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ProviderView Quarterly eNewsletter

October 2019

We Hear You: Patient Survey Results

We Hear You: Patient Survey Results

In a recent survey of Avera Health Plans members, 84% of respondents said their physician usually or always listened to them carefully.

This reflects a positive experience by most patients, but the response has trended slightly downward over the last two years.

Research confirms these simple practices improve the way patients feel about their provider:

  • Smile, make eye contact, and greet the patient using their first name.
  • Introduce yourself and shake hands with the patient and others in the room.
  • Apologize if you are late.
  • Sit down, lean slightly forward, and face the patient.
  • Don’t interrupt.
  • Encourage questions.
  • Let the patient know you have reviewed their chart and what you have learned.

Behavioral Health Appointment Access Standards

Behavioral Health Appointment Access Standards

To ensure Avera Health Plans members have timely access to services, providers are required to comply with set standards for appointment access.

The minimum appointment access standards are:

Behavioral Health Appointment Access Standards

Avera Health Plans Offers New Drug Formulary Lookup Tool

Avera Health Plans Offers New Drug Formulary Lookup Tool

Providers can use a new Avera Health Plans drug formulary search tool to identify whether or not a specific drug will be covered by the plan. The tool allows providers to search by therapeutic class, or enter the name of a brand or generic drug in the search bar.

This new tool offers providers two important benefits:

  • Communication. This serves as an enhancement to the static formulary .pdf documents provided by the pharmacy benefit manager (PBM) which were only provided on a quarterly basis. Formulary information is currently updated on a weekly basis.
  • Transparency. Providers can rely on near real-time formulary information to assist in prescribing efforts. The tool eliminates the guesswork and can decrease the administrative burden of PA submission for formulary exception requests by identifying covered drugs at the initial point of prescribing.

It’s important to note that the formulary navigator is not a drug pricing tool. Drug pricing is available to current members via the PBM’s pharmacy resources website only.

DAKOTACARE group members will have access to the benefits of this tool effective Jan. 1, 2020. For more information, please visit the DAKOTACARE website.

Visit the Pharmacy Benefits page to learn more.

Introducing Provider Relations Specialist Maggie Schmidt

Introducing Provider Relations Specialist Maggie Schmidt

The Avera Health Plans and DAKOTACARE Provider Relations team is excited to welcome Maggie Schmidt as a new Provider Relations Specialist.

Maggie received her Master’s of Public Health from the University of South Dakota and developed an interest in insurance while she worked for a local orthodontist as an office manager and then for a counselor.

As a Provider Relations Specialist, Maggie is responsible for initiating the contracting and credentialing process of new and existing network providers. She communicates regularly with providers and their staff to ensure Avera Health Plans and DAKOTACARE are doing everything possible to make provider practices run smoothly so that physicians are able to focus on patient care.

“I highly enjoy assisting providers who are directly serving and impacting the lives of our members,” Schmidt said. “I am proud to be a part of the Provider Relations team and look forward to creating lasting relationships with our network providers and their staff.”

Avera Health Plans and DAKOTACARE Are Moving

Avera Health Plans and DAKOTACARE Are Moving

On Nov. 18, 2019, Avera Health Plans and DAKOTACARE will be moving to a new Sioux Falls location: 5300 S. Broadband Lane.

The Avera Insurance Division campus currently occupies two buildings off of 49th Street and Elmwood Avenue. The move, expected to be completed by the end of November, will consolidate the organization under one roof.

“We are excited to move into this new space, which will help us continue to meet the needs of our members and providers,” said Avera Health Plans CEO Deb Muller. “As we expand our teams and services, our new campus will allow our organization to accommodate that growth.”

Attention: Contracted Durable Medical Equipment (DME) Providers

Attention: Contracted Durable Medical Equipment (DME) Providers

During the transition between 2015 and 2016, the Centers for Medicare & Medicaid Services (CMS) implemented a new durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule methodology. This methodology incorporated data from its competitive bid program (CBP) into its pricing methodology for non-competitive bidding areas (CBA). Avera Health Plans notified our DME suppliers that we would continue to use the 2015 DMEPOS basis values while the changes in the underlying CMS DMEPOS values continued to be evaluated. During this transition, fixing our DME pricing to the 2015 CMS DMEPOS values was favorable to the DME community at large as CMS pricing was generally taking some pretty significant reductions in certain DME categories. New codes added after 2015 were added based on current year CMS DMEPOS values as there would not have been 2015 values for reference.

Since that time, we have continued to evaluate the CMS DMEPOS pricing structure and believe that it has matured and stabilized since 2016. As a result, Avera Health Plans will implement the current year CMS DMEPOS values for all codes beginning Jan. 1, 2020. Under this approach, we will use the higher value of the Rural or Not Rural columns in our calculations.

This action will make Avera Health Plans DME pricing consistent with what we apply within our current Universal Physician Fee Schedule. It will also be consistent with current DMEPOS pricing applied through DAKOTACARE for our DME suppliers. Contact our Provider Relations team if you have questions or need fee schedule data.

Attention: Free-Standing Skilled Nursing Facilities

Attention: Free-Standing Skilled Nursing Facilities

On July 31, 2018, the Centers for Medicare & Medicaid Services (CMS) published the Prospective Payment System (PPS) and Consolidated Billing for Skilled Nursing Facilities (SNF) Final Rule for Fiscal Year (FY) 2019. In this rule, CMS finalized a proposal to replace the current SNF PPS Resource Utilization Group (RUGs) payment model with a new per-diem payment system called the Patient-Driven Payment Model (PDPM) beginning on Oct. 1, 2019.

Avera Health Plans intends to continue to use the Resource Utilization Groups, version IV (RUG-IV) system for those SNFs who are currently contracted on a RUG-IV basis, through at least June 30, 2020. If your contracted SNF payment methodology with Avera Health Plans is RUG-IV-based, please continue to format your claims using the traditional RUG-based reporting system. Contracted SNF providers whose methodology is older and not RUG-IV-based can format and report under PDPM.

If you are a SNF that needs to remain on RUG-IV-based reporting and believe that your business platform is going to have difficulty with reporting the RUG-based format after Oct. 1, please reach out to a member of our Provider Relations team. If you are uncertain that your SNF is impacted or have additional questions, please contact Avera Health Plans Provider Relations staff for assistance.

  • Mike Dooley – Director of Provider Contracting – 605-322-4634
  • Scott Jamison – Manager of Provider Relations – 605-504-3141
  • Michael Nour – Manager of Provider Contracting and Configuration – 605-322-4596
  • Maggie Schmidt – Provider Relations Specialist – 605-322-3643

LiveNOW: Avera’s Personalized Approach to Population Health

LiveNOW: Avera’s Personalized Approach to Population Health

Population health strategies help members get the right care at the right time and in the right place—an approach that reduces the overall cost to members and improves outcomes. Avera encourages members to get an annual wellness physical, which can detect early signs of disease risk and help members manage an existing diagnosis.

Avera offers its employees (and spouses enrolled in the Avera Health Employee Health Plan) the opportunity to participate in its comprehensive employee well-being program called LiveNOW. This program includes a health risk questionnaire, an annual health screening, health coaching (self-referred and clinician referral) and a desktop portal and mobile app.

How does this information impact you? LiveNOW works with your care team to meet the patient’s needs.

There are two ways that an employee can participate in a LiveNOW health screening:

  • Call a primary care provider (PCP) office to schedule a LiveNOW screening and have all the measures collected and recorded in the physician’s office.
    • The patient will have an Alternative Method Screening (AMS) form used by the nurse to record all the required measures (including waist circumference). The participant will fax, email or mail the completed form to the LiveNOW team.
  • Schedule an onsite screening with the LiveNOW team and have a point-of-care screening completed at the member’s worksite.

Why is a patient given the option to complete a point-of-care screening instead of going to their PCP?

The worksite screening conveniently only takes 15 minutes. The point-of-care screenings are not intended to be a diagnostic test and are not intended to replace an annual wellness physical with a PCP.

What measures are included in the LiveNOW health screening?

  • Blood pressure
  • Body mass index (height and weight)
  • Waist circumference
  • Lipids (total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides)
  • Glucose
  • Nicotine metabolites (only for Avera Health Employee Health Plan members)

One of the required measurements of a LiveNOW health screening is a waist circumference, which helps care teams get a full picture of a member’s health risk. We appreciate your support in collecting all the required measurements needed to complete a LiveNOW screening.

What is done with the data collected during the LiveNOW health screenings?

Members who complete the LiveNOW health risk questionnaire and the health screening receive four individualized reports that are available on their LiveNOW desktop portal or mobile app. These reports give members a comprehensive understanding of their five-year risks for a number of chronic conditions (CHD, stroke, diabetes, CHF, COPD and lung cancer) and provide them with personalized next steps to help lower their modifiable risk factors.

In 2020 and beyond, Avera Health Plans and DAKOTACARE will take LiveNOW into the market to help employers manage their population’s health and enhance their employee well-being benefit.

Thank you for being a partner in the population health management of members being served by your facility, Avera Health Plans and DAKOTACARE. If you have any questions about LiveNOW, please do not hesitate to call us at 605-504-LIVE (5483) or email us at