pcp meeting 5/23/2012
DESCRIPTION
Michigan Primary Care Transformation Demonstration Project Primary Care Physicians and Practice Teams May 23, 2012TRANSCRIPT
Michigan Primary Care Transformation Demonstration Project
Primary Care Physicians and Practice Teams
May 23, 2012
Agenda
Demonstration Project Update
• Care Managers
• Transformation Payments
• Participating Payers
• Process and Outcome Metrics
• Pay for Performance
Interesting Facts
Surveys
Comments on transformation activities in Michigan
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Care Management Training Guidelines
• Services provided by Moderate Care Managers are billable AFTER Care Managers complete approved self-management training
• Services provided by Complex Care Managers are billable AFTER Care Managers have completed approved Complex Care Management training
• PDCM*-codes should not be billed by untrained care managers
(PDCM: Provider Delivered Care Management)
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Provider Requirements: Care Management Team
Individuals performing PDCM services must be qualified non-physician practitioners employed by practices or practice-affiliated POs approved for PDCM payments
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Provider Requirements: Care Management Team
The team must consist of:
• A lead care manager : RN, LMSW, CNP or PA who has completed an MiPCT-accepted training program
• Other qualified allied health professionals:
• LPN, LVN, CDE, RD, Nutritionist Master’s Level, Pharmacist, respiratory therapist, certified asthma educator, certified health educator specialist (bachelor’s degree or higher), licensed professional counselor, licensed mental health counselor
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Provider Requirements: Care Management Team
Each qualified care team member must:
• Function within their defined scope of practice
• Work closely and collaboratively with the patient’s clinical care team
• Work in concert with BCBSM, BCN, or other participating payer’s care management nurses as appropriate
Note: Only lead care managers may perform the initial assessment services (G9001)
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BCBSM Patient Eligibility
The patient must have active BCBSM coverage that includes the BlueHealthConnection® Program. This includes:
• BCBSM underwritten business
• ASC (self-funded) groups that elect to participate
• Medicare Advantage patients
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Services billed for non-eligible members will be rejected with provider liability.
BCBSM Patient Eligibility
Checking eligibility:
• Eligible members with PDCM coverage will be flagged on the monthly patient list
• Providers should also check normal eligibility channels (e.g., WebDENIS, CAREN IVR) to confirm BCBSM overall coverage eligibility
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Services billed for non-eligible members will be rejected with provider liability.
BCBSM Patient Eligibility
The patient must be an active patient under the care of a physician, PA or CNP in a PDCM-approved practice and referred by that clinician for PDCM services
• No diagnosis restrictions applied
• Referral should be based on patient need
The patient must be an active participant in the care plan
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Services billed for non-eligible members will be rejected with provider liability.
Recent BCBSM Developments
All underwritten groups are participating
Self-Funded groups that have joined:
• URMBT, Zeledyne, Severstal, Magna, Visteon, Gordon Foods
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BCBSM High Deductible Health Plans
Only members who have a High Deductible Health Plan with a Health Savings Account will be financially liable for PDCM services
To identify the amount of cost share, providers can use Web-DENIS or CAREN IVR to verify if deductible has been met
• Amount of payment will vary based on where member is at in fulfilling their deductible requirement
• Patient cost share can be identified by looking in the patient liability column, similar to what you would see for any other patient
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BCBSM General Conditions of Payment
For billed services to be payable, the following conditions apply:
• The patient must be eligible for PDCM coverage.
Non-approved providers billing for PDCM services will be subject to audit and recoveries.
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BCBSM General Conditions of Payment
For billed services to be payable, the following conditions apply:
• The services must be delivered and billed under the auspices of a practice or practice-affiliated PO approved by BCBSM for PDCM reimbursement.
• Based on patient need
• Ordered by a physician, PA or CNP within the approved practice
• Performed by the appropriate qualified, non-physician health care professional employed or contracted with the approved practice or PO
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BCBSM Billing and Documentation: General Guidelines
The following general billing guidelines apply to PDCM services:
• Approved practices/POs only
• Professional claim
• 7 procedure codes
• PDCM may be billed with other medical services on the same claim
• PDCM may be billed on the same day as other physician services
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BCBSM Billing and Documentation: General Guidelines
• No diagnostic restrictions
• All relevant diagnoses should be identified on the claim
• No quantity limits (except G9001)
• No location restrictions
• Documentation demonstrating services were necessary and delivered as reported
• Documentation identifying lead CM isn’t required, but documentation must be maintained in medical records identifying the provider for each patient interaction
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PDCM Codes
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CODE SERVICE
G9001 Initial assessment
G9002 Individual face-to-face visit (per encounter)
98961 Group visit (2-4 patients) 30 minutes
98962 Group visit (5-8 patients) 30 minutes
98966 Telephone discussion 5-10 minutes
98967 Telephone discussion 11-20 minutes
98968 Telephone discussion 21+ minutes
BCN PDCM Payment Policy
BCN will pay the lesser of provider charges or BCN’s maximum fee
• CNPs or PAs paid at 85%
No cost share imposed on members
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BCN General Conditions of Payment
For billed services to be payable, the following conditions apply:
• The patient must be eligible for PDCM coverage.
• The services must be delivered and billed under the auspices of a practice or practice-affiliated PO approved by BCN for PDCM reimbursement.
• Billed in accordance with BCN billing guidelines
Non-approved providers billing for PDCM services will be subject to audit and recoveries.
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BCN Patient Eligibility
Provider panels are available through Health e-Blue web
The patient must be an active patient under the care of a physician, PA or CNP in a PDCM-approved practice No diagnosis restrictions are applied
• Order for PDCM should be based on patient need
The patient must be an active participant in the care plan
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Services billed for non-eligible members will be rejected with provider liability.
Medicaid Patient Attribution
Medicaid managed care population only
Attributed member:
• Medicaid beneficiary enrolled in a Medicaid Health Plan AND
• assigned Primary Care Provider is affiliated with participating practice/PO
Enrollee Lists
• Attribution process occurs on the first business day of the month
• Medicaid enrollee lists submitted to Michigan Data Collaborative (MDC)
• MDC will post enrollee lists on MDC secure site for retrieval by PO –Automated message from MIShare at UMHS
• PO responsible for transmitting enrollee lists to practices
Medicaid Payment Calculation
Medicaid payments calculated as Per Member Per
Month (PMPM) based on monthly attribution
counts:
• $1.50 PMPM Practice Transformation paid to Practice
• $3.00 variable payment based on performance paid to PO
Provider Enrollment Required for Payment
PO’s will be enrolled as an MCO in CHAMPS
system by DCH.
Practices must enroll as either an individual sole
proprietor or as a group in Medicaid CHAMPS
system.
PO Enrollment questions: [email protected]
Provider Enrollment questions: 800-292-2550
Payment Timing
• Quarterly EFT payments appear as gross adjustment
• Reconcile payment amount with your enrollee list
• Payments released mid month after end of the quarter
–April (QTR 1)
–July (QTR 2)
–October (QTR 3)
• Regularly check the Payment Update Tab on MIPCTdemo.org for new/updated information
• Payment questions: [email protected]
UMHS CMS Payment Processing and Distribution to POs
CMS does not have a mechanism to pay POs directly
individual line item remittances to UMHS (as they did
for practice transformation to the practices).
Though not ideal, CMS will not change their practice –
thus UMHS must receive, reconcile and then
distribute payments
Work is underway and a front-end application has
been built to:
- Reconcile claims with member lists
- Calculate PO payments
UMHS CMS Payment Processing and Distribution to POs
This will result in a payment delay for the first set of
care coordination payments. Goal is to distribute to
POs by early June. Earlier if at all possible.
Afterward UMHS will work to get on a regular cycle of
payment distribution.
Interesting Facts…
18 MNO PCMH currently participating in MiPCT
35 Primary Care Physicians one referral physician co-
located in PCP PCMH
Participation continues as long as PCMH designation
is maintained
Two practices are being reviewed by BCBSM
Attributed/Assigned population varies monthly
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Interesting Facts: E&M Uplift
Four physician family practice: $91,654
Four physician pediatric practice: $68,546
Two physician adult practice: $48,929
Solo family physician: $10,984
Average amount: $11,777
Medical Network One PCMH: $412,197
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Interesting Quality Scores
7 PCPs with poor quality and cost scores de-
participate
PCP highest aggregate quality score
• Anchor Bay Clinic: 78.50%
• Macomb Pediatrics: 85.92%
PCP lowest aggregate quality score
• Adult medicine: 42.10%
• Pediatrics: 20.00%
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Interesting Quality Scores 2011*
BCN Average 71.36%
BCBSM Average 68.02%
(MiPCT PCP cohort)
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Metrics
Six months:
• Patient registry
• After hours access
• Moderate Care Managers hired, trained and working
• Complex Care Managers hired, trained and working
• Moderate/Complex Care Managers=Hybrid Care Managers
• HEDIS Specific Clinical and Process Measures
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Diabetes
Ages 18-75 Type 1 or 2 1. A1C 2. Poor Control A1c>9 3. Control A1c< 8 4. LDL-C Test 5. LDL-C Controlled < 100 mg/dl 6. BP <140/90 7. Retinal Eye Exam 8. Nephropathy Screen or Evidence of Nephropathy*
32
Asthma
Self-Management Plan
Asthma Action Plan
(ages 5-50) Non HEDIS
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Performance Incentive Payment Process
Health plans contribute $3.00 PMPM to the incentive program pool
Metrics are assessed every six months and points are calculated for each PO
POs are ranked by total points and grouped into payment categories
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Performance Incentive Payment Process
Entire pool is paid out in variable amounts based on ranking
PO retains the agreed upon percentage 20%
PO distributes 80% to the PCMH
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Issues in 3 x 5