Connect eNewsletter November Edition

Coventry Health Care Completes Buyout of Florida’s Vista Healthplans

November 2007

Coventry Health Care recently completed its acquisition of Vista Healthplans, marking its entrance into the Florida market. Health First Network spoke with a representative of the company to gain insight into its operations. Here’s what we learned:

Q. What is the corporate structure?
A. Based in Bethesda, Maryland, Coventry Health Care (NYSE: CVH) is a diversified company operating health insurance, workers’ compensation, and partnering with physician networks. In each division, we are driven to understand and meet the needs of our customers. Because we are in a service industry and cost is a concern for customers across all of our divisions, Coventry’s businesses distinguish themselves with a focus on:

  • Service excellence;
  • Financial discipline for maintaining a low-cost structure; and
  • Day-to-day execution of business fundamentals.

We are a national organization that is able to bring “best practices” to each of our markets and, in turn, to our customers. In addition, with regional offices in Sunrise and Tallahassee, Florida, many of our business operations and services are handled at the local level.

Q. How far reaching is your organization?
A. With offices in 20 states and four million members across the U.S., Coventry has a growing portfolio of products. Other features underscoring our leadership in the market include:

  • Extensive national networks of pharmacies (now over 64,000 in our retail network) and preferred transplant facilities
  • An array of Medicare options such as Medicare Advantage, Medicare private fee-for-service, and Medicare prescription drug products
  • A State Government (Medicaid) presence in more than half of the states in the country (through both Health Plan MCOs and ASO State Contracts)
  • A growing portfolio of individual consumer product options
  • An integrated suite of workers’ compensation care management, pharmacy benefit management, and network services.

Q. What is your product mix?
A. Through our commercial business, individual consumer business, government business, and specialty business divisions, Coventry provides a full range of risk and fee-based managed care products and services to a broad cross-section of individuals, employer and government-funded groups, government agencies, and other insurance carriers and plan administrators.

Q. What can providers expect?
A. Coventry’s dedication to strong provider relationships has helped drive the company’s success, and we are bringing this commitment to the Florida marketplace. We have a customer-driven philosophy, which makes providers a top priority.


Sweeping Changes to Strongly Impact the Medicare Program

November 2007

In the past two months, the Centers for Medicare and Medicaid Services (CMS) have released information regarding some of the broadest changes to impact the existing Medicare program in years. To help physicians sort through these changes, Health First Network will highlight some of them in upcoming issues of Connect. In this issue, Dr. Whibbs will focus on the new CMS “Present on Admission” (POA) indicators.

Other changes include but are not limited to new case mix adjustments affecting hospital reimbursement from Medicare; the assignment of severity levels to Medicare Diagnosis Related Groups (DRG’s) to improve predictive power and better capture patient severity; an updated complications and co-morbidities list that affect DRG assignment; and the consolidation of 538 DRG’s into new base DRG’s and increase the number of DRG’s by an additional 207. Learn more about these changes in upcoming issues.


Helping Patients Understand Medicare Open Enrollment

November 2007

Medicare Open Enrollment is quickly approaching, and Health First Network encourages its physicians to support their patients through this process. In the last issue of Connect, we shared information about Medicare with you. The one-page handout which highlighted key dates of the enrollment process was so popular that we added it to our online resources on our website www.hfni.com. Click here to download this handout for your patients.


Did You Know?

By Dr. William Whibbs (November 2007)

News of the CMS “Present on Admission” Indicators

In an effort to improve the quality of inpatient care and to reduce spending, the Centers for Medicare and Medicaid Services (CMS) will reimburse acute care hospitals based on a patient’s condition on admission. This will require acute care hospitals to report―for each primary and secondary diagnosis billed (with few exceptions)―whether conditions were present when the order of admission was written. If a condition is not reported as “Present on Admission,” CMS will assume it is hospital acquired.

This is a huge step in holding hospitals accountable and helping ensure the delivery of quality care to Medicare beneficiaries. Currently, when a patient develops a complication as a result of a hospital-acquired condition, such as a vascular catheter-associated infection, the hospital is reimbursed at a higher rate. Beginning in 2008, this will no longer happen. CMS will reimburse hospitals based on a person’s condition at admission and treatment related to that condition.

In essence, CMS will no longer “reward” hospitals for hospital-acquired conditions that were reasonably prevented through the application of evidence-based guidelines. Such conditions outlined for implementation in 2008 include serious, preventable events such as objects left in surgery, air embolism, blood incompatibility, catheter-associated urinary tract infections (UTI), decubitus ulcers, vascular catheter-associated infections, falls, and surgical site infections (i.e. mediastinitis after CABG). CMS will announce additional conditions in time.

This change affects Health First Network physicians because hospitals depend on us and other health care professionals to document a patient’s condition and response to medical/surgical treatment during a hospital stay. Our documentation positions a hospital to provide appropriate care and treatment, as well as allows hospitals to accurately code and capture information required for reimbursement.

Because of these changes, meticulous, comprehensive documentation at the time of admission will become even more critical than it is today. Ultimately, POA reporting, done correctly, will enhance care, cut costs, and reimburse hospitals fairly. In Florida, POA reporting was suggested as of October 1, 2007; it will be required beginning January 1, 2008.

The financial impact will be felt as early as April 1, 2008. Psychiatric and rehabilitation hospitals are exempt. A thorough explanation of POA reporting is available in the ICD-9-CM Official Guidelines for Coding and Reporting. Additional information and official instructions can be found on the CMS website by visiting www.cms.hhs.gov/transmittals/downloads/R1240CP.pdf.


Health First Network Upholds Its Commitment to the Community

November 2007

Health First Network recently earned United Way’s Spirit of Giving Award. This award reflects the organization’s continued commitment to service. Here is just a glimpse of recent initiatives that Health First Network led as part of its promise to improve the health care experience and quality of life for people in Northwest Florida:

  • Day of Caring: As a signature sponsor, Health First Network staff joined more than 1,100 local volunteers to participate in United Way’s Day of Caring, spending time reading to, doing crafts with, and nurturing children at Kids Express Early Learning.
  • Living with Asthma Night: Health First Network held its second annual event targeting children, parents, and families affected by asthma. More than 70 people attended this successful and worthwhile community event held at Sacred Heart Hospital.
  • Lunch & Learn: Health First Network sponsored a “Lunch & Learn” luncheon for the Pediatric Residents in the Florida State University/Pensacola Pediatric Residency Program at Sacred Heart Hospital.
  • ElderCare Donation: Health First Network donated $6,000 to the ElderCare Health Recovery Project, a program aimed at helping “at-risk” seniors who come home from the hospital without a capable caregiver to support them.

Welcome New Members

November 2007

Health First Network would like to welcome the most recent physicians who joined the Network:

  • William M. Bone, M.D. – Family Practice-Pensacola Primary Care, Inc
  • David Bowen, M.D. – Radiology-Radiology Associates of Pensacola, PA
  • Alexa Canady, M.D. – Pediatric Neurological Surgery-Sacred Heart Medical Group Sub Specialist
  • Maria A. Carmona-Gonzalez, M.D. – Hospitalist―Sacred Heart Medical Group Sub Specialist
  • Rex Delaune, M.D. – Family Practice-Pensacola Primary Care, Inc
  • Joe A. Dunn, M.D. – Family Practice-Pensacola Primary Care, Inc
  • Jennifer C. Estes, M.D. – Hospitalist-Baptist Physician Associates, LLC
  • Erica Frank, M.D. – Pediatrics-Pensacola Primary Care, Inc
  • Roger A. Gilmore, M.D. – Family Practice-Pensacola Primary Care, Inc
  • Andrea J. Hackel, M.D. – Internal Medicine-West Florida Internal Medicine, LLC
  • Klaus A. Hollmig, M.D. – Hematology/Oncology-Hope Medical Group
  • Marta Jacenyik, M.D. – Family Practice-Tiger Point Family Practice
  • Pamela L. Juba, M.D. – Internal Medicine- West Florida Internal Medicine LLC
  • Michael E. Kasabian, D.O. – Family Practice-Pensacola Primary Care Inc
  • Lawrence King, M.D. – Neurology-Sacred Heart Medical Group
  • Rod Krentel, M.D. – Radiation Oncology―West Florida Medical Center Clinic, PA
  • Gerald Lowery, M.D. – Radiation Oncology- West Florida Medial Center Clinic, PA
  • Alan D. Neal, M.D. – Internal Medicine- West Florida Internal Medicine, LLC
  • Rick M. Pekarek, M.D. – Family Practice-Pensacola Primary Care, Inc
  • Ronald Pendleton, D.O. – Family Practice-Pensacola Primary Care, Inc
  • Carol Preud’Homme, M.D. – Internal Medicine―West Florida Internal Medicine, LLC
  • Tammy G. Pruse, D.O. – Family Practice-Pensacola Primary Care, Inc
  • Christopher H. Rush, M.D. – Family Practice-Pensacola Primary Care, Inc
  • David R. Smith, M.D. – Family Practice-Pensacola Primary Care, Inc
  • Andy Somesan, M.D. – Sacred Heart Medical Group Sub Specialist
  • Thomas D. Sunnenberg, M.D. – Hematology/Oncology-Sacred Heart Medical Oncology Group
  • Venancio S. Teves, M.D. – Pathology-Gastroenterology Associates of Pensacola, PA
  • Marlanne Tullus, M.D. – Family Practice-Pensacola Primary Care, Inc
  • John J. Varenholt, M.D. – Family Practice-Pensacola Primary Care, Inc
  • Malcolm A. White, M.D. – Pediatrics-Pensacola Primary Care, Inc
  • William S. Willis, M.D. – Family Practice-Pensacola Primary Care, Inc
  • Frank E. Witter, M.D. – Internal Medicine―West Florida Internal Medicine LLC