Latest Announcements

Utilization Management Requests at Bellin

Effective for Dates of Service on or after October 1, 2011

All requests for elective procedures or services to be performed by non-participating providers at an in-network facility will be re-directed to participating providers at participating facilities. However we may approve requests for elective procedures or services if they are not available at in-network facilities. Non-Participating providers include:

• Anima Family Counseling
• Stephen Arbes PDM, FACFAS
• Bellin Anesthesia Associates
• Center for Asthma and Allergy
• Dermatology Clinic, SC
• Gastroenterology Associates
• Neurology Consultants of NE WI
• Neuropsychology of Green Bay
• NEW ENT, SC
• NEW Surgical Associates
• OB/GYN Associates of Green Bay, LTD
• OB Associates of Green Bay – West
• Orthopedic & Sports Medicine Specialists of Green Bay
• Peninsula Podiatry LLC
• Radiation Oncology Specialists of Appleton
• Surgery Specialists of Green Bay
• Urology Associates of Green Bay
• Edward Vanbeek, DPM

Falls Risk Management

Falls among older adults are a costly and preventable health issue. According to the CDC, falls are the leading cause of injury death among people age 65 and older. Falls are also the most common cause of non-fatal injuries and hospital admissions for trauma.

Because of the major impact of this issue, Falls Risk Management is one of Medicare's Health Outcomes Survey core measures. This survey is completed by randomly chosen Medicare beneficiaries and consists of four questions regarding falls risk, falls history, and patient/provider discussion of interventions to prevent falls.

Being asked about falls risk by the health care provider is the most significant influence on preventing future falls. Primary care providers (PCPs) can have a tremendous impact on not only the survey responses given by their patients, but more importantly, on how well patients are prepared to avoid falls and the complications that result from them.

You can make a difference by effectively screening your older adult patients. Interventions that you can discuss include vision and hearing assessment, medication review, and referral to physical therapy for strength and balance assessment. You can also provide your patients with educational materials and offer your at-risk patients' research-based falls prevention programs such as "Stepping On," offered through Network Health Plan.

For more information, review the American Geriatric Association Falls Prevention Clinical Guideline.

Low-impact Fracture Defines Osteoporosis

According to the Agency for Healthcare Research and Quality (AHRQ), osteoporosis causes 90 to 95 percent of all hip and spine fractures and 70 to 80 percent of all forearm fractures in women over the age of 65. One in two women and one in four men will have an osteoporosis-related fracture in their lifetime. At least 90 percent of all hip and spine fractures among older white women are attributable to underlying bone fragility.

Based on AHRQ's clinical guidelines, HEDIS recommends that women age 67 and older have either a bone mineral density (BMD) test or begin medication to treat or prevent osteoporosis within 180 days of sustaining a fracture. In 2010, only 20.6% of Network Health Plan members who fit this criteria met this measure, so providers can make a big impact in this area by ensuring that 100% of at-risk patients are tested or treated.

The following is a list of osteoporosis medications approved by the FDA and NCQA:

SPIROMETRY Required to Confirm COPD

COPD has become the third leading cause of death in the United States and early diagnosis and treatment increases life expectancy and quality of life for those with COPD. The Global Initiative for Chronic Obstructive Lung Disease GOLD recommends that a COPD diagnosis be considered for people over age 40 with one or more of the following indicators:

• Chronic cough
• Breathlessness on exertion
• Chronic sputum production
• Frequent exacerbations of bronchitis
• History of exposure to risk factors, especially tobacco smoke, occupational dusts and chemicals, home cooking and biomass fuels

According to HEDIS measures, spirometry is required two years prior to or six months after a COPD diagnosis. Last year, only 54% of our members with a new COPD diagnosis received a spirometry test within this recommended time frame.  We want to remind providers to order spirometry testing for all our members who are, or who are likely to be, diagnosed with COPD.

Glaucoma Screenings Important For Older Adults

Explain the need for annual screenings (posted 12/10/10)

Please remind your older adult patients about the importance an annual glaucoma screening. The risk for glaucoma is much greater than average after patients reach age 65, and recent Network Health Plan audits show that only 71% of members in this age group were screened last year.*

Glaucoma is the second leading cause of irreversible blindness in the United States. It’s known as the “silent thief of sight” because only half of the more than 4 million Americans who have glaucoma know they have it. Most often the disease is painless, progresses slowly, and presents no symptoms that cause alarm or concern for patients. 

While vision lost to glaucoma cannot be restored, considerable progress has been made in the management of the disease. Glaucoma can be effectively controlled, and sight can be preserved when the condition is detected early through comprehensive screening.

Considering the dire consequences of glaucoma, it’s imperative that all Network Health Plan members in this age group receive their annual glaucoma screenings. Please discuss this with each of these patients at their next visit.

* Represents Network Health Plan members over age 65 (1) without a history of glaucoma, and (2) who have not already been identified as at risk for glaucoma.

Overuse of Antibiotics 

Tips for reducing antibiotics usage among your patients (posted 12/8/10)

Overuse of antibiotics has lead to increasingly wide-spread drug resistance. The Centers for Disease Control (CDC) estimates that 50 percent of the 133 million courses of antibiotics prescribed by doctors each year are unnecessary because they are often being prescribed for colds, coughs and other viral infections. Read more

Incomplete Medical Records

Providers assistance needed to ensure that all patient reports are submitted to their permanent medical records (Posted 11/03/2010)

During a recent medical record audit, it was discovered that the majority of specialists’ consultation reports are not reaching Network Health Plan participants’ permanent primary care medical records. We believe in supporting the ability of our providers to offer quality care, and this includes continuity of patient care and a smooth flow of vital information between providers who are caring for the same person. Consultation reports from specialists are a key part of a patient’s medical record, and we need your help to make sure your reports reach your patients’ permanent records.

Please review your processes to make certain that each of your consultation reports is being submitted to your patients’ Primary Care Physicians so the reports can be placed into your patients’ permanent medical records. By doing this you can help ensure that your patients receive the best possible care and achieve the best possible health outcomes.

Updated Provider Manual

Latest version of the Network Health Plan Provider Manual now available online (Posted 10/25/2010)

The Network Health Plan Provider Manual contains information about our services, contracting with Network Health Plan, as well as an overview of our policies and procedures. Click here to access a copy.

ThedaCare Provider Update

Utilization Management Requests at Theda Clark Regional Medical Center and Appleton Medical Center - Effective for Dates of Service on or after August 1, 2010 (Posted 7/30/2010)

All requests for elective procedures or services to be rendered by non-participating providers at a plan facility will be re-directed to participating providers at participating facilities.  However, our Medical Director may approve requests for elective procedures or services if  they are not available at in-network facilities.

Non-Participating Specialists include:

• Children’s Hospital of Wisconsin – Fox Valley and physicians
• Fox Valley Pulmonary Medicine, LLC
• Radiation Oncology physicians of Appleton Radiology Associates (Radiation Oncologists on the campus of Appleton Medical Center)