Premium Designation Questions

Transcription

1 Premium Designation Questions Q. Are all doctors going to be Tier 1? A. All Primary Care Providers Family Practice, Internal Medicine, OB GYN, and Pediatrics will be considered at the Tier 1 Level for 2015 ONLY. Then in 2016 and beyond, it will be depend upon their Tier designation on the UMR website. For all other specialties, there will still be a Tier 1 or Tier 2 Designation for Q. Consideration to add Nurse Practitioners to Tier 1. A. Nurse Practitioners/Physician Assistants are not part of the Premium Designation program. NP/PA s are not able to provide the complete range of care that medical doctors are able to. The Premium Designation program is based on the quality standards and cost efficiency processes applied to medical doctors. If the bill comes in under the supervising provider, the Plan will make an accommodation for 2015 to allow claims received from a primary care doctors (Family Practice, Internal Medicine, Ob GYN, Pediatrics) to be processed at the Tier 1 level of benefits for If the provider is a specialist the benefits will depend on whether that specialist is Tier 1 or Tier 2. Q. I heard the representative from UMR state there were approximately 66,000 in network doctors. Can you provide us with the number that reached Tier 1 status? What proportion of area providers are Tier 1 vs Tier 2 A. There are 643,554 physicians listed on the Choice Plus network site in the United States. Of these 106,707 have a Tier 1 Premium Designation status. Please note that not all specialties are currently included in the Premium Designation program, and there are certain areas of the U.S. that are also not currently included in the program. Within a 20 mile radius of Green Bay, WI there are 1,501 physicians listed on the Choice Plus network site, of these there are 219 included with a Tier 1 Premium Designation status. A reminder that the Premium Designation program does not include all the specialties listed in the network. Q. How do I check to see if my doctor is Tier 1? A. There are instructions on page 7 of the booklet at ubdepartment=e28d8e8b1fe6 If an employee has further questions they can contact UMR for assistance at

2 Q. If a specialty like Nurse Practitioner is not in Tier 1, is it automatically Tier 2? A. Yes, but if they are billing under a primary care provider, it will be allowed at the Tier 1 level of benefits because an accommodation has been made for 2015 to allow primary care providers (Family Practice, Internal Medicine, Ob GYN, Pediatrics) to be processed at the Tier 1 level of benefits. Q. How are doctors evaluated to be Tier 1? Who evaluates the doctors, what is the process to become Tier 1? Are the benchmarks & standards for Tier 1 listed? A. The UnitedHealth Premium physician designation program uses clinical information from health care claims and other sources to assist physicians in their continuous practice improvement and to help consumers make more informed and personally appropriate choices for their medical care. The program uses evidence based, medical society, and national industry standards with a transparent methodology and robust data sources to evaluate physicians across 25 specialties. The program works to advance safe, timely, effective, efficient, equitable and patient centered care. The program supports practice improvement and provides physicians with access to information on how their clinical practice compares with national and specialty specific measures for quality, and with cost efficiency peer groups in the same geographic area. Evaluation for quality compares a physician s observed practice to the UnitedHealthcare national rate among other physicians who are responsible for the same interventions. Cost efficiency is assessed by comparing the case mix adjusted cost of care attributed to the physician to a benchmark and applying a statistical test to determine if the difference is statistically significant. Quality is the fundamental measurement, demonstrating our commitment to evidence based practice. The quality designation is separate from the cost efficiency designation. Although the quality and cost efficiency evaluations are performed separately, the results are used together to determine the physician s designation. Quality and cost efficiency evaluations each incorporate adjustments for the case mix of the physician and the level of the patient s severity of illness where appropriate. Physicians who meet both the quality and cost efficiency designation criteria will receive the quality and cost efficiency designation. Physicians who meet the quality designation criteria will receive the quality designation regardless of their cost efficiency evaluation. Physicians who meet the cost efficiency designation criteria will receive the cost efficiency designation if they do not have enough data to assess quality. Q. Are all Retail Clinics Tier 1? A. The Tiering does not apply to Retail Clinics the copay of $10 is applied to in network retail clinics. 2

3 Q. Is there a plan to evaluate the doctors to get more on Tier 1? A. The next assessment period is in the Fall of 2014 for a January 2015 release. No assessments occur other than the scheduled periods. Q. Are unevaluated doctors Tier 2? A. Yes. The fact that a doctor does not have a Tier 1 Premium Designation quality designation does not mean that the doctor does not provide quality health services. All doctors who are part of the UnitedHealthcare Choice Plus network must meet standard credentialing requirements (separate from the Premium program). Q. Routine care is 100% coverage, doesn t matter if it is Tier 1 or 2? A. Correct Preventive/Routine care is covered at 100% when provided by an in network provider. Q. Does UMR get paid for Tier 1 doctors being added? A. No. Q. Do you have to check throughout the year to make sure your doctor doesn t move from Tier 1 to Tier 2? A. Once evaluated, the providers generally should not move from Tier 1 to Tier 2, but it is always a good idea to check if you have not seen the provider in a while. Q. If you see an on call doctor but your doctor is Tier 1 and on call is Tier 2, what will happen? A. The service will be paid based on the Tier of the billing provider. Q. Are labs Tier 1 or 2? A. Neither. Only physicians within the 25 current specialties are included in the Tier 1 Premium Designation program. Q. Are there ShopKo s in Appleton that will work with a $10 copay? A. There are fast care facilities in the Appleton area, but they may not have your Brown County plan loaded in their system and may ask you to pay the bill in full and then submit the claim to UMR. 3

4 Q. I have an EOB and it states the provider is Aurora Baycare Medical Center. How will this be paid? 100% or 80% after the co pay? A. It will depend on the physician who is listed on the bill provided to UMR. If this is a physician claim the provider name would have been listed on the bill, but may not appear on the EOB. For an office visit when it is a Tier 1 provider the Plan will apply a $15 copay, and then process the balance of the office visit charge at 100%. If it was a Tier 2 or In network provider it would apply a $30 copay then process the balance of the office visit charge at 80%. All other services provided that day will apply as follows: deductible is waived and the balance is paid at participation (90% or 80%) level, depending on the physician s Tier. Q. Is there a way we can search to see what tier our current providers will be in before January? A. Yes. This is available now on the website. The Tier 1 Premium Designation is listed on the Choice Plus provider network site now. When you access the network via the UMR Member site you can select them under the Common Physician Searches: And you will see the designation by the provider s name: PHA Questions Q. There are Brown County employees that score 75 to 100 points, but have had numerous costly procedures, surgeries, etc. Is this factored in to the tiers? A. Claim activity is NOT factored into the outcome based tiering. The score is based on the conditions screened through Healics tool which are meant to engage members and help to prevent chronic conditions. An individual with high cost claims could be related to a catastrophic event, which is not considered lifestyle or controllable. The goal is to have employees engaged in their lifestyle, know their numbers and have opportunity to have an active role in their health. Q. Our 2013 PHA report shows us that a Healics score of 86 points puts us in the light blue category which is considered minimal risk and is in the optimal health category. However, a score of 86 will put an individual in the proposed silver category, not the optimal gold. A. Based on feedback in the meetings and a conversation with Bellin, we will be changing the tiering to match the Healics point categories gold, Silver, Bronze and 60 and below Standard. 4

5 Q. What will the RAS be? A. Information will be posted on the Intranet outlining the Reasonable Alternative Standards for Brown County. Please note that there will be goals and objectives that are specific to employees based on their results of the health assessments. Q. How long will it take to get scores? A. Result packets are mailed once documented in Healics system; typically it takes up to 3 weeks. Q. Spouses are not required to take PHA and their scores will not count, but they will get $25 incentive? Is that correct? A. In 2015 the spouse has the option of taking the PHA. They will get the $25 incentive, but their score will not be used to determine premium. This will be based on the employee s score only. Q. Will the patch show up on the test? A. The test for tobacco is looking for nicotine, so if you are using the patch or nicotine gum it will most likely show signs of nicotine in your blood stream. Excessive exposure to second hand smoke can result in a positive nicotine test as well. Q. What if you have a hard time drawing blood? A. Bellin has certified labs that can be utilized if an employee is having a hard time during an onsite PHA blood draw. If that is the case during your PHA, please work with the Nurse in coordinating the blood draw. Q. What if you are pregnant? Will you be penalized? How will it work? A. The participant should schedule a PHA and bring a note from their physician stating they are pregnant. The participant does not need to fast, Healics will give them full points for glucose, triglycerides and cholesterol. If the participant screened with Healics in previous year, Healics will duplicate the measurements for weight and body fat score. If the participant did not screen with Healics, Healics will use their pre pregnant weight, if provided, to calculate the body fat. Q. How are employees who participated at their spouses employers going to get their PHA score loaded into the system? Is there any other way than making them go for a PHA and handing in a questionnaire, it seems to not make sense to make them do this step. How will employees who were hired in 2014 show up on the report? Do they need to do any additional steps? A. Employees can contact Kate Bartell at kxbart@bellin.org. Employee must state they would like their data duplicated from the other organization. 5

6 Q. How will employees who were hired in 2014 show up on the report? Do they need to do any additional steps? A. If an employee tested in 2014 as new hires, there is nothing further they need to do. General Questions Q. How do I go about search for a provider in Delta Dental? A. Go to deltadentalwi.com and at the top there is a link to the provider search. If you click on this, you can search for in network dentists but location, zip code, or name. Q. Have we looked at other plans like the State plan? A. All options are looked at when considering the renewal. We do look at other plans and carriers in the process including the state plan. Q. What happens to your unused HRA dollars? A. If you are insured under the group plan, unused HRA dollars will roll over to 2015 calendar year. If you are no longer insured you will have 2 years to spend down the dollars that are left in the HRA. Q. Are prescriptions for maintenance meds staying the same? A. There are some prescriptions for maintenance medication that are covered in full with a $0 copay. Optum has made a change to the list of medications and if you are impacted you will be getting a letter in Nov. on the impact and alternate medications. Q. Is UMR adding providers in the Madison area? A. UnitedHealth Networks is continuously working to provide access in areas where there currently are noted gaps. Q. Are HRA incentives automatic? A. Yes. Genesis is sent a report quarterly from all of the carriers involve in the incentive program. When they get his report that shows the activity, they will automatically fund your HRA account with the earned incentive dollars. Q. How often does UMR in network get updated? A. The Choice Plus network website is updated once a week. If an error or omission is noted it will be corrected at the next update. 6

7 Q. What is the definition of a true emergency? A. UMR has a listing of over 5,300 diagnosis codes that define True Emergency conditions. In general: Waive if true emergency defined as: "Emergency means a serious medical condition, with acute symptoms that require immediate care and treatment in order to avoid jeopardy to the life and health of the person." True Emergency examples: Open wounds, fractures, chest pain, fever Non Emergency examples: General symptoms like Abdominal Pain, Vomiting Alone, Nausea, sore throat (no fever) Q. How will the $500 roll for Flex work? A. This will happen automatically. At the end of each year any insured who has $500 or less in their account will automatically get that amount rolled over to the next calendar year. This will happen starting at the end of