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Provider Outreach: Meet the Provider Relations Team
MCHO has a dedicated team supporting our provider partners from the initial contracting credentialing process and beyond. We will be highlighting a member of the team in each of the next few editions of the newsletter so you can get to know us better.
Lisa Dionne joined Maine Community Health Options' Provider Relations Team in May of 2014, bringing nineteen cumulative years of medical experience.
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Provider Spotlight
Elliot Health System is a nonprofit organization serving the healthcare needs of the community
since 1890. The largest provider of comprehensive health care services in southern New
Hampshire, Elliot Hospital, a 296-bed acute care facility and the first community hospital in the
state, serves as the cornerstone of the health system.
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MCHO Partners with MMC Physician-Hospital Organization's Behavioral HealthCare Program
Maine Community Health Options (MCHO) and MMC Physician-Hospital Organization Behavioral HealthCare Program (BHCP) have partnered to create a new model of behavioral healthcare delivery that leverages BHCP's broad New England-wide network of Providers and expertise to provide integrated behavioral healthcare services to MCHO Members.
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A Request for Medical Records
As a qualified health plan on the exchange, subject to NCQA accreditation, Maine Community Health Options (MCHO) must participate with the Healthcare Effectiveness Data and Information Set (HEDIS) measurement project. Starting in March 2015, MCHO will request a sample of health plan Member medical records for the "Controlling High-Blood Pressure" HEDIS measure. In 2016, MCHO will collect additional HEDIS measures, a list of which will be provided later this year.
In addition to the HEDIS program, MCHO must also participate in a Risk Adjustment Data Validation (RADV) project administered by CMS. As part of the RADV project, MCHO will request medical records for 200 MCHO Members. CMS will select the Members whose medical records MCHO must retrieve. The requests for medical records for the RADV project are slated to begin in July 2015.
As an MCHO Provider, you could receive a letter on behalf of MCHO requesting a patient's medical record information. MCHO appreciates your participation in these projects. If you have any questions, please call Provider Relations at (207) 402-3347.
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Important Information for Providers
Maine Community Health Options (MCHO) provides our Members a Rights and Responsibilities document annually. We believe you should also have a copy of this document, which is available in the MCHO Provider Manual.
In early 2014, MCHO shared with you a few nationally-recognized practice guidelines to follow when providing care to patients. The following guidelines can be found through the Health Portal: (1) Asthma guidelines (2) Diabetes guidelines, and (3) Preventive Care guidelines.
MCHO continues to offer our Members a Disease Management Program to help them manage a chronic illness such as Diabetes and Asthma. You can refer Members to our Disease Management Program if you believe the program may help. The Provider Manual Contains more information about this program and how to make a referral.
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Chronic Illness Support Program Expanded to Include Coronary Artery Disease
Maine Community Health Options (MCHO) has identified a fifth major chronic condition to add to our value-based insurance design for 2015. Coronary Artery Disease now joins Asthma, Chronic Obstructive Pulmonary Disease, Diabetes, and Hypertension, as conditions for which we have reduced Members' out-of-pocket costs to make routine management- office visits, medications, lab tests, self-management classes, equipment, and supplies- less costly and therefore financially feasible.
Cost-sharing for disease management under our Chronic Illness Support Program is significantly reduced, compared to benefits and coverage for products that do not include this program. The program is designed to save both lives and money by reducing emergency department (ED) visits and potentially avoiding hospitalizations. The ultimate success of this approach will be in the utilization numbers over the long term.
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Utilization Management (UM) Now
In-House
Maine Community Health Options (MCHO) is excited to announce that we have successfully transitioned our UM operations to our Lewiston office beginning January 1, 2015. MCHO staff is now managing all of our utilization review operations. The local presence provides the UM professionals with clear insight into challenges commonly faced by our Provider community and gives them the opportunity to build solutions with you, our Providers.
Our team of nurses and UM liaisons have extensive clinical and UM experience that enriches our ability to determine medical necessity. In addition to our experience, we use MCG clinical guidelines, nationally recognized for their evidence-based approach. Our experience and local presence, combined with our clinical guidelines, will better inform our discussions with our Providers requesting medical services. The UM team also partners closely with MCHO's Care Management team to ensure our Members are fully supported.
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