Introduction
Gateway's success, as measured by the benefits received by the practitioners, members, the Centers for Medicare and Medicaid Services (CMS) 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 as 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.
Updates to the Gateway Health Plan Medicare Assured® Provider Office Policy and Procedure Manual can be found at our website: www.gatewayhealthplan.com. Click the link for Medicare Assured®.
Gateway Health Plan®, LP was established in late 1992 to provide a managed care option to Medical Assistance recipients in the Commonwealth of Pennsylvania.
In 2005, Gateway Health Plan® was awarded a contract by CMS to provide Medicare Part A, Part B and Part D services to dual eligible beneficiaries in Pennsylvania beginning January 2006. Gateway Health Plan® expanded into Ohio effective January 2007.
Gateway Health Plan®'s Medicare plan is called Gateway Health Plan Medicare Assured®.
Gateway Health Plan Medicare Assured® is a Medicare Advantage HMO Special Needs Plan for individuals with Medicare Part A, Medicare Part B and Medicaid (Full Medicaid or Qualified Medicare Beneficiary (QMB).
Gateway is dedicated to providing benefits to the Medicare and Medicaid populations to meet their medical and social needs. The specific needs of our membership have led to Gateway's development of wellness, education and outreach programs to improve immunization compliance, to identify high-risk pregnant women, and to provide effective case management for members with chronic conditions such as Asthma, Diabetes, chronic heart conditions, and HIV/AIDS.
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 that ensures the availability of high quality medical care for the Gateway member, based upon access, quality and financial soundness.
Gateway is a "win-win" situation for all: the member, the practitioner and applicable state or federal agencies.
Benefits to the Gateway Health Plan Medicare Assured® Member:
In addition to receiving added benefits currently not covered by Medicare, Gateway members enjoy improved access to primary medical care, health and wellness programs and 7-days a week assistance from Gateway's Member Services Department.
Benefits to the Practitioner: Timely payments, simplified administrative procedures and dedicated provider servicing are benefits of being a Gateway Health Plan Medicare Assured® practitioner.
Benefits to Gateway: Gateway benefits by fulfilling our mission, which ensures the availability of high quality medical care for the dual eligible population to positively affect the personal health of our members.
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 Health Plan Medicare AssuredSM in no way precludes participation in any other program by the practitioner.
The definition of a primary care practitioner is a "specific practitioner or practitioner group 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 member."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 the member's care must be provided or referred (a paper referral form is not required) 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.
Gateway Health Plan Medicare Assured® provides coverage for outpatient mental health services for its Pennsylvania and Ohio membership through Community Behavioral Healthcare Network of Pennsylvania (CBHNP).
Please call CBHNP to access a participating network provider in the member's area.
Also, if you have a member who needs additional assistance in accessing an outpatient mental health provider or has questions, please direct the member to call CBHNP.
(Refer to the Quick Reference section in this manual for the appropriate telephone number.)
Gateway Health Plan® has a comprehensive policy for handling the prevention, detection and reporting of fraud and abuse. It is Gateway's policy to investigate any action by members, employees or practitioners that affects the integrity of Gateway and/or the Medicare Program.
As a participating practitioner with Gateway, the contract that is signed requires compliance with Gateway's policies and procedures for the detection and prevention of fraud and abuse. Such compliance may include referral of information regarding suspected or confirmed fraud or abuse to Gateway and submission of statistical and narrative reports regarding fraud and abuse detection activities.
If fraud or abuse is suspected, whether it is by a member, employee or practitioner, it is your responsibility to immediately notify Gateway.
It is Gateway's policy to discharge any employee, terminate any practitioner or recommend any member be withdrawn from the Medicare Program who, upon investigation, has been identified as being involved in fraudulent or abusive activities.
Some common examples of fraud and abuse are:
- Billing for services not rendered
- Billing for supplies not being purchased or used
- Billing more than once for the same service
- Dispensing generic drugs and billing for brand name drugs
- Falsifying records
- Performing inappropriate or unnecessary services
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.
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 and behavioral health care, drug and other health care 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 health care, and b) chronic health care 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 health care 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 health care 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, measure the impact and effectiveness of the program 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 health care resources, quality of care, and access to services;
- Based on assessment of the population, develop and update guidelines that address key health care 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, determine barriers and 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 health care.
Review results for barriers, opportunities and apply interventions to increase satisfaction and to improve the quality of care and services provided;
- To involve actively practicing physicians in the development and approval of utilization management criteria and operational policies and procedures, including initial and continued authorization of services to ensure written protocols for utilization review are based on current standards of medical practice;
- To continually monitor and update criteria to ensure that relevant, current criteria are consistent with standards of medical practice used to make appropriate utilization management decisions;
- To maintain utilization at or below target levels while maintaining a high quality of care and service for all Gateway members and employ mechanisms to detect both under and over utilization of services.
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 health care 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 Health Care 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. (Refer to the Quick Reference section in this manual for phone number.)
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, Cardiac Medical Management, Child Preventive Care, Diabetes 2005 ADA, Hypertension, Lead Screening and Follow-up Guideline, Management of the Patient with Asthma, Routine and High Risk Prenatal Care and Primary Care Physicians Treating Depression. Also located in the Quality Improvement Manual are Gateway's Medical Record Review Standards. To facilitate distribution of the most current version of these guidelines and standards, 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. Health care errors can occur at any point in the health care delivery system and can be costly in terms of human life, function, and health care dollars. There is also a price in terms of lost trust and dissatisfaction experienced by both patients and health care 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 or "close calls" 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.jointcommission.org/PatientSafety/NationalPatientSafetyGoals
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
Medical Record Reviews Gateway performs several different medical record reviews
to:
- Help ensure quality services are provided
- Allow for proper disease management
- Respond to regulator’s requests
- Facilitate accurate and complete data is sent to CMS
- Allow for proper risk scoring by CMS of each member
Complete and accurate coding is essential for Gateway to accomplish the above objectives
and our mission.
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 December 1, 1991.
The Patient Self-Determination Act applies to hospitals, nursing facilities, providers of home health care 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 the Gateway Health Plan Medicare Assured® 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 should ask members age 21 and older whether they have executed an advance directive and document the response.
Providers will receive educational material regarding member's rights to advance directives upon entering the Gateway practitioner network.
Gateway practitioners can request assistance from the Preventive Health Department to provide additional education to members who need further explanation on such issues as the importance of keeping scheduled appointments.
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 Health Plan® 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 Preventive Health Department at 1-800-685-5212 for Pennsylvania providers or 1-888-447-4506 for Ohio providers, and press option 4. You can also fax the Member Outreach Form to the fax number listed on the Form.
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