Introduction

• About This Manual
• Overview of Gateway Health Plan
  • History
  • Mission
  • Prospective Care Management
  • Gateway Lines of Business
  • Membership/Network
  • Quality Accomplishments
  • Continuing Quality Care
  • Wellness and Disease Management
  • Healthcare Disparities
  • Community Involvement
  • Awards and Honors
• How Does Gateway Work?
  • Gateway’s Practitioner Network
  • Gateway Provider Relations Role
  • Primary Care Practitioner’s Role
• Department of Public Welfare Master Provider Index Number
• Contracts/No Gag Clause
• Quality Improvement
  • Purpose of the Quality Improvement/Utilization Management Program
  • Goal of the Quality Improvement/Utilization Management Program
  • Objective of the Quality Improvement/Utilization Management Program
  • Scope of the Quality Improvement/Utilization Management Program
  • Quality Improvement Manual
• Patient Safety
• Living Will Declaration
  • Advance Directives
• Member Outreach

Gateway Health Plan's^® (“Gateway”) success, as measured by the benefits received by the practitioners, members, Commonwealth of Pennsylvania and Gateway, is dependent upon strong educational processes. Understanding Gateway’s policies and procedures is essential. Gateway’s Provider Relations, Provider Services, Member Services, and Member Outreach staff, among others, is committed to providing accurate, up-to-date, and comprehensive information to our member and practitioner populations through prompt and dedicated service. The Provider Office Policy and Procedure Manual is one way of providing participating practitioner offices with information regarding Gateway’s policies and procedures. This manual should be considered a general guideline for practitioner offices. The manual is a ready reference and is designed to be updated as needed. Please retain all updates with your manual.

This Manual and any updates can also be found at our website under the Pennsylvania Medicaid/Provider/Reference section: www.gatewayhealthplan.com.

Overview of Gateway Health Plan^®

In 1992, Gateway Health Plan^®, Inc. was established as an alternative to Pennsylvania’s Department of Public Welfare’s Medical Assistance Program. For more than 15 years, members have benefited from services such as disease management, health and wellness programs and preventive care. Today, Gateway Health Plan^® is a top-ranked managed care organization that provides service to more than 255,000 members eligible for medical assistance. Gateway Health Plan Medicare Assured^®, a Special Needs Plan for those eligible for both Medicare and Medicaid, is one of the nation’s largest Medicare programs for the dual-eligible population.

Gateway Health Plan^® emphasizes the development and delivery of innovative programs to positively affect the personal health of its members.  Gateway Health Plan^® maintains a healthcare delivery system which ensures the availability of high quality medical care for Gateway Members based upon access, quality, and financial soundness.

Gateway’s goal is to help improve the health and well-being of its members. In an ongoing effort to accomplish this goal, Gateway developed Prospective Care Management (PCM^®), a proactive holistic approach to healthcare. By identifying the Behavioral, Environmental, Economic, Medical, Social, and Spiritual (BEEMSSSM) issues a member faces, Gateway can design a plan to ensure that the member receives the care he or she needs.

Gateway offers two products:

• Medicaid HMO available in Pennsylvania
• Medicare Special Needs Plan available in Pennsylvania

Unlike many health insurance companies, Gateway focuses entirely on serving the needs of the most vulnerable citizens - the poor, elderly and disabled. Since its inception, Gateway has focused on providing the best possible healthcare to a growing number of Medicaid members. Gateway offers care for all kinds of health needs – everything from regular doctor visits to emergency care.

In January 2006, Gateway expanded its services to include a Medicare approved Special Needs Plan, Gateway Health Plan Medicare Assured^®. This program is available to individuals who have both Medicare and Medicaid. As of January 2008, Gateway Health Plan Medicare Assured^® is available to individuals in 27 counties in Pennsylvania and 12 counties in Ohio – making it one of the largest plans of its kind in the country. Gateway offers the following benefits to members enrolled in Medicare Assured^®.

• All the benefits of Original Medicare
• No monthly premiums
• Prescription drug coverage
• Hearing and vision benefits
• Health and wellness education, such as heart disease, diabetes and asthma programs and smoking cessation
• Fitness Assured^®, a fitness program to help members stay active
• Transportation

Gateway Health Plan^® serves more than 255,000 members. Gateway Health Plan Medicare Assured^® has more than 24,000 members in Pennsylvania. Gateway’s provider network includes more than 8,000 healthcare providers, over 100 hospitals, a network of pharmacies, home healthcare agencies and other related healthcare providers.

Gateway Health Plan^® holds an ‘Excellent’ rating from the National Committee for Quality Assurance (NCQA), an independent agency that accredits and certifies managed care organizations, for its Medicaid HMO product. This rating is only awarded to those health plans that meet or exceed NCQA’s rigorous requirements for consumer protections and quality improvements. Gateway’s ‘Excellent’ rating indicates the strength of the health plan’s overall member focus, from efficient and timely claims processing to assisting its members in receiving the care they need. In 2000, Gateway became the first Medicaid health plan to receive NCQA’s ‘Excellent’ accreditation and was the first to repeat that level of accreditation in 2006 and 2009.

Gateway Health Plan^® is proud to be recognized with a five-star “Excellent” Member Quality Rating from the 2008 CAHPS^® Survey. This rating is based on how Gateway members rated Gateway’s overall quality in the survey. This honor is the result of passion, a commitment to excellence, and the dedication of a compassionate staff. Our work is a reflection of our guiding principles and our mission to distinguish ourselves as the health plan with superior quality and service.

Healthcare is an ever-changing field and Gateway strives to stay on top of its members’ needs. Gateway is committed to continuous improvement and providing high standards of quality in every aspect of service. This commitment is led by Gateway’s 18-member Quality Improvement/Utilization Management committee, made up of experts in a wide variety of medical fields. The QI/UM Committee evaluates Gateway’s ongoing efforts as well as new protocols and clinical guidelines in order to improve services and care for its members.

Gateway is committed to improving the life of its members and working to find new ways to promote wellness, illness prevention and health education as demonstrated by the following programs:

• Preventive healthcare guidelines
• Free quit tobacco program
• Pediatric and adult immunization reminders
• Cardiac disease prevention program
• Free personalized programs to assist patients with diabetes, asthma and depression

Gateway understands that in order to help improve the quality of life of our members, we must take into account their cultural and linguistic differences. For this reason, addressing disparities in healthcare is high on our leadership agenda. We believe a strong patient-provider relationship is the key to reducing the gap in unequal healthcare access and healthcare outcomes due to cultural and language barriers. Gateway is continuously working to close the gap in health outcomes by focusing on education and prevention. One example of how we are working to close the quality gap can be seen in our culturally sensitive diabetes disease management programs. In order to improve information based interventions at the point of care, Gateway pays for Primary Care Practitioners to perform in office HbA1c tests. Test results are available in five minutes and can be administered by a non-clinician. For more information, please contact your Provider Relations Representative. In addition, Gateway has cross-cultural education programs in place to increase awareness of racial and ethnic disparities in healthcare among our employees, members and providers.

Gateway is an active partner in the community through many outreach and community based activities. Gateway strives to improve the health and quality of life of its members as well as the community-at-large.

• Gateway participates in community events and sponsorships and provides assistance to community and social agencies that also serve a high-risk, vulnerable population.
• Gateway continually develops a variety of outreach programs for adults and children to provide education on health, wellness and safety issues. These programs are offered to the community at no cost.
• Gateway informs and partners with individuals and organizations through the Health Literacy Initiative. The goal of the initiative is to develop and implement programs that positively impact health and well-being by helping people better understand and navigate the healthcare system.

For the fourth consecutive year, Gateway Health Plan^® was named one of “America’s Best Health Plans” and ranked among the “Top 20” of all Medicaid health plans in the nation, according to U.S.News & World Report and the National Committee for Quality Assurance (NCQA). The most recent report dated November 7, 2008 ranked Gateway Health Plan^® No.19 nationally and second in Pennsylvania. In 2009, Gateway was recognized by the Disparities Solution Center at Massachusetts General Hospital for innovation and success in addressing healthcare disparities. The rankings are testament to Gateway’s continued exemplary performance as a top-ranked Medicaid plan.

How Does Gateway Work?

Gateway contracts directly with primary and specialty care practitioners, hospitals, and ancillary providers to provide care for our membership. Practitioners and other healthcare providers are chosen in such a manner that existing patterns of care, including patterns of hospital admissions, can be maintained. Participating practitioners treat patients in their offices as they do their non-Gateway patients, and agree not to discriminate in the treatment of or in the quality of services delivered to Gateway’s members on the basis of race, sex, age, religion, place of residence, or health status. Because of the cultural diversity of our membership, participating practitioners must be culturally sensitive to the needs of our members. Participation in Gateway in no way precludes participation in any other program with which the practitioner may be affiliated.

We are keenly aware that, to provide exceptional access and quality of healthcare to our members, it is essential that our providers and their staff have a solid understanding of the member’s needs, our contract requirements and other protocols, as well as applicable contract standards and Federal and/or State regulations.

Within 30 calendar days of successful completion of provider credentialing and approval to participate in our network, our Provider Relations Department provides introductory training to providers and their office staff. The Provider Manual is delivered and reviewed in detail at this on-site orientation. This provider training familiarizes new providers and their staff with Gateway’s policies and procedures.

Each participating primary care practice, specialty care practice and hospital is assigned a Provider Relations Representative, who is responsible for ongoing education in their assigned Service Region. As a follow-up to the initial orientation session, the assigned Provider Relations Representative regularly contacts each provider and their staff to ensure that they fully understand the responsibilities outlined in the Provider Agreements and Manual.

The definition of a primary care practitioner is a “specific practitioner, practitioner group or a CRNP operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, and providing primary care services; locating, coordinating, and monitoring other medical care and rehabilitative services and maintaining continuity of care on behalf of a Medical Assistance Consumer.” The primary care practitioner is responsible for the coordination of a member’s healthcare needs and access to services provided by hospitals, specialty care practitioners, ancillary services and other healthcare services.

Although members may obtain some healthcare services by self-referral, the majority of their healthcare services are obtained either directly from or upon referral by the primary care practitioner. With the exception of self-referred services, all of the member’s care must be provided or referred by the primary care practitioner except in a true medical emergency when time does not permit a member to contact their primary care practitioner. To ensure continuity and coordination of care, when a member self-refers for care, a report should be forwarded to the primary care practitioner. By focusing all of a member’s medical decisions through the primary care practitioner, Gateway is able to provide comprehensive and high quality care in a cost-effective manner.

Our goal is to work together with a dedicated group of practitioners to make a positive impact on the health of our membership and truly make a difference.

All network practitioners are required to have a Department of Public Welfare issued identification number and must adhere to PA Code 55, Chapter 1101. If a practitioner would like a copy of PA Code 55, contact Gateway’s Provider Services Department at 1-800-392-1145. The Office of Medical Assistance Programs (OMAP) may be contacted to obtain a Master Provider Index (MPI) Number at (717) 772-6140 from 8:00 AM to 12:00 PM, or leave a message at anytime at (717) 772-6456. Information about the Department of Public Welfare Office of Medical Assistance Programs may also be found on the Internet at www.dpw.state.pa.us.

Gateway allows open practitioner-patient communication regarding appropriate treatment alternatives without penalizing practitioners for discussing medically necessary or appropriate care for the patient. All of Gateway’s contracts with practitioners and providers include an affirmative statement indicating that the practitioner can freely communicate with patients regarding the treatment options available to them, including medication treatment options available to them, regardless of benefit coverage limitations. There is no language in Gateway’s contracts that prohibits open clinical dialogue between practitioner and patient.

Quality Improvement

The Quality Improvement/Utilization Management (QI/UM) Program’s purpose is to ensure the quality, appropriateness, timeliness, availability and accessibility of care and service provided to Gateway members. A complete review and assessment of care, demographic/household, and community data, along with current scientific evidence, is key in understanding members and developing programs to meet the member’s needs. The development of health programs must be done with the aid of partners including members, practitioners, community agencies, regulators, and Gateway staff, not only to meet the current needs of the member, but also to begin to address the future needs of the member. Necessary to the success of these programs is the development of meaningful data and measurement to assess the improvements in the quality of care and to identify where opportunities may exist.

The QI/UM Program focuses on reviewing medical care, drug and other healthcare services and improving the quality of care and service by monitoring and evaluating the correctness of care provided by Gateway’s practitioners. Quality Improvement methods are used to measure and improve care and service, member satisfaction, and performance. Of specific importance, the QI/UM Program focuses on two key areas: a) preventive healthcare, and b) chronic healthcare conditions. The Program attempts to improve members’ compliance with preventive guidelines and those treatments that are important to the success of managing chronic conditions. Also, the QI/UM Program aims to improve patient safety by educating members and practitioners in regard to safe practices and by assessing and identifying opportunities to improve patient safety throughout the practitioner/provider network.

By reviewing population demographics and health risks, use of healthcare resources, and financial analysis, Gateway ensures that the major membership groups are represented in QI/UM activities and health programs chosen for assessment and monitoring. This information, along with high-volume/high-cost medical and pharmaceutical/drug reports, health risk appraisal data, disease/illness management and case management data, satisfaction survey information, and other usage reports, is used to identify members with special needs and/or chronic conditions to develop programs and services to assist in managing their condition.

The objectives of the QI/UM Program are similar to Gateway’s mission, committing to effective use of healthcare resources, and to continuous quality improvement. To ensure that the current needs of the population are being reviewed, changes noted, programs implemented to address the needs of members, and to ensure continuous quality improvement, an annual QI/UM Work Plan is developed. The QI/UM Program is assessed on an annual basis to determine the status of all activities and identify opportunities that meet the QI/UM Program objectives.

Objectives are as follows:

Implement a QI/UM Work Plan that identifies and assures completion of planned activities for each year:

• Ensure processes are in place using Total Quality Management values to assess, monitor, and implement actions when opportunities are identified regarding the utilization of healthcare resources, quality of care, and access to services;
• Based on assessment of the population, develop and update guidelines that address key healthcare needs, which are based on scientific evidence and recommendations from expert and professional organizations and associations;
• Conduct studies to measure the quality of care provided, including established guideline studies, evaluate improvements made, barriers, opportunities and develop actions to address those opportunities;
• Conduct studies to measure the quality of care provided, including established guideline studies, evaluate improvements made, barriers, opportunities and develop actions to address those opportunities;
• Evaluate the utilization and quality performance of Gateway practitioners and vendors to assure Gateway standards are met and to identify both opportunities and best practices. In a group effort with practitioners and vendors, identify barriers, opportunities and apply interventions as needed;
• Conduct satisfaction surveys to determine member and provider satisfaction with Gateway services, organizational policies, and the provision of healthcare. Review results for barriers, opportunities and apply interventions to increase satisfaction and to improve the quality of care and services provided.

Implementation and evaluation of the QI/UM program is embedded into Gateway’s daily operations. The QI/UM Program has available and uses appropriate internal information, systems, practitioners, and community resources to monitor and evaluate use of healthcare services, the continuous improvement process and to assure implementation of positive change.

The scope of the Program includes:

• Enrollment
• Members’ Rights and Responsibilities
• Network Accessibility and Availability, including those related to Special Needs
• Network Credentialing/Recredentialing
• Medical Record Standards
• Member, Provider and Employee Education
• Member and Provider Services
• Claims Administration
• Fair, Impartial and Consistent Utilization Review
• Evaluating the Healthcare Needs of Members
• Preventive Health, Disease Management, and Case Management Services
• Clinical Outcomes
• Oversight of Delegated Activities
• Patient Safety
• Continuous Quality Improvement using Total Quality Management Principles

To request a copy of the Quality Improvement Program, Work Plan or Annual Evaluation please contact Gateway’s Provider Services Department at 1-800-392-1145.

The Quality Improvement Manual is designed as a resource to assist practitioners in caring for Gateway members. The manual consists of guidelines that are developed using evidence-based clinical guidelines from recognized sources or through involvement of board-certified practitioners from appropriate specialties when the guidelines are not from recognized sources. The guidelines are evaluated on an ongoing basis and are developed based on the prevalent diseases or conditions of Gateway members. The use of guidelines permits Gateway Health Plan^® to measure the impact of the guidelines on outcomes of care and may reduce inter-practitioner variation in diagnosis and treatment.

Clinical guidelines are not meant to replace individual practitioner judgment based upon direct patient contact. The manual consists of an introductory page, along with the following guidelines: Adult HIV Clinical Practice Guideline, Adult Preventive, Care of Adults with Diabetes Mellitus, Child Preventive, Cardiac Medical Management, Hypertension, Lead Screening and Follow-up Guideline, Management of the Patient with Asthma, Medical Record Review Procedure, Prenatal Care and Primary Care Physicians Treating Depression. To facilitate distribution of the most current version of these guidelines, they have been added to Gateway’s web site at www.gatewayhealthplan.com. A paper copy of the Quality Improvement Manual and individual guidelines are available upon request. For a paper copy, please contact the Quality Improvement Department at 412-255-1144.

Patient safety is the responsibility of every healthcare professional. Healthcare errors can occur at any point in the healthcare delivery system and can be costly in terms of human life, function, and healthcare dollars. There is also a price in terms of lost trust and dissatisfaction experienced by both patients and healthcare practitioners.

There are ways practitioners can develop a Patient Safety Culture in their practice. Clear communication is key to safe care. Working in collaboration with members of the multidisciplinary care team, hospitals, other patient care facilities and including the patient as an important member of his care team are critical. Examples of safe practices include providing instructions to patients in terms they can easily understand, writing legibly when documenting orders or prescribing, and avoiding abbreviations that can be misinterpreted. Read all communications from specialists and send documentation to other providers, as necessary, to assure continuity and coordination of care. When calling orders over the telephone, have the person on the other end repeat the information back to you.

Collaborate with hospitals and support their safety culture. Bring patient safety issues to the committees you attend. Report errors to your practice or facility’s risk management department. Offer to participate in multidisciplinary work groups dedicated to error reduction. Ask Gateway’s Quality Improvement Department how you can support compliance with our safety initiatives.

Gateway also works to ensure patient safety by monitoring and addressing quality of care issues identified through pharmacy utilization data, continuity and coordination of care standards, sentinel/adverse event data, Disease Management Program follow-up, and member complaints.

If you would like to learn more about patient safety visit these web sites:

Institute of Medicine report: To Err is Human-Building a Safer Health Care System
http://www.nap.edu/books/0309068371/html
JCAHO National Patient Safety Goals 
http://www.jcaho.com/accredited+organizations/patient+safety/npsg.asp
National Patient Safety Foundation
http://www.npsf.org
The Leapfrog Group for Patient Safety
http://www.leapfroggroup.org
Agency for Healthcare Research and Quality
http://www.ahrq.gov

Living Will Declaration

Advance Directives

The Omnibus Budget Reconciliation Act (OBRA) of 1990 included substantive new law that has come to be known as the Patient Self-Determination Act and which largely became effective on Dec 1, 1991.

The Patient Self-Determination Act applies to hospitals, nursing facilities, providers of home healthcare or personal care services, hospice programs and health maintenance organizations that receive Medicare or Medicaid funds. The primary purpose of the act is to ensure that the beneficiaries of such care are made aware of advance directives and are given the opportunity to execute them if they so desire. It is also to prevent discrimination in care if the member chooses not to execute advance directives.

As a participating provider within Gateway’s network, you are responsible for determining if the member has executed an advance directive and for providing education when it is requested. You can also request a copy of a “Living Will” form from the Quality Improvement Department by calling 412-255-1144. There is no governmentally mandated form. A copy of the “Living Will” form should be maintained in the medical record. Gateway’s Medical Record Review Standards state that providers ask members age 21 and older whether they have executed advance directives and will document the response.

Providers will receive educational material regarding member’s rights to advance directives upon entering the Gateway practitioner network.

Member outreach or advance directive forms are made available through Gateway’s Member Handbook and Member Newsletter, or by visiting Gateway’s website at www.gatewayhealthplan.com.

Gateway’s Member Outreach activities help members better understand their healthcare benefits and to appropriately access services within a managed healthcare plan. Gateway practitioners can request assistance from the Member Services Department to provide additional education to members who need further explanation on such issues as the importance of keeping scheduled appointments, obtaining referrals for specialty care and utilizing the emergency room appropriately.

Practitioners can refer non-adherent members for additional education regarding their benefits and services by completing a Member Outreach Form, which can be found in the Forms and Reference Material Section of this Manual. A Gateway representative will contact the member and follow-up with the practitioner at the practitioner’s request.

For more information or to request member outreach, please call Gateway’s Care Management Department at 1-800-642-3550, press option 4. You can also fax the Member Outreach Form to the fax number listed on the Form.