An Open Letter to Orange County Providers from Dr. Richard Pitts, CalOptima Chief Medical Officer |
Dear Colleagues,
I was practicing in Orange County and active in the Orange County Medical Association when CalOptima was born in 1995. The intent was to improve the delivery of health care for Medi-Cal patients through a community-based health plan — and I emphasize community-based health plan.
To me, being community-based means having great partnerships with all stakeholders, including patients, physicians, allied providers, hospitals, community clinics, and other community support programs and services. Since my arrival as the Chief Medical Officer, I have been working with our new CEO, Michael Hunn, the Board, and the leadership team, focusing on improving provider outreach, communications, issues resolution and partnerships.
Here are provider quotes from three recent emails to CalOptima:
- We know this is working well. We are not getting the same complaints from our physicians.
- We are very grateful for your collaboration and work on improving service for providers and members. Thank you for the great efforts and work achieved this past week on helping us with some difficult situations.
- Thank you, Kelly Giardina and Mike Shook for assisting us. We are grateful for this partnership.
This positive feedback stems from more productive collaboration and communication. I’ve been gathering input from providers about the most critical “pain points” that we can work to resolve together. The following is a list of accomplishments, from the past five months, that reflects our efforts to rebuild and strengthen partnerships between CalOptima and our health networks and hospitals. I hope you agree that we are making progress. I am open to your feedback.
Experienced Leadership Team: CalOptima has a highly qualified and experienced clinical leadership team that is committed to an open-door approach. I am working with Executive Director of Clinical Operations, Kelly Giardina, to set a new tone that promotes direct engagement with health network clinical leaders and staff. We have established a clear escalation path that includes our involvement, if needed, and we are building a reputation for being responsive to requests for clarification, case status or meetings to discuss any member, process or system issue. I want you to feel comfortable reaching out to me directly as the CMO at richard.pitts@caloptima.org.
Improved Communication: Many of our partners identified the opportunity for real-time clinical case discussions with CalOptima on inpatient cases and difficult discharges. This is being addressed through a new practice of regular “rounding” meetings. Prior to this rounding process, there was not an easy way to have member-specific discussions, and I acknowledge there was a gap. In addition to this improvement, CalOptima also resumed holding consistent quarterly Joint Operations Meetings (JOMs) with individual health networks and hospitals, so we can drill down on focused issues. The JOMs augment our longstanding practice of having monthly Health Network Forums to address topics of broad interest to all partners. The overarching goal of these changes is proactive communication that delivers quicker resolution to challenges and increased awareness of CalOptima programs.
Better Clinical and Operations Connections: CalOptima has implemented an alignment plan to connect our operations and clinical teams for robust issue resolution and improved care coordination for members. The strategy targets high-volume hospitals and health networks, and I would like to thank Providence St. Joseph for being the first inpatient facility team that we worked with on this initiative. The process led to the rounding practice described above that now supports real-time, peer-to-peer patient care discussions, resource coordination and education. Many cases under medical review have been decisioned and agreed upon during these rounding meetings. Six of CalOptima’s large-census facilities are now benefiting from the alignment plan.
Timely Treatment Authorizations: CalOptima has implemented significant process improvements to decrease turnaround times for treatment authorizations. Using the Provider Portal, providers will often receive immediate authorizations. Additionally, in-network treatment authorizations are now turned around on average within 24–48 hours, which is well within the maximum allowable timeframe of five days. It is our vision to achieve same-day treatment authorizations within the next 36 months, or less, through improved information technology systems and structures.
Focused Engagement and Training: CalOptima’s Claims Administration and Grievance and Appeals Resolution Services (GARS) teams are committed to responding to individual facility or network requests to discuss trends and concerns, and we plan to set a quarterly cadence to engage with all partners about any provider dispute and appeal issues. The teams have recently provided some partners with targeted training related to the claims payment process and provider disputes. The GARS team is also working on an upcoming formal training for providers related to appeals for both medical and claims issues.
In Conclusion: The above changes have helped CalOptima learn from every encounter with your clinical teams, and we are bringing those best practices forward to apply with all partners. For example, UCI Medical Center developed a list of 30 pain points, and CalOptima’s clinical team immediately set up working sessions to review the issues and potential resolutions with UCI inpatient and ambulatory Case Management and Utilization Review teams. To date, the team has addressed 29 out of 30 issues, with the last issue to be resolved this month. Solutions in one facility are leading to improvements that will be implemented across the entire CalOptima network.
In writing this letter, I want to assure you and your teams that CalOptima intends to be accountable for being responsive, building provider collaborations and supporting the clinical community in new ways. CalOptima cannot fulfill our mission without you, and our mission of delivering quality health care to Orange County’s most vulnerable residents affects us all. We are Better. Together.
Sincerely,
Richard Pitts, D.O., Ph.D.
Chief Medical Officer
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CalOptima Board Approves $64 Million in Added Provider Support |
On June 2, CalOptima’s Board of Directors approved a Fiscal Year 2022–23 budget that amplifies financial support for Orange County’s provider community in a variety of ways. Effective July 1, hospitals, health networks and providers will receive extended supplemental funding for COVID-19 expenses, totaling $58.2 million for the year. Further, the agency is continuing to protect providers from $6 million in Medicare cuts, maintaining maximum reimbursement in programs serving seniors. Finally, CalOptima allocated $45.2 million for digital transformation efforts designed to streamline and improve interactions with the provider community.
The COVID-19 supplemental payment increase of up to 7.5% will fund efforts by CalOptima-contracted providers to promote and administer COVID-19 vaccinations, cover increased costs for testing and treatment, and help address additional variants of the COVID-19 virus. The payments will be made for a full year, from July 1, 2022, to June 30, 2023. The Board first approved supplemental payments in 2020 after recognizing the additional strain put on providers by the pandemic and the potential for interruption in necessary Medi-Cal services. This financial support also supports the health care safety net generally, given that CalOptima membership grew 23% during the pandemic to nearly 900,000.
“COVID-19 cases are fluctuating, and providers are continuing to grapple with the pandemic. CalOptima wants to support our partners with the resources they need to ensure quality care for our vulnerable member population,” said Michael Hunn, CalOptima Chief Executive Officer. “The supplemental funding will provide stability for the health care system as we prepare to transition out of the Public Health Emergency.”
CalOptima’s Medicare programs include OneCare (HMO SNP), OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) and the Program of All-Inclusive Care for the Elderly (PACE). The programs are subject to 2% federal cuts that total $6 million annually. The Board voted to protect providers from this reduction particularly during this time as CalOptima will transition approximately 14,500 members from OneCare Connect to OneCare on January 1, 2023. California is closing Cal MediConnect Plans as part of a larger initiative known as California Advancing and Innovating Medi-Cal (CalAIM).
Announced in March, CalOptima’s digital transformation is part of a new three-year strategic vision to deliver efficiencies for providers, including same-day treatment authorizations and real-time claims payment. CalOptima’s new budget allocates $45.2 million to this effort and signifies that the agency is moving forward with strengthening its systems on behalf of Orange County’s provider community. A few initiatives identified for the first year are provider portal enhancements, a provider data management system the integrates contracting and credentialling, and robotic process automation to better connect members to providers offering the services they need.
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Updated Facility and Medical Record Audit Criteria Now in Effect |
On July 1, the Department of Health Care Services (DHCS) will implement new tools and standards for scoring Facility Site Reviews (FSRs) and Medical Record Reviews (MRRs). CalOptima will use these updated standards when conducting FSR and MRR audits.
The changes to the FSR and MRR criteria cover subjects such as exit routes, emergency procedures, staff training, pharmaceutical services, infection control and sterilization. These updates align with local, state and federal guidelines for preventive services, as well as recommendations from the American Academy of Pediatrics, U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, and Advisory Committee on Immunization Practices.
For your convenience, CalOptima is sharing documents, presentations and videos of the new policies and DHCS trainings. These can be found at the links below:
Please review these documents with your staff and make any necessary modifications to your policies and procedures.
Providers with questions regarding the updated FSR and MRR standards can contact Kathryn Noyes, RN, BSN, PHN, Quality Improvement Manager, via email at knoyes@caloptima.org.
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OneCare Connect Transitioning to OneCare on January 1, 2023 |
OneCare Connect, CalOptima’s Cal MediConnect Plan (Medicare-Medicaid Plan) will end on December 31, 2022. At that time, all OneCare Connect members will transition seamlessly to OneCare, CalOptima’s Dual Eligible Special Needs Plan.
Here’s what members need to know:
- Members will automatically transition to OneCare on January 1, 2023.
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Members do not need to do anything to enroll in OneCare.
- Members will continue to receive benefits and will not have a gap in coverage. They will not have premiums, fees or deductibles to obtain health care services from providers.
- Members will be notified by mail about the transition, but providers can talk to them to ensure they know they will still be covered after the change.
OneCare has been a CalOptima program since 2005. It will continue to assist members with their health care needs and coordinate benefits, including medical care, home- and community-based services, medical supplies, and medications.
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Providers Must Resume Initial Health Assessments |
After a temporary suspension due to the COVID-19 Public Health Emergency (PHE), providers are again required to perform Initial Health Assessments (IHAs) for Medi-Cal members. After the PHE was declared in 2020, the IHA requirements were suspended retroactively to December 1, 2019. On October 1, 2021, DHCS stipulated that providers must resume performing IHAs.
Health plans are required to identify all members who enrolled since December 1, 2019, or who have not met the IHA requirements outlined in All-Plan Letter (APL) 20-004. Updated reports of members whose IHAs are still outstanding, or who enrolled after December 1, 2019, were sent to health networks for distribution to individual providers. If you have not received your file, please reach out to your network administration and ask for your member list.
For more information about completing an IHA, please see the IHA reference guide on CalOptima’s website under the Provider tab.
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Virtual Meeting Will Highlight HEDIS Measures and Audits |
Providers and office staff are invited to attend a virtual meeting about Healthcare Effectiveness Data and Information Set (HEDIS) measures and audits.
The 90-minute meeting will be held on GoToMeeting at noon on August 3, 2022. It will cover an overview of HEDIS, including pediatric, women’s, diabetic and adult measures. Providers will also receive a better understanding of hybrid measures, common chart deficiencies and the documentation required to meet National Committee for Quality Assurance quality of care standards.
To register, email imunoz@caloptima.org before August 1, 2022. Please include “HEDIS Training” in the email’s subject line.
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National Strategic Plan Lays Out Approaches for Treating Hepatitis |
The strategic plan lays out individual, community and structural approaches that include:
- Prevention through vaccination
- Screening for hepatitis B and hepatitis C
- Awareness of innovations in testing, including diagnostics
- Breaking down treatment barriers for patients with hepatitis B and hepatis C
When treating members with hepatitis, providers should document all coexisting conditions, underlying etiology and complications that affect your medical decision-making and the member’s care management, quality of life and treatment response. Elaborate on the member’s complete clinical picture during each episode of care. Please use the codes on this table when referencing the clinical evidence used as part of your decision-making.
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In the June Provider Update, CalOptima shared new DHCS requirements for discharge hours in all outpatient PACE claims. CalOptima is clarifying that the change, found in the most recent version of DHCS’ 837 Institutional Encounter Data Transaction companion guide, is referring to the Post-Adjudicated Claims and Encounter System when it says PACE.
For more information and to review the format for including the discharge hour, see Section 3.26 in the 837 Companion Guide here.
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APLs Gives Guidance on Non-Specialty Health Services, Housing and Homelessness Incentive Program, COVID-19 Testing and Treatment, and Cancer Biomarker Testing |
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As a result of the nationwide infant formula crisis, DHCS distributed a reminder on June 14, 2022, about Policy Letter 98-10, which mandates that managed care plans provide breastfeeding-related services, including promotion, education and counseling services.
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On June 27, 2022, DHCS released APL 22-010: Cancer Biomarker Testing, which provides information about coverage requirements for cancer biomarker testing, in accordance with Senate Bill 535.
- On June 30, 2022, DHCS informed managed care plans that the Proposition 56 Value-Based Payment (VBP) plan, allowing payments for meeting specific measures related to prenatal/postpartum care, early childhood preventative care, chronic disease management and behavioral care, ended effective June 30, 2022. The program was schedule to end December 31, 2022, but was terminated early due to legislative funding restrictions.
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Policies and Procedures Monthly Update |
Click on the link below to find an outline of changes made to CalOptima policies and procedures during June 2022. The full description of the policies below is available on CalOptima’s website at www.caloptima.org.
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Health Education: Trainings and Meetings |
Click below for a list of training webinars and links happening in July 2022:
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Based on Medi-Cal Bulletins and NewsFlashes, CalOptima has updated the procedure codes or relevant information for the subjects listed below:
- Update: Second Booster Dose for Select COVID-19 Boosters Now a Benefit
- Preventive Medicine Services Update for Initial and Periodic Preventive Medicine E&M Visits
- Updated LDCT Lung Cancer Screen Criteria
- Age Eligibility and Availability Revised for Cabenuva
- Policy Clarification for Select Rapid Whole Genome Sequencing Codes
- New Medi-Cal Benefit for Hepatitis B Vaccine
- Annual Cognitive Assessment Added as a Medi-Cal Benefit
- American Rescue Plan Act Postpartum Care Extension Program Has Replaced the PPCE
- Respiratory Supplies: Updates to the List of Medical Supplies Billing Codes, Units and Quantity Limits
- EWC Mammography Screening Age Restrictions Update
- Policy Update for Psychological and Psychiatric Services
- One-Time Injection Administration Fee Update
- National Correct Coding Initiative Quarterly Update for July 2022
- July 2022 Medi-Cal Provider “Coffee Break” Event
- August 2022 Medi-Cal Provider Training Webinars
- Postpartum Care Expansion for Medi-Cal and MCAP Beneficiaries
- Respiratory Supplies: Updates to the List of Medical Supplies Billing Codes, Units and Quantity Limits
- Fiscal Year 2021–22 Two-Week Checkwrite Hold for Specific Provider Payments
- HAP Client Eligibility System Updated to Capture Modality Used for Enrollment
- Antiretroviral Ibalizumab-uiyk Injection Available for Managed Care Plans
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- CalOptima Board of Directors: August 4 at 2 p.m.
- CalOptima Joint Provider and Member Advisory committees: August 11 at 8 a.m.
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Follow CalOptima on Social Media |
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CalOptima regularly posts on social media to engage members with heath tips, community resources, event dates, program updates and other pertinent information. Follow the agency on Facebook, Instagram, Twitter and LinkedIn.
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CalOptima, A Public Agency www.caloptima.org
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