Introducing AmeriHealth Caritas Georgia A presentation for Georgia providers.

Transcription

1 Introducing AmeriHealth Caritas Georgia A presentation for Georgia providers. CPC; Q2-2015; V13

2 Who We Are Who We Serve Agenda Our Mission AmeriHealth Caritas Georgia Questions 2 2

3 Who We Are AmeriHealth Caritas Georgia is part of the AmeriHealth Caritas Family of Companies ( AmeriHealth Caritas ), one of the largest Medicaid managed care organizations in the United States. We offer a full spectrum of managed care services such as physical health, behavioral health, and prescription drug management. For more information about AmeriHealth Caritas visit us online at We are: An industry leader in managing medically complex members. A company whose history includes 30 years of experience serving Medicaid beneficiaries and other low income populations in rural and urban settings. Today we operate in 16 states and the District of Columbia and touch the lives of over 6 million members. A mission-driven company whose goal is to keep families and communities healthy by helping them connect to their physicians with a focus on preventive care and health maintenance. 3

4 Who We Serve

5 We help people get care, stay well and build healthy communities. Our Mission AmeriHealth Caritas provides expertise and success in helping families get care and stay well. By partnering with dedicated providers and working with local communities, we expect to achieve positive health outcomes for Medicaid enrollees in Georgia. 5 5

6 AmeriHealth Caritas Georgia Georgia Medicaid Redesign Georgia s Department of Community Health (DCH) released a request for proposal (RFP) in February The RFP includes a redesign of Georgia s statewide, managed care Medicaid and CHIP (PeachCare for Kids) program, known as Georgia Families. The RFP also includes Georgia Families 360, the Georgia managed care program for children, youth, and young adults in foster care, children and youth receiving adoption assistance, and select youth involved in the juvenile justice system. These newly-designed programs are scheduled to begin in summer AmeriHealth Caritas Georgia intends to pursue this opportunity to provide Medicaid managed care in Georgia. 6

7 AmeriHealth Caritas Georgia Looking for providers like you AmeriHealth Caritas Georgia is currently reaching out to health care providers throughout Georgia with an invitation to join us. We re meeting with providers like you to introduce ourselves and build relationships. We hope you ll consider partnering with us. Here are a few reasons to choose AmeriHealth Caritas Georgia 7

8 Our Qualifications AmeriHealth Caritas Georgia is uniquely qualified to help Medicaid enrollees in Georgia receive the care they need. As a leader in health care solutions for the underserved, our qualifications include: A nationwide presence, serving over 6 million covered lives. NCQA accredited managed care plans. Unmatched expertise in the Medicaid managed care market. Excellent customer service and the systems to achieve administrative ease. A family of companies that includes pharmacy benefits management and behavioral health care management services. Effective integrated care management and coordination programs. An emphasis on supporting providers by sharing tools, resources and information. 8

9 Record of Success The success of AmeriHealth Caritas mission-driven programs is evidenced by the national recognition and awards received. All of our eligible Medicaid plans retained a Commendable NCQA status in , putting us in the top 21 percent of all Medicaid plans. Our South Carolina health plan continues to rank as the top Medicaid health plan in that state. Our two eligible Pennsylvania health plans remain among the top four Medicaid health plans in the Commonwealth. Based upon NCQA Medicaid Health Insurance Plan Rankings , issued September

10 Unique, Integrated Care Management Model We work to address care gaps and foster health equities with a proven integrated care management (ICM) model. This model incorporates a member-based decision support system that drives both communication and care-plan development through a multidisciplinary management approach. Successful Care Management Programs We offer chronic and acute care management programs to improve health outcomes for members with asthma, cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, sickle cell anemia, depression and other conditions. Through these and other programs, we re consistently improving member outcomes. In 2013 we improved targeted member medication adherence rates by: 22.4% for hypoglycemics. 24.1% for antihypertensives. 25.5% for statins. 5.2% for asthma controllers. 10

11 Easy Identification of At-Risk Members Providers receive clinical alerts when checking member eligibility via our free provider portal. The alerts notify providers when a member is at-risk for missing recommended services or for under-utilization of disease-specific controller medications. For high-risk members, providers can request intervention through the Rapid Response and Outreach Team (RROT). Responsive Care Teams Our responsive care teams, comprised of plan medical directors, care managers (registered nurses and social workers), and skilled care connectors (for non-clinical issues), collaborate with internal care managers and providers to identify and address members health needs. The RROT also helps members achieve better health outcomes through plan benefits education, personal outreach and access to community resources. 11

12 Clear Utilization Management Our goal is to ensure both members and providers can easily understand and identify which services require prior authorization. Referrals are not required for specialist care. We notify providers of utilization management changes in a timely manner via the plan website or individual outreach, as needed. Prior authorization requirements include, but are not limited to, inpatient, limited outpatient and out-of-network services. We are sensitive to the interruption that prior authorization may cause in a provider s workflow. Requests for services requiring prior authorization may be submitted electronically via single sign-on through our provider portal. Discharge planning assistance, member education and coordination of care help simplify the process. 12

13 Administrative Ease via E-Health Solutions We believe in easing the administrative burden for our providers through the following electronic health solutions: Electronic claims submission (837 transactions). Electronic remittance advices (ERA / 835 transactions). Electronic funds transfer (EFT). Electronic prior authorizations for many services. Access to web-based information including: o Member eligibility and panel rosters. o TPL information. o Claims status information, updates and reports. o Customizable clinical reporting to identify gaps in care, members due for specific services, at-risk members, performance data and more. AmeriHealth Caritas processes over 25 million claims annually. Of those, 84 percent are auto-adjudicated. Clean claims are processed in an average of 13 days. 13

14 Emphasis on Provider Support AmeriHealth Caritas Georgia is dedicated to ensuring our participating providers have everything they need to partner with us and provide quality care for our members. Our approach includes: Dedicated account executives (AEs) who live and work in Georgia and who are available to assist you and meet face-to-face on a routine basis. Provider Network Management team available at Frequent communication including alerts, fax notifications, newsletters and website updates with meaningful content. Provider workshops and small roundtable meetings to obtain feedback and communicate important information. Opportunities for ongoing education, including continuing medical education (CME) credits and continuing education units (CEUs), via webinars and inperson sessions. Peer-to-peer access to locally-based Medical Directors. 14

15 Focus on Patient-Centered Medical Homes (PCMH) AmeriHealth Caritas Georgia is excited to partner with you to offer our members access to quality, coordinated care through the PCMH model in Georgia. We believe the PCMH model of care improves health outcomes while conserving costs. That s why we advocate and promote this whole-person approach to care. We offer many resources to help providers achieve, maintain and enhance their PCMH status: A roadmap tool for guiding practice transformation to the PCMH model. Sharing of best practices and real-world examples. Data transparency to help practices visualize and understand performance in key measures. An online Provider Toolbox full of ready-to-use resources, including member engagement materials, practice implementation tools and more. On-going learning opportunities on PCMH and related topics. 15

16 Innovative Payment Opportunities AmeriHealth Caritas is leading the way in innovative payment methods to share savings through collaborative provider partnerships. The PerformPlus suite of products represents a major shift in physician engagement. To reward providers for preventing illness as well as treating it, each PerformPlus program is customized to meet goals and to ensure providers have the tools for success. Performance benchmarking establishes reasonable metrics that take into account length of participation in a given program. PerformPlus products are available to physicians, hospitals and integrated delivery systems, including primary care providers (PCPs) and specialists. To learn more, please ask your Account Executive for more information. 16

17 What Makes PerformPlus Products Different? Unique focus on clinically preventable events. Custom dashboards to provide you with the data and transparency you need to succeed. Many opportunities for performance rewards within each program. Peer-based and trend-based measures. Programs tailored to your needs. Excellent customer service and satisfaction. Programs available for specialty groups. Reliable risk adjustment. Member and provider analytics (MPA) and self-service reporting. 17

18 Consider Partnering with AmeriHealth Caritas Georgia We are excited to pursue this opportunity to partner with the state of Georgia, and with you, to provide health care services for individuals and families. Our 30 years of experience and expertise in Medicaid make AmeriHealth Caritas Georgia the best Medicaid managed care choice for eligible members in Georgia. Questions? Please contact Provider Network Management by: Telephone

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