Progress Notes NEwS YOU CAN USE

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1 Progress Notes NEwS YOU CAN USE FIRST QUARTER (623) N. 83rd N. 83rd Avenue, Avenue, Suite 201 Suite Peoria, 201 Arizona Peoria, Arizona We encourage you to schedule a training overview of the AIP Practice Management & Compliance WebCenter by contacting Kris Gates with Health Endeavors at (623) or gates@healthendeavors.com AIP LAUNCHES THE PRACTICE MANAGEMENT & COMPLIANCE WEBCENTER AIP is excited to announce the launch of the AIP Practice Management and Compliance WebCenter, a web-based platform providing AIP affiliated practices with 24/7 access to tools, resources and educational material necessary to effectively address today s practice administration and regulatory challenges. Physician practices today are faced with evergrowing and increasingly complex administrative and regulatory issues that require expertise on a wide variety of subject matter, said Keith Dines, CEO of Arizona Integrated Physicians. By consolidating all of this information in a single location and providing anytime access, we have created a solution that will help AIP physicians continue to be successful in the administration of their practices. The AIP Practice Management & Compliance WebCenter includes the following resources: Resource Center: Online database of forms, documents, checklists and webinars in a variety of areas such as risk management and regulatory compliance, plus access to hundreds of policies and procedures. Service Partners: Web-based tool for frequently used contacts and a menu of top quality service partners. Tracking Center: Web-based tracking tools to help organize and track your contracts, practice information, conflicts of interest, customer service scorecards and physician incentive compensation. Coding Center: Submit coding questions or note audit request to Certified Professional Coders to ensure optimal reimbursement and OIG compliance. Training Center: Pre-formatted and customized training modules for your staff and p h y s i c i a n s, i n c l u d i n g compliance, practice orientation, Stark Law overview and many other topics. In today s healthcare business climate, the pressure for physicians to reduce costs, ensure compliance and maximize operational efficiencies has never been greater. We invite you to come witness the power that the WebCenter can bring to your practice by attending the AIP WebCenter Introduction and Product Overview: MARCH 22 5:30 7:00 p.m. Hampton Inn & Suites West Grand Ave Surprise, AZ MARCH 23 5:30 7:00 p.m. Banner Boswell Medical Center (Memorial Hall) N. 103rd Dr Sun City, AZ Please RSVP by March 15 by calling (623)

2 IMPROVE YOUR PERFORMANCE MEASUREMENT SCORE PERFORMANCE INCENTIVES FOR PRIMARY CARE PHYSICIANS AIP OFFERS A COMPETITIVE REIMBURSEMENT STRUCTURE FOR OUR PHYSICIANS Reporting/Billing with CPT Category II Service Codes Because Performance Measurement Scores (Quality of Patient Care) are calculated using claim information collected from MediSun, it s imperative patient information entered into the practitioners billing system contain accurate patient coding and servicing information throughout the claim billing and MediSun payment cycle. This includes reporting/ billing with CPT Category II Service Codes. It s important to note, CPT Category II Service Codes are supplemental tracking codes specifically designed to measure clinical performance. CPT Category II Service Codes describe clinical components typically included in an E&M Service or other clinical service/ procedure and therefore a separate RVU has not been assigned. The CPT Category II Service Codes facilitate data collections relating to quality of patient care by enabling services and test results nationally supported by evidence based quality patient care to be coded and billed/reported. This includes test results from clinical labs, radiology tests, or other procedures required to comply with state/federal laws. CPT Category II Service Codes can apply to members who are seasonal residents, or when new patients have quality related services completed by another practitioner prior to becoming an AIP member, or in situations where billing /coding errors prevent recognition of the CPT service code. Finally, and more importantly, billing with or reporting CPT Category II Service Codes eliminates the need for manual chart reviews, minimizing administrative burdens on Practitioners and the office staff. The most current listing of CPT Category II codes, Guidelines, and Cross-reference to respective Measures associated with each Category II code can be accessed at Please contact TIFFANY DUNN at or at tdunn@azphysicians.org if additional Performance Measurement Specifications are needed. Each year AIP distributes performance incentives to our network physicians for quality and clinical results, among other contributing factors. Listed below are the PCP Performance Incentive Measures for Plan Members with Diabetes Retinal Eye Exam Colorectal Cancer Screening Testing to Confirm COPD Kidney Function Testing For Members With Diabetes Poor Control of HbA1c (> 9) Diabetics Patient Satisfaction Documentation and Coding for Risk Adjustment Scores To learn more about performance incentives for PCPs, please visit our website at

3 CMO UPDATES JOE JOHNSON, MD THE VALUE CHALLENGE IN HEALTH CARE AVOIDING THE SPECTER OF FINANCIAL ARMAGEDDON- HEALTH CARE AND THE FEDERAL DEBT The government now pays for approximately half of all health care costs in the United States. Because federal debt and health care policy are so deeply entwined, it is important to understand the basic implications for health care reform. The deficit is the gap between expenditures and revenues in any given year ($1.4 trillion in the United States in 2009). The debt is the accumulated past deficits, the total owed by the government ($7.5 trillion at the end of 2009). Federal health care spending is 5% of the gross domestic product (GDP) and 20% of all federal outlays in Forecasts have indicated health care will rise to 12% of GDP by Interest payments on the federal debt consume 1.3% of the GDP (2009), and 5.3% of total federal spending. This reduces the resources available for other programs. In 2009, the U.S, debt-to-gdp ratio was 53%. It is estimated it will pass the 90% mark by the end of 2020, absent major policy changes. Growth in health care spending is one of the primary contributors to increases in debt over the long run; therefore a strategy to slow that growth is imperative. It is clear that physicians and the health care community must play a strong role in this process. Physicians will be instrumental in identifying clinically informed strategies that permit quality to improve in an environment of slower spending. Physicians control 80% of all health care spending. The current system of rewarding volume over value will be replaced by value based / outcomes driven payment systems. Ambulatory data from Practice Mgmt systems using vmine and data files generated by practices Lab Data (Quest, LabCorp, Other) FIGURE 1 Pertinent information will be aggregated from across the continuum of care and as well as evidencedriven medical information and imported into a data warehouse. (see FIGURE 1). A rules Engine will provide actionable information on each patient, to meet key Care Targets (see FIGURE 2). Physician Offices Hospital Billing Data Payor Claims Data June 15, 2010 Other Physician Performance Data FIGURE 3 Data Flow for Clinical Integration Program Data Warehouse Hospital Quality Data Reports and Support Tools Protocol Compliance Quality Performance Action Lists Patient Profiles Manual Self- Reported Data using Web Tools FIGURE 2 12 AIP is in the process of developing tools that will allow value based incentives supported by timely, actionable, and accurate information that will enable physicians to bridge the current value gap. It will move Primary Care Physicians (PCP) into a position of empowerment and leadership. PCP s will be enabled to quarterback the care for their patients with appropriate incentives and actionable information. The system will provide value based incentive structure with actionable member and physician engagement data. Key metrics will be aligned to value based reimbursement. AIP will assist its physicians to move to a model of Clinical Integration through the delivery of real time data, improved coordination among physicians, common protocols and shared clinical goals. See Figure 3 to the left as an example of how the data flows into a Data Warehouse. AIP looks forward to working with its physician partners to lead the market in the development of infrastructure to support performance improvement.

4 QUALITY COUNTS AIP continually monitors our clinical results, both for individual physicians and across the physician network. We provide our physicians with data on their performance to ensure continual improvement at the individual practice level, and compensate our physician commensurate with the quality of care provided to AIP health plan members. Specifically, PCPs are assigned a Quality Group based on their respective performance results derived from Quality Measures, Organizational Guidelines, Industry Standards and Clinical Benchmarks. The following is a summary of the measures that will be used to evaluate performance for 2011: Reduce and Control Per Capita Cost of Care - This measure includes utilizing generic prescriptions, and managing specialty care costs, hospital admissions, ER visits, and Re-Admission rates. Enhance the Patient Experience of Care This measure is based on the results of the CMS CAHPS / STARS targets for patient satisfaction that include getting needed care, physicians who communicate well, reduced waiting room times, and respect and courtesy from office staff. PCP Accessibility and Plan Member Retention This measure includes PCP outreach and PCP member retention. Improve the Health of the Patient Population This measure is based on CMS STARS quality metrics for ACE / ARB therapy diabetic patients with hypertension, osteoporosis management, reducing the risk of falling, and improving bladder control. AIP Engagement This measure is based on office staff attendance at Quarterly Staff Education Sessions and PCP attendance at PCP POD Meetings. Bonus Points Physicians may earn bonuses for maintaining active board certification status and for health plan exclusivity with AIP. To learn more about the performance measures and Quality Groups, please visit our website at REASONS TO REFER TO CASE MANAGEMENT SERVICES Banner MediSun Case Management performs a focused comprehensive medical/psychosocial assessment to identify an individual s needs and facilitates compliance with established medical treatment plans or initiation of new treatment plans in collaboration with the Primary Care Physician and/or Specialist. Nurse Case Managers and Social Workers assist to manage appropriate utilization of health plan benefits as well as obtain appropriate services from community resources/programs. TOP TEN REASONS TO REFER YOUR PATIENT: 1. Frequent hospital visits 2. Missed office appointments 3. Concern that your patient cannot manage independently for a variety of reasons including lack of support, disabilities, lack of transportation, visually and/or hearing or memory impaired; overwhelmed with health care needs 4. Discussion and providing advanced directives documents and long term planning 5. Patient/family/caregiver assistance with obtaining resources for in-home care, long term placement (Assisted Living nursing facility), transportation, financial (not filling drugs/relies upon samples), legal, hearing or visual aids, and/or support groups 6. Safety concerns in the home or with taking medications 7. Not understanding or managing disease processes or medications 8. Explanation of how to access or use health plan benefits 9. Patients with mental or physical decline, poor hygiene, weight loss, inappropriate dress, or at risk for falls 10. Discussions with your patient about the services provided through Hospice/palliative care For a Case Management Referral Form, please visit our website at CLAIMS CORNER Emdeon is now available for electronic claim submissions for MediSun members. It is important to separate MediSun claims from other Banner Health Plan claims. The Payor ID is To avoid timely filing denials, claims must be received by Banner MediSun within 100 calendar days from the date of service, including weekends and holidays. Requests for Reconsiderations may be submitted to Banner MediSun within 100 calendar days, including weekends and holidays, of the remit date. Requests are logged into the system within 48 hours of receipt and may be viewed through the Provider Portal at Remember to include the physicians 12 digit Practitioner ID #, assigned by AIP, in box 33 of the CMS 1500 claim form. AIP requires all physicians to submit claims for services rendered to Banner MediSun patients regardless of the payment methodology. Additionally, the billed charges must be greater than zero; 0 billed charges will be returned to the provider for correction. Box 32 on the CMS 1500 form must be filled in with the physical address of the site of service. Claims received with a P.O. Box or the word same in box 32 will be denied. PHYSICIAN STAFF EDUCATION SESSIONS AIP strongly encourages the office staff to stay informed about new initiatives offered through AIP, health plan updates, and the latest information on healthcare trends. AIP Provider Relations invites you to join us for lunch at our next Physician Staff Education Sessions. The same information is presented on several dates and locations for your convenience. May 2, 2011 Banner Boswell Medical Center May 5, 2011 Banner Del E. Webb Medical Center May 16, 2011 Banner Estrella Medical Center May 17, 2011 MediSun Sales Office

5 AIP WEBSITE YOUR SOURCE FOR EVERYTHING AIP Over the course of the last 6 months, AIP has been re-developing its website with the sole purpose to provide valuable information and tools to our physicians and their staff. Whether it is the implementation of the Secure Document Delivery (SDD) system to replace many of our current Paper processes or the routine updates from our Provider Relations department, we want ensure that we are delivering the tools and information that best assists you in managing your practice. We are constantly evaluating our website in an effort to ensure the content available best suits the needs of those using the site. With that in mind, we want to hear from you! The continued feedback of our physician community will transform our website from good to GREAT! Please send your comments to: feedback@azphysicians.org UPCOMING PHYSICIAN MEETING FOR PCPS The next PCP POD meeting is scheduled for March. The PCP POD is the mechanism for which the Primary Care Physicians can address their concerns to the Committees that govern Arizona Integrated Physicians. As an affiliated physician of AIP, you have a right to participate in the review of data and decision making that occurs at the PCP POD level. PCPs will be compensated $100 for POD Meeting attendance. Additionally, your attendance is reflected in PCP ABC scorecards that are used for annual risk share distribution and future base compensation rates. Please visit the AIP website at to see a summary of the material presented at previous PCP POD Meetings MARCH 10, 2011 ARROWHEAD COUNTRY CLUB 5:30PM 7:00PM (Dinner is served)