early Refills: The system detects requests for refills before the previously dispensed supply is exhausted. The pharmacist is alerted when prescriptions are refilled outside an allowable refill time period, which is based on days' supply. (For example, a prescription might specify a 21-day supply of medications.)

Incorrect Dosage: The calculated daily dose (quantity dispensed/days' supply) is compared to the maximum and minimum daily dose recommended by the Food and Drug Administration. Pharmacists are alerted for potential subtherapeutic or overdose problems; if appropriate, the physician can be contacted for dosage adjustments.

Average Days Supply: The current claim is checked against plan-specific dispensing limits and other restrictions. Edits include allowable days' supply for chronic and acute conditions, metric quantity, and maintenance drug lists. The pharmacist is alerted to quantity and days' supply restrictions when data is entered.

Drug Interactions: The drug on the current claim is checked against other drugs on the patient's active profile. If a significant interaction is detected, the pharmacist receives a specific message indicating the drug(s) involved.

High Utilization/Fraud: Questionable drug utilization is identified during online processing. These instances are reviewed for appropriate pharmacy intervention, inappropriate prescribing patterns, and patient over-utilization. If the review indicates additional monitoring is needed, prior authorization can be required on a drug-specific or patient-specific basis. In case of stolen prescription blanks, claims can be denied based on a questionable Drug Enforcement Agency (DEA) number.

Duplicate or Concurrent Therapies: The current claim is analyzed against other drugs on the patient's active profile to detect and alert the pharmacist to redundant prescriptions. This edit detects different dosages or forms of the same drug, as well as different drugs in the same therapeutic class.

The Controlled Drug Substance (CDS) Letter Program is an extension of the DUR process that identified potentially unauthorized, improperly prescribed or abusive controlled drug use, as well as potentially dangerous combinations and/or quantities of controlled substances. Criteria for member selection in the CDS Letter Program includes any member receiving greater than or equal to 540 individual dosage units of any controlled drug substance (Schedules II, III, IV, V) during a 90-day period.

Interventions:

• Distributed a CDS overview letter along with a member drug utilization report and a controlled substance questionnaire to each prescribing physician:
• Each physician is blinded in the letter generation/drug utilization report process.
• Each physician is requested to respond regarding the appropriateness of information.
• Reported information of physician and member identified with abuse/misuse issues to BCBSTX Fraud and Abuse Department for investigation.
• BCBSTX Clinical Pharmacy Department responded to physician CDS inquiries.
• Developed database to capture physician responses to questionnaires. (Clinical Pharmacy Programs is in the process of inputting responses.)
• Published information on the CDS Letter Program in the physician newsletter, Blue Review.

Quality Improvement Programs
The Quality Improvement Programs Department has implemented the following initiatives related to patient safety:

• Investigation of Quality Indicator Codes to identify quality of care issues
• Investigation of complaints involving potential quality of care issues
• Development of Wellness Guidelines
• Evaluation of annual HEDIS results
• Hospital Quality Program
• Antidepressent Medication Management Initiative

Credentialing/Recredentialing
Participating Providers must meet established standards to participate in the HMO Blue Texas Managed Care Network. Thee standards meet or exceed TDI and NCQA requirements and include:

• Verification of education or board certification appropriate to the specialty
• The National Practitioner Data Base for malpractice and sanction information
• Appropriate state licensing agency to evaluate status of license
• Verification of facility accreditation and/or state licensure
• Performance of a physician office review for primary care physicians and high-volume specialists to evaluate accessibility, quality of documentation and quality of care

Provider Education
HBT provides ongoing provider education related to patient safety through the:

• Provider newsletter
• Provider administrative manual
• Web site
• Distribution of wellness and clinical practice guidelines
• Distribution of physician report cards reflecting performance for select preventive care screenings
• Physician office review

Member Education
HBT provides ongoing member education related to patient safety through the:

• Member newsletter (HealthStyles)
• Plan web site
• Reminder letters/phone calls to encourage preventive screenings for cervical and breast cancer
• American Cancer Society documents encouraging breast cancer screening
• Expectant and New Parent packets
• Educational materials regarding asthma, diabetes, hypertension, cardiovascular events, pneumonia and colon cancer
• Birthday Cards - childhood, adolescent, and adult immunizations and preventive screenings
• Distribution of wellness and clinical practice guidelines

Accreditation

The National Committee for Quality Assurance (NCQA) has awarded Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HMO Blue Texas) an accreditation status of Excellent for service and clinical quality that meet NCQA's rigorous requirements for consumer protection and quality improvement. The effective dates of accreditation are December 1, 2003 through December 1, 2006.

Other Benefit Issues

Preferred Providers
Primary care physicians (PCP's) manage care and initiate referrals to participating specialists. If a required specialty is not represented within the network, or a required specialist is not geographically available, referrals may be made to out-of-plan specialists. All out-of-plan specialty referrals must receive advance approval from the HMO. Exceptions not requiring PCP referrals include OB/GYN care and visits to network mental health/substance abuse providers. If a PCP refers a patient for specialty care but fails to notify BCBSTX, the patient is held harmless and is entitled to in-network benefits. PCP's initiate referrals by using the automated BlueLINK system, which is available 24 hours a day, through touch-tone phones or through the Internet. The Internet component, BlueLINK Online, includes enhanced security to protect the confidentiality of patient information. Within 24 hours of approval, BCBSTX sends written confirmation to the patient and the provider detailing what was approved. The referral authorization number, which is maintained online in the claims and utilization management systems, allows extensive tracking of referral patterns through claims-based reports and individual physician profiles.

Speech Therapy
Currently, speech therapy coverage is available for all types of medical care. Coverage is available under Inpatient benefits (included in the inpatient admission) and under outpatient benefits (covered at the office visit co-payment). Speech therapy requires a referral from the member's Primary Care Physician to a network provider and also requires preauthorization from HBT.

Smoking Cessation
Currently, coverage for smoking cessation is provided for medications under the prescription drug benefits; however, counseling services for smoking cessation are not provided.

Medicare Coordination of Benefits
We allow dual coverage with Medicare. HMO Blue Texas is primary to Medicare when the member is still actively working and secondary to Medicare when the member is retired. No benefit payment will exceed the Medicare or HMO Blue Texas allowable amount.

If the primary carrier's Explanation of Benefits (EOB) is attached to a submitted claim, we will coordinate benefits. If we receive information confirming other coverage, we will review prior claims to determine the necessity of recovering claims dollars.

Medicare covers individuals who have not reached age 65 that are suffering from end stage renal disease (ESRD). HMO Blue Texas is primary the first 30 months of eligibility for an entitlement to Medicare due to ESRD (30-month coordination period). HMO Blue Texas becomes secondary beyond the 30-month coordination period and you, or a family member, are still entitled to Medicare due to ESRD.

Alternative Benefits and Durable Medical Equipment
Chiropractic care is covered at an office visit co-payment if referred by a PCP; however, we currently have no benefits for pain management or alternative treatments such as acupuncture or biofeedback. There are no plans to introduce these types of coverage in the future.

Currently, orthotics and prosthetic devices are covered under the base medical plan.

Technology Assessment and Medical Policy Development
Medical Policy development is a function within Health Care Service Corporation (HCSC), which includes Blue Cross and Blue Shield health plans in Illinois, New Mexico and Texas. HCSC develops new Medical Policies to establish coverage positions for important medical technologies and services, and revises established Medical Policies, based on scientifically valid data and information. Both internal and external resources are utilized in this process.

BCBSTX has an RN clinical staff that supports and services the HCSC process. It is led by a medical director who is a board-certified physician. The clinical staff researches the clinical and technical issues needed for Medical Policy development and review. It obtains this information from various sources, including:

• The peer-reviewed scientific literature, accessed through recognized medical search protocols, such as Paper Chase and PubMed
• Medical technology assessments performed by the Blue Cross and Blue Shield Association (BCBSA) Technology Evaluation Center (TEC)
• Reference Medical Policies developed by the BCBSA in conjunction with medical directors from Blues health plans and input from medical experts
• Technology assessments and medical policies from other health plans, if available, and coverage positions developed by the Centers for Medicare and Medicaid Services (CMS)
• Input and review from participating specialists in the HCSC networks, which includes physicians from world-class tertiary care centers in Texas, Illinois and New Mexico

The RN staff drafts the new Medical Policies and revises established ones when needed. All Medical Policies are reviewed at least biannually, but they are always open to review and revision when new information about a particular medical technology emerges.

The review process for newly-drafted or revised Medical Policies is extensive:

• The Tri-State (TX, IL, NM) medical directors assigned to Medical Policy are responsible for the initial MD clinical review.
• After completing Tri-State medical director review, drafts are reviewed by other medical directors in HCSC and pertinent outside medical specialists.
• Policies are then reviewed by a broad-based group of high-level HCSC administrative managers, called Enterprise Review, which includes claims, customer service and legal, to assure that Medical Policies are both compliant and administrable.
• Final review and approval of Medical Policies is performed by the HCSC Corporate Consistency Oversight Board (CCOB).

All current Medical Policies are posted on the HCSC Intranet and are also available to providers on the Internet through the websites for TX, IL and NM.

HIPAA Notification

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), has been actively addressing the Administration Simplification phase of HIPAA for more than four years. HCSC provided extensive comments to the U.S. Department of Health and Human Services as it developed the regulations, and the corporation continues to participate in many of the national groups studying various aspects of HIPAA including WEDI, ANSI, and SNIP.

In addition, HCSC works closely with other Blue Cross and Blue Shield Plans, the Blues Plans' Legal Department Cooperative, and the Blue Cross and Blue Shield Association in HIPAA planning and implementation. HCSC also retains the highly respected firm of Michael, Best & Friedrich to help facilitate the HIPAA compliance efforts.

HCSC's goal is to achieve compliance with all applicable HIPAA regulations on or before the dates required by the law. To that end, HCSC established a dedicated HIPAA Program Management Office (PMO) to develop plans and procedures that are designed to guide the corporation in achieving HIPAA readiness and compliance. The PMO is comprised of top-level decision-makers from across business areas in all Divisions. The Team's scope is enterprise-wide and includes implementation and verification oversight of all aspects of HIPAA. The PMO prepares HIPAA project status reports summarizing divisional and corporate progress. These reports are prepared regularly and distributed to the HIPAA Oversight Committee, senior management, and periodically to the Board of Directors.

Transactions and Code Sets
HCSC is accepting all the HIPAA Transactions and Code Sets, except the 820 (Premium Payment). HCSC has implemented the HIPAA Transactions and Code Sets Modifications and is Operationally Compliant as defined by HIPAA and WEDI.

Privacy and Security
HCSC has addressed the HIPAA Privacy regulations and implemented the policies and procedures required to ensure the privacy of an individual's Protected Health Information as intended by the regulations. These policies and procedures were in place by the April 14, 2003, compliance date and are overseen by the HCSC Privacy Office under the leadership of the Senior Vice President for Audit, Compliance and Security.

The Privacy Office's responsibilities include an annual review of all divisional/departmental privacy policies and procedures, to check for consistency with the corporate Privacy policies and procedures and the regulation.

HCSC will review and, if needed, update its Security policies and procedures to ensure the confidentiality, integrity and availability of electronic Protected Health Information (ePHI) based on the Final HIPAA Security regulations. HCSC's plan is to be ready to meet the regulations by the required date of April 21, 2005.

Employer Identification Number
HCSC is evaluating the impact of the final regulation regarding the Employer Identification Number (EIN). HCSC plans to be ready to meet this HIPAA regulation by the required date of July 30, 2004.

Communications
HCSC is communicating general HIPAA-related information to providers and group customers through regular communications vehicles such as newsletters. When final determinations are made on the many issues related to HIPAA, appropriate notifications will be made to group accounts, individual members, providers, and vendors.

Finally, there are several useful resources for HIPAA information on the Internet. You may find answers to most of your questions at one or more of the following Web sites:

• Health Care Financing Administration (HCFA) [now known as Centers for Medicare & Medicaid Services (CMS)] - http://cms.hhs.gov
• ANSI X12 - www.x12.org
• WEDI / SNIP - www.wedi.org/snip

The information provided here and in other communications regarding HCSC's HIPAA efforts are designed to keep you informed about the status of these efforts, not to alter any existing contractual relationships. Such information reflects HCSC's understanding and expectations at the time that it is provided.