August 2021 Provider News - Special Edition
Date: 08/13/21
In This Issue
- Payment Integrity Updates - DRG Audits, DME, Home Homale SNF post-payment audit process
- General Updates - InterQual Connect Live on Web Portal 9/1; Philips recall of CPAP/BIPAP/Ventilator Models
- Reminder - PA Requirements for PT/ST/OT and Home Health effective 8/1/2021
- Training and Education - MCO provider resource page and clinical provider trainings
______________________________________________________________________________________
Payment Integrity Updates
Diagnosis-Related Group (DRG) Audits – Ambetter
Effective 11/1/2021
In an ongoing effort to ensure high quality claims processing and payment, Coordinated Care Corporation is taking additional steps to verify the accuracy of payments made to our contracted facilities. Beginning in November 2021, Coordinated Care will begin auditing selected claims and associated medical recrods to ensure payments were applied in accordance with national correct coding standard rules.
Coordinated Care has contracted with Cotiviti to assist us in this effort. If you have claims selected for audit, you will receive a letter from Cotiviti requesting medical records for these claim audits on behalf of Coordinated Care Corporation.
If you have any questions, please contact Provider Relations. We appreciate your participation in our network and your dedication to the health and welfare of our members and your patients.
Durable Medical Equipment (DME) /Home Health (HH) /Skilled Nursing Facilities (SNF) Post-Payment Audit Process
DME – Apple Health Core Connections & AmbetterHH/SNF – Ambetter Only
Effective 11/1/2021
Effective November 1, 2021, Coordinated Care of Washington, Inc. and Coordinated Care Corporation (collectively Coordinated Care) will implement a DME, Home Health, and Skilled Nursing Facility Post Payment audit process for a select sample of network claims each month.
To support this process Coordinated Care will use an approved vendor, Performant, to complete these audits.
For providers who may have a claim selected for post-payment audit, they will be provided written notice of the audit and asked to supply Medical Record documentation to Performant to substantiate the services associated with the claim.
If you have any questions please contact Provider Relations.
______________________________________________________________________________________
General Updates
Upcoming Imprements to Web Authorization on Provider Portal
Coordinated Care is pleased to announce, effective September 1, 2021, the redesign of our web authorization request in our Secure Provider Portal, and the integration of an exciting new tool, InterQual Connect™. InterQual Connect (IQC), is an integrated medical review solution, enabling payers and providers to streamline the medical review process, and eliminate redundant reviews. Adding these features will simplify the provider experience. Look for upcoming training dates in August 2021.
The web authorization redesign and InterQual Connect, offers several new capabilities:
- Streamlined web authorization request
- Advises users if a service requires/does not require authorization or is not covered
- Easy access to InterQual Connect to complete medical review
- Completed InterQual medical review will automatically be included with your web authorization submission
- Possible instant approval based on outcome of a completed InterQual medical necessity review
- Identifies non-submitted Service Lines and provides reason for non-submittal
- Provides the assigned Authorization ID on submitted web authorization Service Lines
Philips Recall of CPAP/BiPAP/Ventilator Models
The U.S. Food and Drug Administration (FDA) is alerting people who use Philips Respironics ventilators, BiPAP, and CPAP machines and their health care providers that Philips Respironics has recalled certain devices (see table below) due to potential health risks. The polyester-based polyurethane (PE-PUR) sound abatement foam, which is used to reduce sound and vibration in these affected devices, may break down and potentially enter the device’s air pathway. If this occurs, black debris from the foam or certain chemicals released into the device’s air pathway may be inhaled or swallowed by the person using the device.
Philips Respironics is recalling the following affected devices manufactured between 2009 and April 26, 2021. For details, see Philips' Respironics recall notification External Link Disclaimer (PDF).
| Device Type | Model Name and Number (All Serial Numbers |
|---|---|
Continuous Ventilator, Minimum Ventilatory Support, Facility Use | E30 (Emergency Use Authorization) |
| Continuous Ventilator, Non-life Supporting |
|
| Noncontinuous Ventilator |
|
| Device Type | Model Name and Number (All Serial Numbers) |
|---|---|
| Continuous Ventilator |
|
| Continuous Ventilator, Minimum Ventilatory Support, Facility Use |
|
| Continuous Ventilator, Non-life Supporting |
|
BiPap or CPAP: Recommendations for People Who Use Affected BiPAP or CPAP Machines and Caregivers
- Talk to your health care provider to decide on a suitable treatment for your condition, which may include:
- Stopping use of your device
- Using another similar device that is not part of the recall
- Continuing to use your affected device, if your health care provider determines that the benefits outweigh the risks identified in the recall notification.
- Using alternative treatments for sleep apnea, such as positional therapy or oral appliances, which fit like a sports mouth guard or an orthodontic retainer.
- Initiating long term therapies for sleep apnea, such as losing weight, avoiding alcohol, stopping smoking, or, for moderate to severe sleep apnea, considering surgical options.
- Follow the manufacturer’s instructions and recommended cleaning and replacement guidelines for your CPAP machine and accessories. Ozone cleaners may worsen the breakdown of the foam, and there are other potential risks associated with the use of ozone and ultraviolet (UV) light products for cleaning CPAP machines and accessories.
- Register your device(s) on Philips Respironics’ recall websiteExternal Link Disclaimer to stay informed of updates from Philips Respironics regarding any new instructions or other corrective fixes, which the FDA is requiring.
- Report any problems with a device through the FDA’s MedWatch Voluntary Reporting Form.
Ventilators: Recommendations for People Who Use Affected Ventilators At Home and Caregivers
- Do not stop or change ventilator use until you have talked to your health care provider.
- Alternate ventilator options for therapy may not exist or may be severely limited for patients who require a ventilator for life-sustaining therapy, or in cases where therapy disruption is unacceptable. In these situations, and in the judgment of the treating clinical team, the benefit of continued usage of these ventilator devices may outweigh the potential risks identified in the recall notification.
- Talk to your health care provider about using an inline bacterial filter, which may help to filter out particles of foam, as indicated in the Philips recall notification. At this time, the FDA does not have evidence of the safety and effectiveness of a filter for mitigating the foam risks, and the FDA’s evaluation is ongoing. It is important to note the following considerations:
- Filters will not help to reduce exposure to certain chemicals that may be released from the PE-PUR foam.
- Filters may affect ventilator performance because they may increase resistance of air flow through the device.
- You should closely monitor for possible accumulation of foam debris on the filter or resistance-related problems in the breathing circuit after filter placement.
- Register your device(s) on Philips Respironics’ recall websiteExternal Link Disclaimer.
- Report any problems with a device through the FDA’s MedWatch Voluntary Reporting Form.
Recommendations for Health Care Providers and Facilities
- Follow the recommendations above for the affected devices used in health care settings.
- Review the recommendations above with patients who use the affected devices.
- Service affected devices and evaluate for any evidence of foam degradation.
- If there is evidence of foam degradation, such as black debris in the device, stop use of the device, if possible, and report any problems with a device through the FDA’s MedWatch Voluntary Reporting Form.
PE-PUR Foam May Be Inhaled or Swallowed, Presenting a Potential Health Risk
Polyester-based polyurethane (PE-PUR) is a sound abatement foam used to reduce sound and vibration in these devices and other medical equipment. The PE-PUR foam in the affected Philips Respironics CPAP, BiPAP, and ventilator devices may:
- Break down (degrade) into particles which may enter the device’s air pathway and be inhaled or swallowed by the user
- Release certain chemicals into the device’s air pathway, which may be inhaled
These issues can result in serious injury, which can be life-threatening, cause permanent impairment, and require medical intervention to prevent permanent damage.
To date, Philips Respironics has received several complaints about the presence of black debris/particles within the device's air pathway. Philips Respironics also has received reports of headache, upper airway irritation, cough, chest pressure, and sinus infection, which may be related to this issue, though the cause of the symptoms cannot be definitively linked.
The potential risks of particulate exposure include irritation to the skin, eye, and respiratory tract, inflammatory response, headache, asthma, and toxic or carcinogenic effects to organs, such as kidneys and liver.
The potential risks of exposure to chemicals released into the device's air pathway from the PE-PUR foam include headache; dizziness; irritation in the eyes, nose, respiratory tract, and skin; hypersensitivity; nausea/vomiting; and toxic and carcinogenic effects.
The foam degradation may be exacerbated by high heat and high humidity environments, and by use of unapproved cleaning methods, such as ozone.
To date, there have been no reports of death as a result of these issues.
Frequency Asked Questions:
- The FDA posted answers to frequently asked questions about this recall: Philips Respiraonics CPAP, BiPAP, and Ventilator Recall: Frequently Asked Questions.
- If the affected equipment has exceeded its recommended lifetime use and is due for routine replacement Coordinated Care will cover replacements in accordance with plan benefits.
- For Apple Health (Medicaid): If a temporary rental is needed while repairs or replacements are pending providers can follow the standard process for requesting benefit limitation extensions by submitting a Prior Authorization with an attached Limitation Extension request form
______________________________________________________________________________________
Reminders
As a reminder from the News Blast notification sent from Coordinated Care of Washington, Inc., on April 29, 2021: Prior authorization requirements, suspended as of December 1, 2020, are resuming for all Medicaid Physical, Occupational, and Speech Therapy as of dates of service August 1, 2021.
What does this mean to you as an Apple Health (Medicaid) provider rendering these therapy services?
- The first 12 physical or occupational therapy services and first six speech therapy services do not require an authorization, but because it is not easy to tell whether another provider has already rendered therapy services, we recommend providers request an authorization for all therapy services with dates of services starting August 1, 2021.
- Post-service review for medical necessity due to a failure to obtain prior authorization will not be granted unless there are extenuating circumstances that prevented prior authorization before the service was rendered. These circumstances must be described in the reconsideration request.
- Neurodevelopmental Centers are exempt from Prior Authorization requirements.
______________________________________________________________________________________
Training and Education
AWHP MCO Provider Resources Page
Coordinated Care encourages providers to visit the Association of WA Health Care Plans MCO Provider Resources at https://www.wahealthcareplans.org/mco-resources. As a MCO member of AWHP, Coordinated Care is committed to ensuring providers have appropriate resources to deliver integrated care to Apple Health members across the state. Training and resources for providers are continuously developed by MCOs and shared on this site.