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a publication of the oklahoma health care authorityspring issue 2007SoonerCare Announces Disease ManagementProvider ConferencesThe SoonerCare Disease ManagementProgram of OHCA will be invitingcommunity health care leaders tocollaborative conferences to promotepartnership with the provider community.The conferences will introduce theSoonerCare Disease ManagementProgram to provide and reinforce evidencebased guidelines for the treatment ofSoonerCare members with chronic healthconditions while also offering a forum todiscuss patient self-management initiatives.OHCA is bringing together providerswho are dedicated to improving chronicand preventive care to share innovationsand ideas with colleagues across the statein an innovative collaborative format.(Continued on Page 3)OHCA Expands NutritionalCounseling Programin this issueOHCA is expanding its nutritional counseling programin an effort to address the problem of obesity and theoverall poor health of Oklahomans. “As an agency, wehave felt that with the high percentage of the populationfacing obesity and diabetes, two hours of counseling wasnot sufficient,” said Mike Herndon, D.O., of OHCA’smedical review and disease management unit.Anyone who has an illness or condition for whichnutritional therapy is indicated will be covered for sixhours of nutritional counseling. “Our plan is to expandthe program to cover six hours of counseling – forexample, a member could attend a one-hour initial sessionwith 10 subsequent 30-minute follow-up sessions,”Herndon explained. “I believe the members who willbenefit most from this program are those with diabetes,high cholesterol or coronary artery disease as well asthose who are morbidly obese.”(Continued on Page 4)Clinical News2 OHCA to Offer Coverage of Bariatric Surgery4 OHCA and OSU-OKC Take CNA TrainingProgram Statewide6 SoonerPsych Program Helps Contain Costs,Improves Prescribing Practice6 Prior Authorization Starts at the Pharmacy7 Skeletal Muscle Relaxants: Their Place in Therapy7 ePocrates Introduces New Mobile Features10 OHCA Receives Award of ExcellenceClaims / Systems News5 Secure E-mail Now Available5 Did You Know?9 Provider Services Department Offers Assistance11 NPI Required for All Contracts
ohca provider update 2spring 2007OHCA to Offer Coverage of Bariatric SurgeryStarting later this year, OHCA willoffer coverage of bariatric surgery toqualified SoonerCare members.Mike Herndon, D.O., of OHCA’smedical review and diseasemanagement unit, researchedcovering surgery as a treatmentfor obesity. Herndon found thatbariatric surgery was the best andmost effective long-term treatmentfor morbidly obese patients withcertain co-morbid conditions. “I feltthe evidence was overwhelmingly infavor of surgery,” he said.Herndon also found thatproperly identifying the appropriatecandidates, as well as the surgeonsand facilities, are all key componentscontributing to patients’ success.OHCA plans to carefully selectSoonerCare members for surgeryand will require the facility tomeet certification and eligibilityrequirements before they can providethe service. Surgical providers mustbe certified by either the AmericanCollege of Surgeons (ACS) as aLevel I Bariatric Surgery Center orthe American Society for BariatricSurgery as a Bariatric Surgery Centerof Excellence (BSCOE).Members interested in bariatricsurgery will participate in a thoroughprior authorization process.This process is made up of threemain steps: determining if themember is an appropriate candidate;successfully completing a six-monthpresurgical program of mental,physical and nutritional evaluations;and attaining approval based on thepresurgical program.Certain criteria help determine if amember is an appropriate candidate.Members must have tried and failedother weight loss methods, must havebeen obese for five or more yearsand cannot have any contra-indicatedhealth concerns. Members must alsobe between 18 and 65 years old andhave a Body Mass Index (BMI) over35 and an additional diagnosis ofdiabetes, degenerative joint diseaseof a significant nature or another comorbid condition requiring surgery.Members cannot be pregnant orplan to become pregnant within twoyears. Members younger than age18 would need additional case bycase review. Documentation of thecandidate meeting these criteria mustbe submitted by their physician toOHCA for review and approval.If approved, the member willparticipate in a presurgical programcomposed of a psycho-socialevaluation, assessments by a qualifiedbariatric surgeon and internalmedicine physician,a six-month weight loss program,nutritional counseling and aphysician-supervised exerciseprogram documenting progress ona monthly basis. After completing thepresurgical program, documentationis reviewed by OHCA for approval.The data on bariatric surgerystrongly supports this extensiveapproach to patient selection. Thisapproach improves surgical outcomes(Continued on Page 3)
ohca provider update 3spring 2007OHCA to Offer Coverage of Bariatric Surgery (continued from page 2)by preparing patients to adhere to theradical and lifelong behavior changesand strict diet required after surgery.Due to research findings that theRoux-en-Y gastric bypass (RYGBP)had better long-term results, OHCAis establishing the RYGBP as theprocedure of choice unlessa physician shows convincingevidence that a particular patientwould be better served throughanother procedure.The decision by OHCA to extendcoverage to include bariatric surgeryfor qualified members closely mirrorsthat of CMS. OHCA is currently inthe process of setting up systems forpayment and educating providersabout this new coverage.For questions regarding priorauthorization of services, call 800522-0114, option 6; for questionsregarding whether a provider cancontract or if a contract has beenaccepted, call 800-522-0114, option5; or for questions regarding programpolicy, call 877-823-4529.SoonerCare Announces Conferences(continued from page 1)OHCA plans to invite about 700SoonerCare providers to be a partof the “kick-off” conference, and 15to 30 providers to participate in eachregional collaborative. Providers,clinic managers and clinical staff areexpected to attend.OHCA will sponsor one statewideconference later this year andnine regional collaboratives in thefollowing 12 months. These smallerregional collaboratives will be ameans of continued OHCA supportto practice teams.The collaboratives will seekto develop regional clinicalchampions armed with the tools andinformation needed to ignite thechange process within their clinicsand facilities. These leaders willassemble implementation teams.Once the teams are established atthe provider level, momentum andcommunication will be sustainedby the regional practice facilitatoruntil the next collaborative. At theConference Topics Will Include: Supporting the self-management effortsof patients with chronic conditions. Leading change in a medical practice. Implementing practice processimprovement strategies. Discussing the business case forprocess improvement. Facilitating peer-to-peer discussion insmall group sessions.first regional collaborative, providerswill introduce their newly assembledteams. These teams will engage inguided brainstorming and develop anaction plan. Teams will report on theprogress of the action planat subsequent collaboratives.For more information, contactCynthia Wood, RN, programmanager, at 405-522-7629, fax405-530-3268 or e-mailcynthia.wood@okhca.org.
ohca provider update 4spring 2007OHCA and OSU-OKC Take CNA Training Program StatewideOHCA and OSU-Oklahoma City(OSU-OKC) have expanded theircertified nurse aide training programto Oklahomans statewide. Theprogram is now available at no costto qualified individuals.The CNA training program waspiloted in the summer of 2005 toresidents of Oklahoma and Logancounties. During the pilot project,about 300 Oklahomans received theirCNA certification. OHCA staff, alongwith representatives of other agencies,studied various outcomes related tothe effectiveness of the program,made improvements and expandedthe program to two additionalcounties, Cleveland and Canadian.The program has provedsuccessful and will now be offered toOklahomans statewide. Participantsin the program will earn certificationand must gain employment at aSoonerCare long-term care facilityfor at least 12 months.“Oklahoma’s long-term carefacilities in rural areas areparticularly vulnerable to manpowershortages,” said OHCA ChiefExecutive Officer Mike Fogarty. “Inthe pilot stages, this program provedto be successful. We believe thattaking the program statewide willcreate job opportunities by providingthe training that is needed to work in(Continued on Page 10)OHCA Expands Nutritional Counseling Program(continued from page 1)The expansion of the programcame about in part due to theobesity problem our nation is facing.Approximately 30 percent of adultsare obese, with a Body Mass Index(BMI) greater than 30. Nearly 60percent are overweight, with a BMIgreater than 25. Most startling,5 percent, or 1 in 20 people, aremorbidly obese with a BMI of 40 orgreater, an 8 percent increase overthe last decade.The expansion of the nutritionalcounseling program begins toaddress the obesity epidemic andalso offer a preventive service. Theprogram’s main goal is to furtherassist those members facing threemain health concerns: diabetes, heartdisease and obesity. OHCA hopes theexpansion of this program will alertproviders to this underused service.
ohca provider update 5spring 2007Secure E-mail Now AvailableProvider Services is pleased toannounce the arrival of securee-mail. Secure e-mail offers a methodfor providers to send e-mailscontaining private healthinformation. The new e-mailfunction is located on the providerSoonerCare Secure Site (formerlyMedicaid on the Web).Secure e-mail is a safe alternativeto contacting OHCA via telephoneto inquire about policy, coverage,contract compliance or generalquestions. The secure site is notavailable for claim status; those callsshould be directed to the OHCA callcenter, 800-522-0114 or 405-522-6205.Sending a secure e-mail is simple.Providers can log on to the securesite at .Once logged on, providers can xhtmlthe Mailbox and “send mail” sectionto send OHCA a secure e-mail.Providers can visit the Mailbox’s“read mail” section to check for aresponse from OHCA.Providers should find the secureDid You Know?Providers receiving payment from a member’s secondary,private or commercial insurance are not required to submita hard copy attachment if the claim is filed electronically.Electronic claim submission can be accomplished bysubmitting an 837 or direct data entry on the SoonerCareSecure Site.Providers must enter the total dollar amount paid by thecommercial insurance carrier using the decimal point, butno dollar sign. A hard copy attachment of the insurancepayment detail is not required.Providers can save time, paper and postage by submittingclaims electronically. For more detailed information, pleaserefer to OHCA’s Medicaid Provider Billing and ProcedureManual at www.okhca.org. You may also call 800-522-0114 or405-522-6205, option 2, for the Internet and EDI Help Desks.e-mail function convenient andsimple to use. OHCA hopes securee-mail will contribute to improvedcommunication and service forSoonerCare providers.
ohca provider update 6spring 2007SoonerPsych Program Helps Contain Costs, Improves Prescribing PracticeOklahoma is one of 26 statesimplementing programs to improvethe use of behavioral healthmedications for Medicaid patients.Dubbed SoonerPsych (SoonerPrescription Solutions for YourCognitive Health), Oklahoma’sprogram is sponsored by OHCAand the Oklahoma Department ofMental Health and Substance AbuseServices (ODMHSAS).SoonerPsych is proving to be oneof the most effective in the nationin improving quality of prescriptiondrug use while containing thegrowth in the cost of Medicaidbehavioral health prescriptions.Research shows the most effectiveuse of resources results when bestpractice guidelines are followed.Cost is an important considerationbecause behavioral health drugs areamong the most expensive of allmedications. The program’s goalis to promote doctors’ voluntarycompliance with best-practiceguidelines while avoiding thepotential paperwork hassles thatsometimes come when writing apatient’s prescription (such as priorauthorization permission).“Physicians want the best for theirpatients, and this program has giventhem another tool to get the rightdrug to the right person at the righttime. It is this practice that saveseveryone time and health care dollars,”said Dr. Nancy Nesser, pharmacyservices director for OHCA.Comprehensive NeuroScienceInc. (CNS) assists OHCA andODMHSAS in the operation ofSoonerPsych through funding(Continued on Page 8)Prior Authorization Starts at the PharmacyThe medication prior authorization process should start in thepharmacy. Because an individual prior authorization approvalis specific to both the pharmacy and the member, the pharmacyinformation is required to process the petition.If a prescriber contacts the Pharmacy Help Desk for priorauthorization, a blank petition form will be faxed to them.Once the prescriber has completed their portion of the petition,they may fax, mail or forward the form to the pharmacy. Thepharmacy will then enter theirinformation prior to submissionto the Help Desk.Petitions submitted withoutpharmacy information cannotbe processed. If you haveany questions about the priorauthorization process, pleasecontact the Pharmacy Help Deskat 800-522-0114, option 4.
ohca provider update 7spring 2007Skeletal Muscle Relaxants: Their Place in TherapyBy Christendoza Le, Pharm.D.The recommended treatmentsfor musculoskeletal conditions areacetaminophen, NSAIDs, skeletalmuscle relaxants, short-term opioidanalgesics, hot or cold packs, andbed rest for several days. The mostcommon musculoskeletal complaintis low-back pain, and 90 percent ofthese cases resolve in about four to sixweeks with proper care and rest.Oral skeletal muscle relaxantscan be effective when used foracute symptomatic relief of painand discomfort, but little evidencesupports the use of skeletal musclerelaxants for chronic pain. There is alack of high quality studies to suggestthat any skeletal muscle relaxant ismore effective than another. Mostclinical trials of skeletal musclerelaxants are two to three weeks in duration and seldomcontinue beyond six weeks. Some trials show a declinein efficacy to rates similar to that of placebo after fourto seven days. As a result of these trials, these agents areonly recommended for short-term use.Among the skeletal muscle relaxants prescribedfor SoonerCare members during 2005, carisoprodolaccounted for almost one-third of all the agents used.This is not consistent with current treatment guidelinesand research which suggests that use of carisoprodolis generally not indicated due to its unclear risk-benefitprofile. In addition, carisoprodol is metabolizedto meprobamate, a sedative-hypnotic with highlyaddictive properties.Carisoprodol is not scheduled as a controlled dangerousdrug at the federal level, which may lead prescribersto underestimate the abuse and addictive potential ofthis medication. In regular users of carisoprodol, it ismeprobamate rather than carisoprodol that accumulates.Carisoprodol is a controlled dangerous drug in Oklahomadue to abuse concerns.(Continued on Page 9)ePocrates Introduces New MobileFeaturesePocrates is a free online drug and formularybased reference. Available in a Web-based version or download to yourPersonal Digital Assistant (PDA) for added mobility. Look up formulary specific drug information suchas coverage, quantity limits and prior authorizationrequirements. Oklahoma SoonerCare drug list and Medicare Part Dformularies.All ePocrates mobile products now include: My ePocratesNew safety informationNew pharmacology sectionFree decision support toolsMemory card supportMore information on ePocrates online drug andformulary reference can be found at: www.epocrates.com.
ohca provider update 8spring 2007SoonerPsych Program Helps Contain Costs (continued from page 6)from Eli Lilly, a pharmaceuticalcompany. Each month, CNS reviewsSoonerCare’s behavioral healthpharmacy claims and compares themto nationally recognized best practiceprescribing guidelines.Prescribers who show patterns ofdeviating from guidelines receiveeducational messages from Dr.Peggy Jewell, medical director ofODMHSAS. The messages askoutlier prescribers to consideradjusting their patients’ medicationto be more consistent with bestpractice guidelines. The messagesstress that the state is aware that eachpatient has unique problems andneeds, and any changes are at thesole discretion of the prescriber.health medications in 2005.SoonerPsych began to send“Oklahoma can be proud of theeducational messages to prescribersachievements of the SoonerPsychin August 2004. From Septemberprogram,” said Dr. Richard Surles,through December 2004, the average senior vice president and head ofmonthly spending for SoonerCareCNS’ Care Coordination and Diseasebehavioral health drugs held steadyManagement Support Division.at around 12 million. From January “Many state Medicaid agencies wouldthrough December 2005, the average be ecstatic if they could containmonthly spend rate for behavioralbehavioral health medication costshealth drugs was 12.2 million.to the levels Oklahoma has achieved.With less than a 2 percent increaseOklahoma’s experience stronglyin the cost of behavioral healthaffirms our belief that focusing onmedications during 2005, Oklahomathe quality of prescribing practice tostands out against the nationalassure good patient care also resultsaverages. Most states experiencedin the most effective use of limiteda 14 percent to 18 percent annualMedicaid resources.”growth rate in the cost of behavioral
ohca provider update 9spring 2007Skeletal Muscle Relaxants (continued from page 7)The misuse of any medication has potential negativeeffects that may lead to an overall increase in utilizationof health care resources, increased hospitalizations,permanent disability and sometimes death of the affectedindividual. Recently OHCA initiated prior authorizationof all carisoprodol products. These products will beavailable for 90 days of therapy, after which time aprior authorization becomes effective. An additionalapproval for one month will be granted to allowtitration or change to another muscle relaxant. Furtherauthorizations will not be granted, except in cases wherethe member has one of the following diagnoses: musculardystrophy, paralysis, cerebral palsy or multiple sclerosis.References are available upon request.Provider Services DepartmentOffers AssistanceThe provider services department at OHCA assistsproviders with claims issues, provider access issues,contracting, education and policy interpretation.Providers needing a general overview of SoonerCareprograms or onsite education related to any programarea listed above are urged to contact Provider Services.Provider Services can be reached at 877-823-4529, option1, or 405-522-7441. Any member of the staff is availableto work with providers. A detailed contact list is availableonline at www.okhca.org.2007 RBRVS fee scheduleThe physician fee schedule follows the state fiscal year.In July 2007, changes in the Resource-Based RelativeValue Scale (RBRVS) fee schedule will become effective.Please visit our Web site for all fee schedule information.2006 in reviewWe would like to thank all of our providers fortheir continued support of SoonerCare. Over thelast year we have made many improvements with thecontinued assistance of our provider network. Belowis a short overview of some of the changes. (Pleasevisit our Web site, www.okhca.org, to review providerletters from 2006 and earlier.) Disease Management Program for SoonerCaremem
a publication of the oklahoma health care authority spring issue 2007 Clinical News 2 OHCA to Offer Coverage of Bariatric Surgery 4 OHCA and OSU-OKC Take CNA Training Program Statewide 6 SoonerPsych Program Helps Contain Costs, Improves Prescribing Practice 6 Prior Authorization Starts at the Pharmacy 7 Skeletal Muscle Relaxa
