WYOMING TOTAL POPULATION HEALTH MANAGEMENT AND UTILIZATION MANAGEMENT PROGRAM OVERVIEW MAY 28, 2015
WY Health…Get Plugged In Program 2 Integrating Utilization Management (UM), Care Coordination (CC), Disease • Management (DM) and Case Management (CM) into one product/program Case management is a critical component of the overall integrated care management • program Inclusive of both behavioral and medical conditions • The program assist Medicaid clients requiring care coordination as well as clients with • multiple or complex conditions; helping them navigate the health care system; and adopting strength based self-management practices Program Outcome Goals: • Decrease emergency room visits Decrease hospital admissions (preventable) Decrease hospital readmissions Improved health status June 10, 2015
Weight Management Programs 3 Weight Management Program for Adults Weight Management for Youth FitLogix Back in Whack Criteria for program: Criteria for program: Desire to lose 5% (or more) of current body weight Ages 6 – 18 18 years of age or older Adult participates with child 12 month commitment Access to computer with high speed internet 2 – 6 month commitment Clinically appropriate Have access to a DVD player Program Components FitLogix Health Coach Program Components FitBit and Digital Scale provided Regular interaction with Healthy Habits • WYhealth care manager Criteria for program: Educational materials 18 years of age or older 3 – 6 month commitment Incentive Program Components Frequent telephonic teaching and support Nutrition/weight reduction strategies, tips and support Weekly client centered goals June 10, 2015
Choice Rewards Diabetes Incentive Program 4 Choice Rewards provides education, support and accountability through one-on-one care manager coaching, educational materials and telephonic interaction. The goal of the program is to provide Medicaid clients who have a diagnosis of diabetes with knowledge, skills, motivation and tools to help them make life style changes and adopt long-term habits for managing their diabetes. Criteria for program All Medicaid patients with a diagnosis of diabetes Engagement in WYhealth Diabetes Care Management Completion of assessments with questions asked by WYhealth care manager Program components Clients engage in a year long diabetes program focused on health risk identification, self management practices and addressing mental and emotional aspects associated with diabetes Wyhealth care managers provide phone coaching sessions Incentives are available to those that are 18 and older that meet criteria June 10, 2015
Support Services 5 24/7 Nurse Line: Medicaid clients may call a nurse 24 hours a day seven days a week at no cost to ask questions about health problems or discuss a need to go to the Emergency Department Due Date Plus App: Free for all Wyoming pregnant women • Week-by-week guide • What to expect • Look up symptoms • June 10, 2015
Pay 4 Participation 6 The P4P program allows Medicaid providers to receive reimbursement for: Providing health education to Medicaid clients with chronic illnesses Referring clients to the WYhealth Care Management program The program gives healthcare providers additional support to help clients live healthier lives and prevent costly complications associated with chronic disease. The primary goals of the program include: Preventing gaps in care Improving clinical outcomes Promoting compliance with plans of care Reminders for annual preventive screenings When a client is referred, a care manager will contact the client and complete an assessment. The individualized care management program will include reminders to: Receive annual preventive screenings Make follow-up appointments with their provider as needed Comply with their plan of care June 10, 2015
WYhealth Contact 7 Telephone - 888-545-1710 Website – www.wyhealth.net info@wyhealth.net June 10, 2015
HEALTH HELP 8 6/10/2015
Authorization Process Change 9 Effective June 1, 2015, authorizations will be required for Advanced Imaging Services (CT/CTA/MRI/MRA/PET/CNUC) Radiation Therapy (2D3D/BRAC/STER/PROT/IMRT/IGRT Cardiology Diagnostic Cardiac Services Catherterization/Cardiac Devices/Implantable and Wearable Devices/Echo June 10, 2015
Authorization Process Change 10 List of CPT Codes are available at www.wyhealth.net/Cardiology_Radiology.html Claims for these services will require authorization for DOS 6/1/15 forward Authorization numbers are to be requested by the referring provider and provided to the rendering facility June 10, 2015
Authorization Process Change 11 Radiology, radiation therapy or cardiology services rendered in an ER setting that are determined to be non-emergent or elective (in accordance with WDH Policy and NUBC guidelines), will require an authorization through HealthHelp When services are provided after hours, the consultation may occur after service delivery and authorization will be issued retrospectively with appropriate documentation. Services that are emergent do not require an authorization June 10, 2015
Authorization Request Notification Process 12 Internet/Web: www.wyhealth.net/Cardiology_Radiology.html Fax: 1-866-778-6483 (form on website) Phone: 1-888-545-1710 prompt 4 Hours: 6:00AM – 6:00PM MST (after hours requests can be submitted via the web or fax) June 10, 2015
Contact Information 13 Provider Support – Xerox (WYhealth) Morris McGaugh, Morris.McGaugh@xerox.com 307-554-0317 Network Relations Consultant – HealthHelp Andre King kingan@healthhelp.com Office (281) 582-1741 Client Manager - HealthHelp Michael Ideson idesonm@healthhelp.com Office (281) 582-1710 June 10, 2015
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