DOH Medicaid Update June 2001 Vol.16, No.6

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We have added a new page to the Department of Health's website which lists Medicaid providers who have been disqualified from ordering or prescribing Medicaid services.*

If you accept prescriptions or orders from these providers, your claim will be denied.

The website address is:
http://www.health.state.ny.us/health_care/medicaid/index.htm

Look for "Medicaid Fraud" Select "Providers Not Allowed to Order"

The first page you will see is a disclaimer, which should be read in its entirety.

The list can be electronically searched. If you have any questions, please call Peter Zayicek at
(518) 474-9739 or e-mail MAFraud@health.state.ny.us.)

We hope this information will allow Medicaid providers to better serve the Medicaid population.

*These listings have historically been mailed to all Medicaid providers in hard copy on a monthly basis. This hard copy will continue to be mailed.

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The alarming rise of type 2 diabetes in children and adolescents has prompted an expert panel of the American Diabetes Association (ADA) to draft a consensus statement in March 2000 addressing the proper prevention, treatment and diagnostic criteria for children.

The consensus statement is the first to address the growing number of youths who are developing type 2 diabetes, a form of diabetes that is generally diagnosed among adults over the age of 45.

The experts concluded that type 2 diabetes commonly occurs in children who are overweight, usually older than ten years of age, members of certain ethnic groups and who may have a family history of diabetes. Accurate diagnosis and classification of diabetes is crucial in determining appropriate treatment for type 2 diabetes in children. The consensus statement recommends oral agents because of better compliance and convenience than with insulin injections, along with self-management education, proper meal planning and an increase in physical activity.

Testing for type 2 diabetes in children

The ADA consensus statement recommends the following criteria*:

• Weight Overweight (BMI > 85th percentile for age and sex, weight for height > 85th percentile, or weight > 120% of ideal for height), PLUS any two of the following risk factors:
  • Family history of type 2 diabetes in first-or second-degree relative
  • Race/ethnicity (American Indian, African-American, Hispanic, Asian/Pacific Islander)
  • Signs of insulin resistance or conditions associated with insulin resistance (i.e., hypertension, dyslipidemia, acanthosis nigricans)
• Age of Initiation Ten years of age or at onset of puberty if puberty occurs at a younger age
• Frequency  Every two years Test FPG (fasting plasma glucose) preferred

*Clinical judgment should be used to test for diabetes in high-risk patients who do not meet these criteria.

The New York State Department of Health is committed to improving the health of New Yorkers. To decrease the disability, morbidity, and premature mortality from diabetes, the New York State Medicaid Program encourages the screening of those patients deemed at high risk for diabetes and will provide reimbursement for examinations by Medicaid practitioners, including appropriate testing.

If you would like more information about the Medicaid Program's Diabetes Initiative, please contact the Medicaid Bureau of Program Guidance at (518) 474-9219.

For further information regarding type 2 diabetes in children and adolescents, please refer to Information for Providers on the Department's website at http://www.health.state.ny.us or the following websites: http://www.niddk.nih.gov/ and http://www.diabetes.org.

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• Smoking cessation therapy consists of prescription and non-prescription agents. Covered agents include nicotine patches, inhalers, nasal sprays, gum, and Zyban (bupropion).
• Two courses of smoking cessation therapy per recipient, per year are allowed. A course of therapy is defined as no more than a 90-day supply (an original prescription and two refills, even if less than a 30 day supply is dispensed in any fill).
• Multiple smoking cessation therapies, using different routes of administration, are allowed (e.g., Zyban and nicotine patches may be used concomitantly if warranted). Professional judgement should be exercised when dispensing multiple smoking cessation products.
• Duplicative use of any one agent is not allowed (i.e., same drug/same dosage form/same strength).

An additional support available to you and Medicaid recipients is a toll-free smoking help-line, called Quitline, staffed by employees of the Roswell Park Cancer Institute:

• Quitline offers smokers a confidential and convenient way to access immediate help when they are ready to stop smoking or need support to remain smoke-free.
• Health care providers can also call the Quitline to obtain office materials that can be shared with patients.
  Telephone:  NYS SMOKERS QUITLINE - 1-866-NYQUITS (1-866-697-8487)

If you would like more information about the Medicaid Program's Smoking Cessation Initiative, please contact the Bureau of Program Guidance at (518) 474-9219.

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The National Institute of Health, Expert Panel Report 2, Guidelines for the Diagnosis and Management of Asthma, stresses the importance of making the correct diagnosis of asthma. Clinical judgement is required because signs and symptoms vary widely from patient to patient as well as within each patient over time.

Spirometry is needed to establish a diagnosis of asthma. Consider asthma and perform a spirometry if any of the following indicators are present. While these indicators are not diagnostic by themselves, the presence of multiple key indicators increases the probability of a diagnosis of asthma.

To establish the diagnosis of asthma, the clinician must determine that:

• Episodic symptoms of airflow obstruction are present
• Airflow obstruction is at least partially reversible
• Alternative diagnoses are excluded

The following chart, prepared by the National Institute of Health for the initial assessment and diagnosis of asthma, summarizes the indicators. Further information may be found at:

 

• Wheezing-high-pitched whistling sounds when breathing out-especially in children (lack of wheezing and a normal chest examination do not exclude asthma)
• History of any of the following:
  • Cough worse, particularly at night
  • Recurrent wheeze
  • Recurrent difficulty in breathing
  • Recurrent chest tightness

• Reversible airflow limitation and diurnal variation as measured by using a peak flow meter, for example:
  • Peak expiratory flow (PEF) varies 20 percent or more from PEF measurement on arising in the morning (before taking an inhaled short-acting beta₂ -agonist) to PEF measurement in the early afternoon (after taking an inhaled short-acting beta₂agonist).

• Symptoms occur or worsen in the presence of:
  • Exercise
  • Viral infection
  • Animals with fur or feathers
  • House-dust mites (in mattresses, pillows, upholstered furniture, carpets)
  • Mold
  • Smoke (tobacco, wood)
  • Pollen
  • Changes in weather
  • Strong emotional expression (laughing or crying hard)
  • Airborne chemical or dust
  • Menses

• Symptoms occur or worsen at night, awakening the patient

*Eczema, hay fever, or a family history of asthma or atopic diseases are often associated with asthma, but they are not key indicators.

Source:Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda MD) National Institutes of Health,National Heart, Lung, and Blood Institute, NIH Institute: 1997).

REMINDER: The New York State Medicaid Program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of asthma. For more information, please contact the Medicaid Bureau of Program Guidance at (518) 474-9219

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Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:

• Overview of MMIS
• Explanation of MMIS Provider Manual
• Discussion of Medicaid Managed Care
• Overview of Billing Options
• Explanation of 90-day Regulation
• Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend:

August 9, 2001 . 10 AM
Westchester County Dept. of Social Services
85 Court Street
White Plains, NY

August 15, 2001 . 10 AM
*Lockport Public Library
23 East Avenue (rear entrance)
Lockport, NY

Please register early to attend sites marked with (*) because seating is limited. Each seminar will last approximately two hours.

Direct questions about these seminars to CSC as follows:

Please complete the registration information using the link to the form below:

To register, please mail this completed page to:

Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, fax a copy of the completed page to: 518-447-9240

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.

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In the March 2001 edition of the Medicaid Update, we provided you with background information on the Health Insurance Portability and Accountability Act (HIPAA) and the administrative simplification provisions of the Act. HIPAA is a federal law requiring national standards for automated transfer of certain health care data between payers, plans, and providers. As a provider in the Medicaid program, you will be affected by these changes.

This edition of the Medicaid Update focuses on the privacy rule of HIPAA, and provides key components which may impact your current business processes.

Privacy Rule

The privacy rule of HIPAA was published in the Federal Register on December 28, 2000 and became effective April 14, 2001. Most entities will have two years, until April 14, 2003, to comply with the privacy rule provisions. Covered entities include health plans, health care clearinghouses and health care providers who conduct certain administrative and financial transactions electronically.

The privacy rule is intended to ensure the protection of individually identifiable health information and requires that patients be notified of their rights regarding disclosure of their health care information.

The privacy rule has three major purposes:

1. to protect and enhance the rights of consumers by providing consumers access to their health information and controlling the inappropriate use of that information;
2. to improve the quality of health care in the U.S. by restoring trust in the health care system among consumers, health care professionals, and the multitude of organizations and individuals committed to the delivery of care; and
3. to improve the efficiency and effectiveness of health care delivery by creating a national framework for health privacy protection that builds on efforts by states, health systems, organizations and individuals.

Impact on Medicaid

The privacy regulations impact the Medicaid program as follows:

• Individually identifiable health information can be used or disclosed only by a health plan, provider or clearinghouse solely for purposes of health care treatment, payment and operations.
• Health care providers who see patients are required to obtain patient consent before sharing their information for treatment, payment and health care operations.
• Patient authorization for the disclosure of information must meet specific requirements (i.e., signature of individual and date).
• Specific patient consent must be sought and granted for non-routine uses and most non-health care purposes.
• Providers and health plans generally cannot condition treatment on a patient's agreement to disclose information for non-routine uses.
• Providers and health plans are required to give patients a clear written explanation of how they can use, keep and disclose their health information and patients must be able to see and obtain copies of their records.
• Patients have the right to complain to a member provider or health plan about violations of this rule, or the policies and procedures of the entity in question.
• Health plans, providers and clearinghouses that violate any standard of the privacy rule will be subject to civil monetary penalties of $100 per incident, up to $25,000 per person, per year, per standard.
• Federal criminal penalties could be imposed if health plans, providers or clearinghouses knowingly and improperly disclose information, or obtain information under false pretenses.

In addition to the new privacy rule, health information obtained from Medicaid recipients is also protected by other Federal regulations. These regulations provide strict guidelines regarding the disclosure and use of health information for Medicaid enrollees. The privacy rule is not intended to supersede or conflict with these regulations. Instead, the privacy rule supplements the regulations by enhancing the rights of Medicaid recipients in addition to imposing penalties for misuse of the data.

We believe the privacy rule will play a vital role in the security of health information of the Medicaid population. The Office of Medicaid Management plans to work closely with the provider community to ensure that these provisions of HIPAA are appropriately implemented as required. We will address privacy rule provisions in more detail in future Medicaid Updates. Meanwhile, we recommend that providers become familiar with the privacy rule and its potential impact on provider business processes. Additional information is available on the Web at http://aspe.hhs.gov/admnsimp.

Questions about this article can be addressed to Mr. Mario Tedesco of the State Office of Medicaid Management at (518) 257-4496.

(NOTE: Some of the information in the above article is excerpted from the Medicaid HIPAA Plus newsletter published by the Health Care Financing Administration.)

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The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us)

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.state.ny.us/health_care/medicaid/program/main.htm