Pay for Performance Program Guidelines

Transcription

1 Pay for Performance Program Guidelines Health Plan of San Mateo s (HPSM) Pay for Performance (P4P) program offers monetary rewards for practices that provide high quality of care for HPSM Medi-Cal members. The incentives focus on member access and preventative care services that support HPSM s current quality improvement goals. We have designed our P4P program for success success for you, for our members and for HPSM. This quality initiative can improve health outcomes for our members by aligning the care you want to provide, as recommended by evidence-based best practices, with the financial incentives that help show we value the time you spend caring for our Medi-Cal members. Thank you for partnering with us to improve the care of our members. Eligibility Primary care providers (PCPs) who have a Medi-Cal contract with the Health Plan of San Mateo may receive Pay for Performance incentives. Obstetricians serving our Medi-Cal members may participate in the prenatal care, postpartum, and women s health incentives. Incentive payments are made in addition to all other reimbursement received for services, such as capitation. Incentives are applicable to Medi-Cal members enrolled with HPSM. This includes members dually enrolled with Medicare, HPSM CareAdvantage and CareAdvantage Cal MediConnect members. Most incentives are available once per eligible members per calendar year, unless otherwise specified in the incentive description below. Support If you have questions about our P4P program, please contact Nicole Ford, Quality Improvement Manager at (650) or nicole.ford@hpsm.org. Page 1 of 11

2 Pay for Performance Incentives INCENTIVES Extended Office Hours Additional 10% of your monthly capitation payment Payment is included in your monthly capitation check Patient Auto-Assignment Additional 20% of your monthly capitation payment Payment is included in your monthly capitation check Body Mass Index (BMI) $25 Available per assigned Medi-Cal member per calendar year. Paid with your regular Medi-Cal remittance advice (RA) Have at least 8 hours per week (in addition to your contracted 40 per week) that are held after 6 PM on weekdays and/or any time on weekends. The extended hours must be clearly posted in your office and are not by appointment. Contact your Provider Services Representative to verify your extended office hours. Accept auto-assignment of patients to your Medi-Cal panel (provided they meet appropriate age, sex and scope of practice criteria for your practice). You must have a least 30% of your Medi-Cal panel open to start accepting auto-assigned members. (The number of Medi-Cal members assigned to you compared to the maximum number set for your practice must be at least 30%.) Maintain at least 15% open capacity in your Medi-Cal panel that can be filled by additional members. If your open capacity falls below 15%, then the incentive amount will be reduced to only an additional 10% of your capitation. You can no longer receive the auto-assignment incentive if your Medi-Cal panel is full. Contact your Provider Services Representative to add or remove auto-assignment of patients, discuss your current Medi-Cal panel size, and change your Medi-Cal capacity limit. 1. Measure the BMI and BMI percentile (ages 2-20) of each of your patients (adult or child) annually. For adults (ages 21 years and older), record height, weight and BMI in the patient s medical record For pediatrics (ages 2-20 years), complete the Pediatric BMI form provided by HPSM and retain in the patient s medical record For babies (<2 years), measure and record the weight-forlength percentile in lieu of BMI 2. Bill HPSM with CPT code 99411, modifier WT and a BMI diagnosis code (see Appendix). Include nutritional and physical activity counseling diagnosis codes as well for pediatric members Page 2 of 11

3 INCENTIVES Initial Health Assessment $90 Paid with your regular Medi-Cal remittance advice Child Well Visit $90 Available once per eligible member per calendar year. Paid with your regular Medi-Cal remittance advice 1. Perform an initial health assessment (IHA) of new members (all ages) within 120 days of HPSM enrollment that includes: Full history with evaluation of physical, behavioral, and emotional growth and development Complete physical exam Diagnosis(es) and care plan Age specific anticipatory guidance 2. Complete the Staying Healthy Assessment (SHA) Tool 3. Bill the visit with the appropriate IHA CPT code for a new visit. See list of IHA codes in the Appendix. For children ages 3-6 years old: 1. Perform an annual well visit that includes: Full/interval history with evaluation of physical, behavioral, and emotional growth and development Complete physical exam Age specific anticipatory guidance 2. Complete the SHA Tool 3. Bill the visit with the appropriate CPT code for a child well visit. See list of child well visit codes in the Appendix. Please note: this is in addition to the periodic visits determined by CHDP. Do NOT confuse this incentive with CHDP. This annual incentive occurs in accordance with the periodicity guidelines of the American Academy of Pediatrics. Thus, providers should schedule these annual visits and the incentive WILL BE PAID if billed correctly to HPSM, separate from CHDP. Page 3 of 11

4 INCENTIVES Teen Well Visit $90 Available once per eligible member per calendar year. Paid on your regular Medi- Cal remittance advice For teens ages years old: 1. Perform an annual well visit that includes: Full/interval history with evaluation of physical, behavioral, and emotional growth and development Complete physical exam Age specific anticipatory guidance 2. Complete the SHA tool 3. Bill the visit with the appropriate CPT code for an adolescent well visit. See list of child well visit codes in the Appendix. Please note: this is in addition to the periodic visits determined by CHDP. Do NOT confuse this incentive with CHDP. This annual incentive occurs in accordance with the periodicity guidelines of the American Academy of Pediatrics. Thus, providers should schedule these annual visits and the incentive WILL BE PAID if billed correctly to HPSM, separate from CHDP. Women s Health Exam $90 Available once per eligible member per calendar year Paid on your regular Medi- Cal remittance advice For Women years old: 1. Perform each of the following: Cervical (Pap smear) or vaginal cancer screening Full pelvic exam Clinical breast exam 2. Bill HPSM with procedure (HCPCS) code G0101 and an appropriate diagnosis code Page 4 of 11

5 INCENTIVES Depression Screening $30 Available once per eligible member per calendar year. Paid on your quarterly P4P remittance advice. Post-discharge Visit $90 Available per hospitalization, excluding discharges with diagnosis of pregnancy or conditions in the perinatal period Paid on your quarterly P4P remittance advice. 1. For adults (18+ years old), conduct a screening for depression using HPSM s behavioral health consolidated screener or any standard depression screening tool. 2. Bill HPSM with procedure (HCPCS) codes: G8510 for negative screen, or G8431 for positive screen and follow-up plan documented. If HPSM s consolidated screening tool is used, you can also bill alcohol screening with H0049, a $24 Screening, Brief Interventions, and Referral to Treatment (SBIRT) Medi-Cal benefit. Not available with or after billing G0444 within the calendar year. 1. See the assigned adult (21+ yrs.) member within 14 days after he/she is discharged from the hospital: Review the hospital discharge summary and plan, Conduct a clinical assessment, Reconcile medications and document in the medical record 2. Bill for the type and scope of visit. Qualifying outpatient CPT codes include , , , , 99420, 99455, Page 5 of 11

6 INCENTIVES Diabetes Management HbA1C test = $30 LDL-C test = $30 Retinal eye exam = $30 Nephropathy screening = $30 HbA1c control = $65 LDL-C control = $65 Available to you once per assigned member with diabetes per calendar year Paid with your quarterly P4P remittance advice. *Any lab results, chart notes or prescriptions faxed to HPSM must be signed by you and dated to be eligible for the incentive. 1. Order and ensure completion of recommended tests/checkups: HbA1C, LDL-C, retinal eye screening by an eye specialist, and nephropathy screening. When HPSM receives lab results, clinical notes or claims evidence that these tests have been completed, you will get an incentive for each test. 2. Monitor test results and achieve the following range: HbA1C Adults: < 8% Pediatric: Ages < 6: 8.5%; Ages 6-12: 8%; Ages 13-19: 7.5% LDL-C < 100 mg/dl When HPSM receives lab results that the HbA1C and LDL-C are in the desired ranges, you will get an incentive. Blood and Urine Tests/Results: HPSM is usually notified that a test is performed when the lab bills for the test. HPSM also receives lab result data results directly from our hospital labs and the most utilized private outpatient labs. This currently includes San Mateo Medical Center, Quest Diagnostics laboratories, Seton Medical Center, Mills-Peninsula Medical Center and Sequoia Hospital.. If your patients are using other labs for diabetes testing, you may fax lab result reports* to us at (650) Other Evidence of Nephropathy Screening: Treatment with an ACE or ARB inhibitor is considered de facto evidence of nephropathy screening. A chart note* or copy of a prescription* of these medications faxed to HPSM at (650) serves as evidence of this component. Evidence of Ophthalmology Screening: If your patient s ophthalmology consultant bills for the retinal eye exam, that will be sufficient evidence of the screening. Documentation in the patient s chart of a consult note from the specialist indicating this test was done and faxed to HPSM at (650) also serves as evidence of this component.* Page 6 of 11

7 INCENTIVES Referrals by PCP to OB physicians $50 Available per pregnancy Paid on your quarterly P4P remittance advice. OB Visit by OB physician $100 Available per pregnancy Paid with your quarterly P4P remittance advice. Postpartum exam by OB/Gyn physician $50 Available per pregnancy 1. Identify pregnant women as early in pregnancy as possible. 2. Refer the pregnant woman to an OB provider immediately. 3. Help the pregnant woman make an appointment with an OB provider in the woman s first trimester. 4. Complete the HPSM OB referral verification form. 5. Fax the verification form to HPSM at (650) Pads of verification forms are available. A copy of the form can also be found online at 1. Accept referrals from PCPs or other entities to see HPSM pregnant women 2. See HPSM pregnant women in their first trimester. 3. Complete the HPSM OB visit verification form. 4. Fax the verification form to HPSM at (650) Pads of verification forms are available. A copy of the form can also be found online at 1. Perform a postpartum exam on HPSM members within 21 to 56 days after delivery. 2. Bill HPSM with CPT code 59430, modifier PP and indicate the date of delivery on the remarks section of the claim. Paid on your regular Medi- Cal remittance advice Immunization Registry Once you are actively updating patient records, you will get an incentive of $1.00 for every HPSM Medi-Cal member 0-19 years old per month added to your capitation payments. 1. Any PCP caring for pediatric patients needs to join the California Immunization Registry (CAIR). Contact Health Education department at (650) After your practice is signed up and trained to use CAIR, each patient s complete vaccination record must be entered and updated in the registry with each new immunization administered. More information about the CAIR can be found at Page 7 of 11

8 Reports HPSM provides you with quarterly P4P progress reports to assist you as you work throughout the year in HPSM s P4P program. The reports: List each incentive and show how many patients you have who are eligible for the incentive. This is based on our records (e.g. how many diabetics you have, how many total Medi-Cal members you have assigned to you who are eligible for the BMI incentive, etc.). List how many eligible members you have billed for or submitted forms List how much money you have earned List how much more money you are eligible for, if you perform more of the measures in the program. List member names and HPSM ID numbers of the members you have seen and the ones you have not seen. You can use the lists to do chart pulls if you know you have seen members and have data, but haven t submitted to HPSM; or call members if it is time for their well visit or check-up, so you can perform their needed medical care and bill for your incentives at the same time. Resources As HPSM works with you on our P4P program, we recognize that, in addition to the impact and importance that it has for you, your staff and your practice, it also will impact the group we both care for our patients/members. Free Health Education Materials We realize that, with more focus on obesity and weight management, diabetes and other health conditions, our members may turn to you and to HPSM for assistance on how to address these problems. To prepare for this need, HPSM has health education materials in each of these areas. These resources are available in both English and Spanish, If our members are interested in additional health education materials, have them call our Health Education line at (650) Free Health Education Classes that Support P4P HPSM offers free health education classes on a variety of health topics like diabetes, weight management, and prenatal care. We strongly encourage you to refer our members to these classes. We update our class listings twice a year. You may request copies of the latest class schedule for your office by calling our Health Education line at (650) Page 8 of 11

9 If you need any other health education resources that you or your office staff think would be helpful for our members, please let us know. We appreciate working in partnership with you in caring for our members. Feel free to contact our Health Education line with your ideas and suggestions. Terms and Conditions Participation in HPSM s P4P program, as well as acceptance of incentive payments, does not in any way modify or supersede any terms or conditions of any agreement between HPSM and the provider. There is no guarantee of future funding for, or payment under, any HPSM P4P incentive programs. HPSM s P4P Program and/or its terms and conditions may be modified or terminated at any time, with or without notice, at HPSM s sole discretion. In consideration of HPSM s offering of its P4P program, provider agrees to fully and forever release and discharge HPSM from any and all claims, demands, causes of action, and suits, of any nature, pertaining to or arising from the offering by HPSM of the P4P Program. Any monies paid under the P4P program for services deemed inappropriately submitted will be recouped from future payment. All cases of suspected fraud or abuse will be investigated thoroughly and reported to the appropriate authorities. Feedback This P4P program is dynamic and continues to improve with suggestions from our provider network. If you have any ideas about ways to make our program even better, please contact Nicole Ford, Quality Improvement Manager, at nicole.ford@hpsm.org or (650) Page 9 of 11

10 Appendix Body Mass Index (BMI) diagnosis (ICD-10) codes: ADULT BMI adult codes are for use for persons over 20 years old. BMI ICD-10 Code < 20 Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z68.45 PEDIATRIC Note: BMI pediatric codes are for persons 2-20 years old. These percentiles are based on the growth charts published by the Centers for Disease Control and Prevention (CDC) BMI Percentile ICD-10 Code < 5th % for age Z % to < 85% for age Z % to < 95% for age Z % for age Z68.54 Nutrition Counseling Z71.3 Physical activity Counseling Z71.89 Page 10 of 11

11 Diagnosis Codes to use with IHA and Adolescent Well Visits: Diagnosis (ICD-10) Codes Code Definition Z Health examination for newborn under 8 days old Z Health examination for newborn 8 to 28 days old Z Encounter for routine child health exam with abnormal findings Z Encounter for routine child health exam without abnormal findings Z00.00 Encounter for general adult health exam without abnormal findings Z00.01 Encounter for general adult health exam with abnormal findings Z00.8 Encounter for other general examination Z02.0 Encounter for examination for admission to educational institution Z02.1 Encounter for pre-employment examination Z02.2 Encounter for examination for admission to residential institution Z02.3 Encounter for examination for recruitment to armed forces Z02.4 Encounter for examination for driving license Z02.5 Encounter for examination for participation in sport Z02.6 Encounter for examination for insurance purposes Z02.71 Encounter for disability determination Z02.79 Encounter for issue of other medical certificate Z02.82 Encounter for adoption services Z02.89 Encounter for other administrative examinations Z02.9 Encounter for administrative examinations, unspecified Page 11 of 11