Clinical Connections News for February 2024
Dear Colleagues,
WHA’s surveys reveal critical gaps in key ‘patient experience’ questions. For Medicare, please talk to your patients about ‘Fall Prevention Counselling’, address Urinary Incontinence’, and monitor ‘Physical Activity’. WHA patients say their doctor seems uninformed about lab results and specialty consults. Consider your ‘visit script’. State you are ‘reviewing the labs’ or state you are ‘reviewing the specialist consult.
To support clinical practice, WHA is expanding Virta for Type2 Diabetes Reversal, Livongo for Hypertension, Maven Maternity for pregnancy support, Kaia for virtual physical therapy, Quit for Life for smoking cessation, and Real Appeal for weight loss coaching. WHA’s programs through Optum Disease Management now include remote patient monitoring for CHF, COPD, Diabetes, and Asthma.
Looking forward to growing our robust partnerships in 2024
Khuram Arif M.D., MBA, CPE
Chief Medical Officer,
Chief Operating Officer,
Western Health Advantage
New 2024 WHA Programs Patient Handout
Download our new one-page handout, 2024 Program Highlights, to use with WHA patients, encouraging them to take advantage of these programs to support their care – from chronic condition support (hypertension, type 2 diabetes, asthma) to healthy lifestyles such as weight loss, nutrition, and smoking cessation. There’s also pregnancy, fitness, digital physical therapy and more.
- Print and share with WHA Patients: 2024 WHA Program Highlights
Pharmacy Update: Move to Premium Formulary
Beginning next year, WHA members will be transitioned from an open formulary to a new Premium Formulary. While there will be changes in the way WHA maintains and manages drug coverage, this enables WHA to align with industry standards, utilized by most payers, and should be familiar to our providers. The new formulary will introduce the concept of a formulary exclusion, where requests for drugs not included in WHA’s formulary must be submitted via an exception route. Additional information including updated drug lists, criteria, and member impact will be provided as that information becomes available.
Optum Behavioral Health: White Paper + Resources, Substance Use/Opioids
Substance Use Disorder (SUD) is a complex problem, but there are evidence-based treatment approaches that can be accessed to help your patients achieve and sustain recovery. Optum, our behavioral health partner, has published a white paper with strategies to effectively combat the rising human and financial tolls. They also provided links to materials to help improve patient outcomes, coordination of care, and tools to guide MAT, and documentation tips to help improve HEDIS scores.
- SUD white paper and the evidence-based treatment approaches
- Behavioral Health HEDIS Measures Summary for Primary Care (providerexpress.com)
- Treatment for Individuals with Substance Use Disorder (SUD) (providerexpress.com)
- Overview of MOUD & MAUD (providerexpress.com)
Prior Authorization (PA) Resources Help Reduce Denials
While our clinical providers focus on giving patients quality, evidenced-based care, certain clinical services may require prior authorization before a patient may receive the recommended service/care. Look to the Provider Portal to start accessing resources: WHA’s Utilization Management Program, Medical Treatment Guidelines, Prior Authorization, and Durable Medical Equipment Benefits Matrix. In addition, review and share with staff our Provider FAQs. The Benefit Matrix provides a list of services, benefit categories, indicators for prior authorization requirements, and a summary of coverage and/or non-coverage information. It’s important to note that prior authorizations are reviewed by your medical group. Some come to WHA from your medical group. At the medical group level, these can be denied or approved by the clinical teams. The groups use WHA-provided guidance, evidence-based guidelines, and the Benefits Matrix to make their determinations.
WHA’s Advantage Referral Program provides WHA members access to a broader group of specialists (from any of WHA’s medical groups, not just the one a patient’s PCP is in). Two important services under the Advantage Referral Services do not require a referral and/or prior authorization: an annual eye exam (when covered) and an annual Well Woman exam (with a pap smear, insertion, or removal of a birth control device/product, and other services) typically provided as part of the well-woman annual visit.
- Please ensure you/your staff have registered for the Provider Portal, can access the Advantage Referral Handbook, and are familiar with WHA’s members’ WHA's Advantage Referral program.
Care Manager Resource
WHA maintains a resource for Care Managers that identifies WHA’s wellness and chronic condition programs by plan, with links to member information you may share with patients. If you would like access to the resource, email WHA’s Health & Wellness Manager, Alicia Lowe.
New Vendor for our Nurse Advice Line
On Jan. 1, 2024, WHA transitioned our Nurse Advice (24-hour) hotline to Fonemed as a new vendor with a new phone number: 888-656-3574. This service allows WHA members to talk with a registered nurse 24/7 about any health issue. It complements other care options by providing 24/7 advice on minor injuries and illnesses. The registered nurses may also help explain prescription medications or interactions with other medications, and they refer them to the nearest in-network urgent care or ER.