Office Visit

Hello, colleagues. 

I am Dr. Lama El Zein, senior medical director for population health and clinician engagement at EmblemHealth. I am also a practicing family physician at AdvantageCare Physicians (ACPNY).* My focus is on care management, creating equitable programs around chronic and advanced illnesses, and value-based care initiatives. 

A Unique Perspective on Population Health

One of our key goals is to help create healthier futures for our members. To help us meet this goal and influence better health outcomes, we are adopting a population health approach. As doctors working as medical directors for EmblemHealth and ConnectiCare, we are uniquely situated to influence population health. Having you as our partners – supported by data and technology – gives us a broader perspective than what we would see from just treating patients in our own medical practices.  

Changing Ourselves First

In adopting a population health approach, the first thing we are changing is ourselves as medical directors. We are redesigning our role from a traditional, reactive, utilization management-focus to a proactive, multifaceted leadership-focus. We are acquiring new skill sets and have staffed our team with diverse personality traits, cultures, and backgrounds. This diversity gives us better insights into those we serve and makes us better partners for you.  

Transitions of Care

Our data helps us uncover opportunities to improve transitions of care across our full range of services. We are in the final stages of transitioning the management of our post-acute care programs from outside relationships to our own teams. This will allow us to build our clinical partnerships with you, optimizing the transition of care experience when a member is discharged home from a hospital, skilled nursing facility, or other inpatient site. We appreciate our hospital partners who offer our members virtual visits post-discharge and are here to support post-discharge visits to reduce readmissions.  

What’s Next?

Next month, we will look at how our population health approach influences our perspectives on primary care and the use of technology. 

Lama

Lama El Zein MD, MHA

Sr. Medical Director/Population Health

If there are other health topics you would like our perspectives on, you may write to us at 

emblemhealthmedicaldirectors@emblemhealth.com.

While we welcome your suggestions, we ask that you do not send protected health information (PHI) or patient-specific issues to this mailbox. This mailbox should not be used for complaints, grievances, appeals, or claims inquiries. Please use the Claim Inquiry and Message Center features in the provider portals (EmblemHealth|ConnectiCare) for those issues.

*AdvantageCare Physicians is part of the EmblemHealth family of companies.

Effective Jan. 1, 2023, EmblemHealth will expand Child Health Plus (CHPlus) covered health services.

View the latest Medicaid Updates from the New York State Department of Health.

Lab testing is highly complex and constantly evolving. Starting March 1, 2023, EmblemHealth and ConnectiCare will begin a new collaboration with Avalon Healthcare Solutions (Avalon) to implement a Laboratory Benefit Management (LBM) program. This will help us stay current and process laboratory claims with greater accuracy and consistency.

Using their expertise in laboratory services, Avalon will review laboratory services performed in office, hospital outpatient, and independent laboratory settings reported on claims (post-service and pre-payment) for adherence and consistency with our laboratory policies and guidelines, as well as industry standardized rules. Avalon will provide routine testing management services with automated review of high-volume, low-cost laboratory tests.

In support of this program, we will be introducing a new payment integrity policy as of March 1, 2023, as well as new and revised reimbursement policies and guidelines.

The new Laboratory Benefit Management Payment Integrity Policy details the program components, including impacted laboratory services, tests, and procedures. It also includes a section of anticipated frequently asked questions (FAQs).

To provide transparency regarding this program and the review standards that will be used, these reimbursement policies and guidelines will be added to the following sections of our websites in the coming weeks for your review:

• EmblemHealth: Reimbursement Policies
• ConnectiCare:  Reimbursement Policies

New Policies

Starting Dec. 1, 2022, in support of the EmblemHealth PAC insourcing initiative discussed above , we are introducing a new Home Health Care Services Reimbursement Policy for both EmblemHealth and ConnectiCare.

Starting Jan. 1, 2023, a new From/To Date Span Policy, Facility and Professional
(Commercial, Medicare, and Medicaid) Reimbursement Policy is being implemented to ensure we are only paying claims with properly documented dates of service. If the date of service submitted for a procedure is out of the “From” and “To” date calendar range or not in the correct format, claims will be denied.

Revised Policies

We have updated two reimbursement policies. See the revision histories for applicable changes and their effective dates.

Medicare Preventive Services lists (EmblemHealth | ConnectiCare)

COVID-19 Vaccine and Monoclonal Antibody Infusions Policy

No Change – Just a New Look

The Unlisted/Unspecified Procedure Codes (Commercial, Medicare, & Medicaid) reimbursement policy has not changed. However, you will now see it documented in our new policy format which applies to both EmblemHealth and ConnectiCare.

Review the EmblemHealth 2023 Formulary Changes to see the updates being made for next year. 

If you need help navigating our provider portals, review our videos, quick guides, and Frequently Asked Questions pages:

EmblemHealth Videos and Guides

EmblemHealth FAQs

ConnectiCare Videos and Guides

ConnectiCare FAQs

If you still have questions or need additional support, you may contact Provider Customer Service:

EmblemHealth: 866-447-9717

ConnectiCare: Commercial: 860-674-5850, Medicare: 877-224-8230

The Pulse8 webinar schedule has been updated with the 2023 course offerings.

EmblemHealth continues to partner with Pulse8™ to promote risk adjustment and gap-closure education for PCPs caring for EmblemHealth members enrolled in these products:

• New York State of Health (NYSOH) Marketplace
• Medicare HMO
• Medicaid

Pulse8 offers free monthly webinars to help educate providers on best practices regarding the risk adjustment process, including accurate medical record documentation and claims coding to capture the complete health status of each patient. We encourage PCPs and/or their support staff to register for Pulse8’s monthly webinars. Go to Pulse8’s Public Event List and search by webinar date or title.


These Pulse8 webinars are generally held on Tuesdays and Thursdays at 8:30 a.m. and 12:30 p.m. Here are the November and December topics:

• Nov. 15/17 – Breathe Easy: A Deep Look at Coding and Documentation for Diseases of the Respiratory System
• Dec. 20/22 – A Survivor’s Guide to Coding for Cancer and Hematology

If you are interested in learning more about how you can access Pulse8’s provider resources and webinars, please contact Pulse8’s Customer Support team Monday through Friday, 8 a.m. to 8 p.m. at 844-8PULSE8 (844-878-5738) or mail to ProviderEngagement@Pulse8.com. 

We recommend that you take advantage of the training opportunities offered by CMS’s Medicare Learning Network and eMedNY.