The Inside SCOOP!!!

WellCare of South Carolina

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Company Highlights

WellCare of South Carolina EQRO Review

1- Coordinated EQRO review process for 2014 that received a score of 87.

2- Coordinated 2014 contract assessment process—95% complete.

3- Implementation of new reporting requirements and new program requirements in 2014 contract.

We would like to thank everyone who contributed and worked effortlessly to make this a success review. Job Well Done Team!!!!

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PseudoClaims- QUALITY

Greetings and Happy New Year fellow associates! Here is an update on some of the latest “news” in the Quality Department. I am sure you have probably heard the word HEDIS and have probably wondered what’s that all about? Well, HEDIS (Healthcare Effectiveness Data and Information Set) is the tool in which a health plan’s measurement performances are compared to each other on an “apple to apple” basis. Some of the measures that are collected (partial listing) are “Asthma Medication Use, Breast Cancer Screening, Comprehensive Diabetes Care, etc.” These results are reviewed by an accreditation body and information is published about how well our company performed. Additionally, if the performance scores are substandard, this has a financial impact toward our company as well as inhibits us from adding new members to the health plan.

This information may be collected administratively by using claim information or we may need the information from the provider’s medical record (Hybrid). There may be times when the provider has provided the right care, but it is not reflective in our data sources, for example, the coding on the claim. Our goal is for the provider to receive credit for the care that is provided to our member. This is where pseudoclaims enter the picture. In a nut shell, our quality staff contacts the provider’s office to make a visit or to request medical records on members listed on the Care Gap report. The CareGap report contains specific HEDIS measures for that specific member. When the information is received, it is reviewed by a nurse who verifies that the information is correct and enters it into a database. The information is then over-read by a different nurse to make sure that all information was entered correctly (each medical record requires 100% over read by a nurse). The information is then entered into a database. A report is received from the corporate office to notify us of any errors in the data that was entered. The errors are corrected in the database by a nurse. We have until the end of February 2015 to get this done! After this process, the information is validated by corporate IT and uploaded to the HEDIS software.

Ok, I know that’s probably more information than you wanted to know, but we all have a piece of the puzzle in making sure that our members get the very best health care and that our company has the very best HEDIS scores! Looking forward to a great and healthy 2015 year!

Provider Visits- Quality

Provider Visits

In 2014 Provider education focused on all things HEDIS. Because Providers play a critical role in the delivery of healthcare by assisting the Plan in ongoing quality initiatives, including outreach to and educating our members, it is imperative that Providers understand the importance of preventive health screenings and age-appropriate exams. The opportunity to reinforce good health care behavior on topics, such as child development, safety issues appropriate to each age group or disease education becomes more apparent if our Providers are familiar with specific HEDIS measures.

Therefore not only did our quality team teach providers basic HEDIS concepts, the team also explained HEDIS Technical Specifications and how these specifications represent the anatomy of a measure. This information provided guidance on comprehensive documentation assuring full compliance for specific HEDIS measures, as well as the importance of Pseudoclaim submissions.

In addition, teaching Providers regarding the need for proper coding when submitting claims allowed increased capture of services rendered.

When we educate our Providers we continue to increase our interactions with members to improve preventive care compliance and recognize that enhanced interactions between provider and member will assist in improving our members’ health outcomes, ultimately and positively impacting our HEDIS scores as well.

HEDIS Call Center

News Update!

During the 4th quarter of 2014, the Quality department implemented a temporary HEDIS Outbound Call Center in order to educate our members about health behaviors with a goal to improve our HEDIS scores. Through telephonic outreach, the call representatives were able to assist our members in closing care gaps by scheduling appointments with their primary care and specialist providers along with transportation if needed. Representatives also assisted with contacting our providers to gather medical records for Psuedoclaims. What a tremendous service not only to the SC quality staff, but to our members. It was and still is our goal to partner with providers to keep our members in the best state of health possible.”

Community Relations- Community Partnerships

WellCare Health Plans, Inc. (NYSE: WCG) and Dawn Staley are partnering to increase the overall health and wellness of low-income South Carolinians, with a focus on those who are Medicaid eligible in the state. As part of the agreement, Staley will serve as spokesperson for WellCare of South Carolina. WellCare presents INNERSOLE with $10,000 to help provide sneakers for children in need throughout South Carolina.

Since its inception in May 2013, INNERSOLE has given sneakers to more than 5, 700 homeless and low-income children in South Carolina. As a result of the work it will do with WellCare and other partners in 2015, INNERSOLE expects to give the gift of new sneakers to 100 percent of the homeless children in the state through 2017. To learn more about INNERSOLE and to contribute to its mission go to

As of Sept 30, 2014, WellCare serves approximately 70,000 Medicaid members, 33,000 Medicare Prescription Drug Plan members and 3,000 Medicare Advantage members in South Carolina.

Financial Update

Finance Restructure

A restructuring of the company’s Finance groups will allow for more collaboration between teams in the markets and corporate Finance. Specifically, South Carolina will align closely with Georgia. This should allow for a culture of excellence and more consistency across the company. In addition, Selena Tention recently joined the SC Finance team. She will continue to support the Quality Improvement team’s need for data and analytical reports, as well as assisting with other Finance goals.

2015 Budget

The 2015 South Carolina budget was approved and exceeded the corporate net income target. Highlights of the 2015 budget include:

· 8 new staff positions

· 80% growth in Medicare membership

· 8% growth in Medicaid membership

· Corporate and market MEI’s that reflect savings to be recognized both from improvement in utilization and in contract savings

To deliver our targeted income for 2015 will require a focused and coordinated effort from all staff – one I have no doubt we are poised and ready to tackle.

PCRI Payments

The inability of SCDHHS to accurately process the Encounter files submitted by all of the “new” MCO’s (WellCare, Advicare, and Molina) continues to be an issue. This affects processing of the PCRI payments for October, 2013 – December, 2014; rate adjustments for risk scores, and other areas of operation. WellCare is continuing to cooperate with the State to provide a solution and/or workaround to this issue, but until this is resolved, we are unable to provide PCRI payments or details to our providers.


A couple of Compliance reports/grids to share and also a thought for the newsletter (Compliance Corner). This could be a quote or brief article. That is something feasible to include? Not sure what you have in mind for space on submissions.

With the new State Contract---

Did you know…

There are 937 Contractual Requirements:

181 Not Actionable

756 Actionable

692 Business Compliant

35 Deemed Non-Compliant

28 Collaboration (working with Business Owners and/or the State to clarify processes or needs additional guidance due to incomplete sections of the P&P)

Thanks for everyone’s support!

WellCare of South Carolina Christmas Lunch- 2014 California Dreaming