Primary Care ProviderPolicy & Procedures Training

Manual

5/14/2013 MBCHP 2

MBCHP Website and List Serve

In order to reference updated information please go to our website.http://www.maine.gov/dhhs/mecdc/population-health/bcp/index.htm

MBCHP providers are cordially invited to subscribe to the MBCHP Provider List Serve. It is set up to send a one way communication from the MBCHP to subscribed providers via mass email.

http://mailman.informe.org/mailman/listinfo/MBCHP-provider

5/14/2013 MBCHP 3

Purpose of the Training

The purpose of this training is to orient all MBCHP Primary Care Practice staff to the requirements of the Maine CDC Breast and Cervical Health Program.

MBCHP’s History and FundingThe State of Maine is one of 67 states, territories and tribal

organizations receiving funding to support a comprehensive breast and cervical cancer early detection program.

Maine’s early detection program started in September 1994 when Maine received funding from the US CDC.

MBCHP has a cooperative agreement with the US CDC that provides approximately $1.7 million annually.

The goal of the National Breast & Cervical Cancer Early Detection Program (NBCCEDP) is to reduce breast and cervical cancer morbidity and mortality.

5/14/2013 MBCHP 4

Mission & Vision

MissionThe mission of MBCHP is to provide breast and cervical cancer

screening and diagnostic services to underserved women; public education and outreach to promote quality cancer prevention and screening activities; professional education and policy system approaches that enhance statewide cancer control activities.

VisionThe vision of MBCHP is to reduce breast and cervical cancer

morbidity and mortality among all Maine women. The program promotes a better quality of life for women and their families, which benefits all Maine communities.

5/14/2013 MBCHP 5

5/14/2013 MBCHP 6

Eligibility Criteria To qualify for MBCHP services, a woman must meet all of

the following guidelines:– Income must be at or below 250% Federal Poverty

Level by family size (table on the website)– Must be uninsured or underinsured

• But not on MaineCare or Medicare Part B

– Resident of the State of Maine or New Hampshire (within 15 miles of border)

– Age 40-64 (65+ only if a woman does not have Medicare Part B)• Women 35-39 may qualify under special criteria (symptomatic

or have not had a Pap test in 5 or more years)

5/14/2013 MBCHP 7

Policies & ProceduresEnrollment of Women

• Can be done centrally through the toll free line (1-800-350-5180) (recommended)• Or at the PCP site (contact MBCHP for training)

Confidentiality• All program clients sign a consent for Release of

Information on the MBCHP initial enrollment form and annually thereafter

• A copy of the Initial Enrollment form is sent to the providers

5/14/2013 MBCHP 8

Policies & Procedures (cont)

Re-enrollment of clients is done annually• Mailed directly from the MBCHP central office, re-enrollment

forms are sent to women (approx 45 days before due date to re-enroll) to ensure ongoing eligibility

• If eligibility is maintained, client ID# will be the same• If a woman is no longer eligible, a letter is sent to her and

copied to the PCP• Women who fail to re-enroll will be closed out of the program

30 days after their re-enrollment due date

5/14/2013 MBCHP 9

Primary Care Site ResponsibilitiesPrimary care sites under contract will:• Provide covered services (upcoming slides)• Refer women to MBCHP participating diagnostic service providers

(Listed on Website)• Submit clinical data to MBCHP in a timely manner (slide 10)• Ensure billing is done timely and women are not billed for covered

services (slide 36)• Update MBCHP staff of any changes in staff at the practice• Assess women for tobacco use and refer to quit lines for cessation

services when appropriate• Assure patient confidentiality

Submission of Clinical DataMBCHP Form Submitted

byPurpose If screening

outcome is NORMAL

If screening outcome is ABNORMAL

MBCHP Visit Form Part 1

PCP Site To document outcome of:• Pelvic exam• Clinical Breast Exam• Date Pap performedTo document schedule date for:• Mammogram

Mail or fax Part I within 10 days of office visit

Fax:1-800-325-5760287-8944

Fax Part 1 on day abnormal screening result identified with plan for diagnostic services

MBCHP VISIT Form Part 2

PCP Site To document outcome of:• Pap test• Mammogram

Mail or Fax Part 2 and/or results of Pap test/MammogramWithin 10 days of receiving results

Fax Part 2 and/or abnormal Pap/Mamm report on day abnormality identified with plan for diagnostic services

5/14/2013 MBCHP 10

A Word about the Site Capacity (CAP)

• The CAP refers to the maximum number of women the primary care practice has agreed to serve under their contract w/MBCHP

• There is a $ amount assigned to the contract based on the number of women the provider has agreed to serve per year

• The number enrolled can be over the CAP as long as the number of women receiving services is within the contract dollar assignment (not all women enrolled are receiving annual services)

• MBCHP will monitor the contract and contact provider to discuss options if enrollment is close to CAP or goes over designated amount

5/14/2013 MBCHP 11

5/14/2013 MBCHP12

MBCHP Covered ScreeningServices

• Office Visit, which must include one or more of the following screening services: clinical breast exam (CBE), pelvic exam, Pap test alone or Pap test and HPV test (only covered when done by client’s selected MBCHP Primary Care Provider)

• Referral for screening Mammography (if CAD is used, it may not be billed separately to MBCHP or to the patient)

• Interpretation/translation services can be covered only in conjunction with a covered MBCHP service(screening or diagnostic, not treatment) at a non-hospital MBCHP provider site

5/14/2013 MBCHP 13

MBCHP Covered Diagnostic Services Breast Diagnostic Services:• Surgical consults for possible breast cancer (only by a

MBCHP Diagnostic Referral Provider - see website)• Pathology charges for breast biopsies• Diagnostic Mammography (if CAD is used, it may not be billed

separately to MBCHP or to the patient)• Ultrasound (when used as an adjunct to mammography)• Fine needle aspirations• Breast Biopsies (physician charges only)

– Excisional & incisional – Stereotactic & needle core

• Anesthesia for breast biopsies (physician charges only)

5/14/2013 MBCHP 14

MBCHP Covered Services (cont)

Hospital Waivers for Breast Biopsies:MBCHP has agreements with 30 of the 36 Maine

hospitals to waive all hospital charges associated with the breast biopsies.

The hospital waivers allow MBCHP to use its limited funding to screen more underserved women.

5/14/2013 MBCHP 15

MBCHP Covered Diagnostic Services (cont)

Cervical Diagnostic Services (only by a MBCHP diagnostic Referral Provider)- see Website

• Surgical consults • Colposcopy with or without biopsy• Endocervical curettage• Endocervical polyp removal• Pathology charges for cervical biopsies

5/14/2013 MBCHP 16

MBCHP Non-Covered Services

All other services are not covered including, but not limited to:• Blood test• Stool test• Urine test• Transvaginal ultrasound• Chest x-ray• MRI• Prescriptions (including birth control and hormones)• Leep procedure• Bone density test• Hysterectomy• Colonoscopy

5/14/2013 MBCHP 17

Coverage for Treatment

The Treatment Act provides full MaineCare benefit eligibility to uninsured women who are diagnosed with breast or cervical cancer or pre-cancerous conditions through MBCHP

To see if a woman qualifies she must contact the MBCHP case manager. The woman must:– not be eligible for any other MaineCare program– meet all the same eligibility requirements as the MBCHP

screening program– Be uninsured and have received a screening or diagnostic

service from an MBCHP provider

5/14/2013 MBCHP 18

Initial Contact with PCP Site After enrolling, a woman will call her chosen PCP site to make an

appointment for her screening exam. MBCHP encourages clients to identify themselves as “Breast and Cervical” and present primary and secondary insurance cards (if they also have private insurance).

Front office staff are:• Encouraged to talk to all eligible female patients, ages 40-64,

about MBCHP• Encouraged to ask all callers if they are covered by MBCHP• Required to schedule symptomatic women for clinical

evaluation and appropriate diagnostic procedures as quickly as possible

5/14/2013 MBCHP 19

Initial Contact with PCP Site (cont)

Front office staff are: (cont)

• Encouraged to ask women for their MBCHP card

– If patient does not yet have her card, call MBCHP (1-800-350-5180) to confirm she is enrolled

– Complete the first section of MBCHP Visit Form with demographic information and date of office visit

5/14/2013 MBCHP 20

MBCHP Visit Forms/Abnormal Breast and/or Cervical Screening Follow-Up Reports

Required Reporting

fax: 1-800-325-5760 or 207-287-8944

5/14/2013 MBCHP 21

Special Consideration w/Cervical CareVery important Cervical Screening information to keep in mind

during exams:

• Pap after hysterectomy for any benign condition will not be covered unless a part of the cervix remains

• Pap after hysterectomy is covered ONLY if surgery was done for cervical neoplasia or invasive cervical cancer

• Pap test alone or Pap test and HPV test, (co-testing) are both covered

• USPSTF screening interval recommendations are promoted when results are normal:

Screen with cytology (Pap smear) every 3 yearsScreen with co-testing (cytology+HPV testing) every 5

years

Special Consideration w/Breast Care

Very important breast information to keep in mind during exams:

• Positive CBE with negative mammogram is not considered an adequate work-up unless there is documentation that the lump was previously evaluated and determined benign

• All palpable lumps must be evaluated beyond a negative mammogram, preferably with a referral to a breast specialist or surgeon

• Inform MBCHP as soon as possible if mammogram result is Birad 0 (assessment incomplete), Birad 4, or Birad 5. These are considered abnormal results requiring further diagnostic work-up

5/14/2013 MBCHP 22

5/14/2013 MBCHP 23

Special Consideration Breast and Cervical Care

• Most important: Interval between initial abnormal screening and final diagnosis should be 60 days or less (as per CDC, & NBCCEDP Standard)

• Most Important: Interval between diagnosis and initiation of treatment for breast or cervical cancer should be 60 days or less (as per CDC & NBCCEDP Standard)

5/14/2013 MBCHP 24

Case Management

Case management may be requested by the client or the provider by:

• Indicating on the MBCHP Visit Form, Part 2 • Calling Case Manager at 1-800-350-5180, press 3 at the

prompt

Case management may also be requested by clients, their family members or an MBCHP staff member

5/14/2013 MBCHP 25

Case Management

The MBCHP Case Manager can help enrolled women find:

• Transportation help for MBCHP appointments• Translation/language interpretation services• Information on breast and cervical health issues• Community resources for bills not covered by MBCHP• Diagnostic referral providers for recommended Follow-up

Testing • Assistance in applying for the Treatment Act (Mainecare)

for clients with a diagnosis of breast or cervical cancer

Breast Cancer Screening:Clinical Summary of U.S. Preventive Services Task Force Recommendation• Screening for Breast Cancer: U.S. Preventive Services Task Force, 2002• Screening for Breast Cancer: U.S. Preventive Services Task Force, November 2009Cervical Cancer Screening:• Clinical Summary of U.S. Preventive Services Task Force Recommendation• Screening for Cervical Cancer: U.S. Preventive Services Task Force, 2012• The American Congress of Obstetricians and Gynecologists (ACOG) Recommendations• Ob-Gyns Recommend Women Wait 3 to 5 Years Between Pap TestsAmerican Society for Colposcopy and Cervical Pathology (ASCCP)(MBCHP) obtained permission from the American Society for Colposcopy and Cervical Pathology (ASCCP) to provide the following links: • 2006 Consensus Guidelines and Algorithms for the Management of Women with Abnormal Cervical Cancer Screening Tests

http://www.asccp.org/consensus/cytological.shtml• 2006 Consensus Guidelines and Algorithms for the Management of Women with Cervical Intraepithelial Neoplasia or

Adenocarcinoma in situhttp://www.asccp.org/consensus/histological.shtml

The copyright of the algorithms, both on the ASCCP web site and in the original Journal of Lower Genital Tract Disease article, is owned by the ASCCP.

5/14/2013 MBCHP 26

Clinical Guidelines

5/14/2013 MBCHP 27

Notifying Patients of Results

All MBCHP patients must be notified of the results of their screening tests.

PCP must communicate abnormal results to MBCHP immediately upon receipt of result.

Normal Pap result letters are sent by MBCHP to the client:– If the results are received by MBCHP beyond 3 months of the

screening date, no notice will be sent.Mammography facilities notify women of mammography results.PCP sites are to complete MBCHP Visit Form Part 2 to notify MBCHP of

results or fax the mammography and/or cytology report 2 (1-800-325-5760 or 207-287-8944) .

5/14/2013 MBCHP 28

Follow-up of women with abnormal results

• Clients with abnormal results should be notified as quickly as possible, and– Given assistance in arranging follow-up services– Referred for further diagnostic testing with MBCHP Diagnostic Referral

Provider• If a provider is having difficulty arranging follow-up services, the

MBCHP Case Manager should be contacted• PCP responsible for obtaining follow-up outcome from

diagnostic referral providers

5/14/2013 MBCHP 29

Referrals for Diagnostic ServicesReferrals to Diagnostic Referral Providers:• The PCP manages the care of the referred woman and reports

results to MBCHP• See Diagnostic Referral Provider list

– See the website for colposcopy, fine needle aspiration and breast biopsy providers and sites

• If the diagnostic referral provider does not participate with MBCHP, but is a MaineCare provider:– Call MBCHP: We will contact the provider to determine if the provider is

interested in participating– If the provider is not willing to enroll with MBCHP, the Case Manager will

work with the PCP & client to find a participating diagnostic referral provider

5/14/2013 MBCHP 30

Referrals (cont)

Referrals to Diagnostic Referral Providers: (cont)

• Providers should identify patients as MBCHP clients when referring for diagnostic services

• Providers should also give the diagnostic referral provider the client’s billing ID# to ensure smooth transfer of patient billing information

• Diagnostic referral providers will report results directly to the PCP, and the PCP should report results to MBCHP as soon as possible

• MBCHP Case Manager may contact the PCP or diagnostic referral provider directly for diagnostic results to timely care protocols.

5/14/2013 MBCHP 31

Administrative InformationTracking and Follow-up• MBCHP maintains a centralized database that monitors the

disposition of all women enrolled in the program statewide• Primary care sites receive regular reports from the MBCHP

tracking system including:1. Monthly rescreening reminders

• Women who are due for rescreening in 75,45 and 15 days• Women who are 3 and 5 months overdue• Providers are encouraged to also remind women of their rescreening dates• MBCHP also provides a page of address labels for providers to send

rescreening reminders

5/14/2013 MBCHP 32

Administrative Information (cont)

Tracking and Follow-up (cont)• Reports to providers (continued) 2. Monthly list of women enrolled, re-enrolled and dis-enrolled 3. Bimonthly missing data reports if clinical information has

not been sent to MBCHP • MBCHP sends reminder letters to women who are due

or overdue for rescreening– Due for rescreening in 45 days– Overdue for rescreening by 3 and 5 months

5/14/2013 MBCHP 33

Administrative Information (cont)

Quality AssuranceMBCHP monitors the PCP compliance with MBCHP reporting

requirements and NBCCEDP Standards.

• Tracking clinical and data reporting

– Number and percent of missing data– Late submission of data– Billing for services for which no data has been submitted– Late billing of services– Office visits with no MBCHP covered services performed

5/14/2013 MBCHP 34

Public Education

MBCHP Public Health Educators support education by:

• Mailing clients cancer prevention and screening promotion information and updates

• Contracting with Maine Association of Broadcasters to air public service announcements every year (January-May)

• Participating in presentations, education and promotion events

5/14/2013 MBCHP 35

Reimbursement & Billing

Reimbursement for covered services will be the lowest of:– The provider’s usual and customary charge, or– The MBCHP rate for the procedure (NBCCEDP utilizes Mainecare rates)

Providers need to assure that coding done on site for date of service is an MBCHP approved procedure and diagnostic code (see website).

Providers participating in MBCHP are required to accept payment as the payment in full. The allowance is established annually for MBCHP covered services.

Patients cannot be billed for any portion of a MBCHP covered service

.

5/14/2013 MBCHP 36

Reimbursement & Billing (cont)

MBCHP is the payer of last resort• Providers and billing agencies should call MBCHP directly with

questions before processing bills• If client holds private or group insurance, providers must seek

payment for services through the primary insurance prior to billing MBCHP

• Claims for MBCHP covered services must enter the MIHMS claims processing system within 180 days from the date of service or the system will deny payment as untimely

• A claim denied for being untimely may not be billed to the client• MBCHP fiscal year runs from July 1 to June 30 which means that all

claims for services during that time period must be reconciled by September 1st

5/14/2013 MBCHP 37

Reimbursement & Billing (cont)

Use of Voice Response to obtain client ID#:• MBCHP staff will enter client information into the ACES system

2-3 business days after receipt of the MBCHP Initial Enrollment Form

• Once entered, eligibility information is available through MIHMS Automated Customer Services System at 1-866-690-5585

OR• Contact MBCHP directly at 1-800-350-5180

5/14/2013 MBCHP 38

MBCHP Contact Information

Maine CDC Breast & Cervical Health ProgramDepartment of Health & Human Services

Maine Center for Disease Control & PreventionDivision of Population Health

State House Station 11Augusta, ME 04330

Phone: 1-800-350-5180 or 207-287-8068Fax: 1-800-325-5760 or 207-287-8944Website: http://www.maine.gov/dhhs/mecdc/population-health/bcp/index.htm

5/14/2013 MBCHP 39

Thank you!

MBCHP would like to thank you for your

continued participation.

We appreciate all the work you do to help Maine’s underserved

women.