Payment Transformation Learning Series Session 3: And Go! For PCPs & Staff June 22, 2017
Learning Series Session 1: Get Ready (April 20, 2017) Introduction to Payment Transformation, PCP engagement measures, Cozeva view; learning modules and provider resources Session 2: Get Set (May 25, 2017) Payment Transformation model, PMPM bands, performance measures, new Report to Provider Session 3: And Go! (Thursday, June 22, 2017) Patient attribution Claims and reporting PCP tool kit Importance of doing well in pay for quality 6
Importance of Member Attribution Patient attribution part of Pay for Quality and Patient-Centered Medical Home from the beginning Greater importance Monthly Payment Transformation payment = Base PMPM Rate X Attributed Members Performance (quality) max potential = Performance PMPM X Attributed Members each month (or member-months ) Reminder: Payment Transformation global payment is paid based on Member Attribution from one month earlier. (July 2017 payment is based on June 2017 member attribution) 7
Choosing PCP Upon Enrollment For three plans, HMSA members select a PCP upon enrollment HMSA s HMO plans: Select an HMO health center and a PCP within the health center HMSA s QUEST Integration: Select a PCP or clinic HMSA s Akamai Advantage: Encouraged to select a PCP The name of the member s PCP is stored in HMSA s member data base and printed on their ID card New PCP selection process for Payment Transformation uses a Patient Attestation Form 8
Patient Attestation Form Form is only for Payment Transformation PCPs https://hmsa.com/p ortal/provider/zav_ pel.aa.pay.100.ht m 9
Process for Changing PCP: HMO, QUEST and Akamai Advantage Please ensure patients are informed and agree they want you as their primary care provider. Explain your role as their PCP and Patient Attestation Form Member completes form and signs. Follow instructions on form so change is documented by HMSA: HMO members: must fax form to HMSA QUEST Integration members: must fax form to HMSA Akamai Advantage: must fax form to HMSA PPO members: DO NOT fax form to HMSA HMSA s internal processes will attach member to PCP for purposes of patient attribution count for HMO and QUEST 10
Process for Changing PCP Please ensure patients are informed and agree they want you as their primary care provider. Explain your role as their PCP and Patient Attestation Form Member completes form and signs PPO members, including Fed 87: file in your medical record In Cozeva, add member for patient attribution count by selecting Add the patient to the P4Q program or Payment Transformation Program 12
How to Add a Patient in Cozeva Fill out all necessary information in the form and click Search Click the circle next to the member s name to confirm the system found the correct member Click the first box to confirm the medical need t access the member s information Click second box, Add patient to P4Q or Payment Transformation program
Adding Patients: Summary Step 1: What to do with Patient Attestation form? Step 2: What to do in Cozeva? HMO Fax to HMSA Click on first and second box in Cozeva to add patient to your panel QUEST Integration Fax to HMSA Click on first and second box in Cozeva to add patient to your panel Akamai Advantage Fax to HMSA Click on first and second box in Cozeva to add patient to your panel PPO Retain in medical record DO NOT Fax to HMSA Click on first and second box in Cozeva to add patient to your panel 14
HMSA s Attribution Logic Step 1: Apply line of business rules HMO and QUEST: Attribute member to the PCP the member selected upon enrollment (should match HHIN and member ID card) PPO and Akamai Advantage: Attribute member to PCP who most recently added that patient to panel in Cozeva. Patient must sign attestation form to confirm relationship with PCP. Step 2: If no member selection (e.g., PPO), HMSA looks at claims for face-to-face encounters over 16 months and attributes the member to the PCP: Seen most frequently; or, In case of a tie, seen most recently. Step 3: If no member selection and no claims history at all, patient is not attributed to any PCP 16
Cozeva Reports Patient Counts By line of business on Dashboard page: Total at the top of the Registry page: 18
Panel Management Current = PT or P4Q patient count Added = Patient added by PCP after affirming PCP selection; patient transferred and accepted New = Member added through enrollment or claims logic Declined = PCP declined member Left = Member removed because coverage ended; patient died; patient added by another PCP or attributed to another PCP by claims logic 19
Panel Management Other Member for whom the provider is NOT the member s PCP (not included in that PCP s member count for Base PMPM, Performance or Engagement measures) Patient recently seen for urgent care or consult Provider is not claiming to be the PCP. Provider did not check the box, Add the patient to P4Q program or Payment Transformation program 20
Adding Patients Once a PPO or Akamai Advantage member is added to a PCP s panel via Cozeva, or HMO/QUEST member is added through fax to HMSA, HMSA will not allow claims logic to reassign the member to another provider If one PCP has already submitted an Add Patient request for a PPO member for that month, no other provider will be able to add the member in the same month Attribution to the new PCP stays until another PCP adds the member to his panel Use professional judgment in adding patients 21
Adding a Patient in Cozeva Reporting Member s Subscriber ID number on Cozeva, using the member ID card For HMSA PPO, HMO, and Akamai Advantage members: Use one letter followed by 12 digits. Include all leading zeroes. Do not include the BlueCard prefix of the first three letters. Example: If the card says XLHR000012345678, enter R000012345678. For HMSA QUEST Integration: Use 10 digits. Include all leading zeroes. Do not include the BlueCard prefix of the first three letters. Example: If the card says XLQ0000123456, enter 0000123456. 22
Monthly Global Payment Global payment paid on or about the 15th of the month Also called bundled rate of care Also called monthly PMPM Uses member attribution from 1 month earlier Example: January 2017 member counts used for February 2017 payment Check is cut outside of the claims-processing system and will be mailed to PCP s claims-payment address on file (like PCMH checks) Notify your biller about the significance of the global payment check. Remittance line will start with a date and PT. Will include detailed report on payment. July 2017 transitions: Service dates through June 30, 2017 paid FFS; after that, global payment. Impact on reconciliation. 23
Claims Filing and Payment Continue to file claims for commercial, QUEST Integration and Akamai Advantage as you do now. NO change to HMSA claims filing process Continue to file claims with current coding rules (procedure codes, diagnosis codes, modifiers) Member s coinsurance, copayment and deductibles still apply and continue to be collected by the provider Completeness, accuracy and specificity in coding matter! Use diagnosis codes to the highest level of specificity that best describe the patient s condition Ensure biller knows about new codes to be reported on claims 24
Two Federal Plans Federal Plan 87 is an HMSA commercial plan with a PPO benefit structure and is ACA-compliant. Claims are paid under the monthly global payment. Under Payment Transformation, claims for Federal Employee Program (FEP) with coverage codes 104, 105, 106 for Standard Option and 111, 112, and 113 for Basic Option) are still paid fee for service. FEP has preventive care services for adults age 22 and older, including services recommended by the U.S. Preventive Service Task Force. FEP has benefits for children up to age 22, including services recommended under the ACA and by the American Academy of Pediatrics. 25
Claims Payment Report to Provider (RTP) and claims payment issued on the same schedule. Checks will be smaller. RTP improved for 2017 to show how claim was paid (FFS or global payment) Billers will use RTP to reconcile accounts Explanation for each claim, more clearly indicating Eligible Charge, Payment (what was recognized by HMSA) and the Withhold Amount (paid under global payment) Primary Payment or Secondary Payment adjudication for each claim Summary Page shows Total Amount Approved for Payment in This Report = Sum of total approved payment Net Amount Due to Provider = Check amount for FFS payments (e.g., immunizations) 26
2017 Claims Example: Commercial RTP shows member coinsurance of $11.07. Of total eligible charge of $140.16 recognized, $120.43 is the WITHHOLD AMOUNT and included in the monthly global payment. Message code 1306 = Payment for this service has been withheld and is included in your monthly bundled payment. Payment on this claim is $8.66 for immunization. 27
2017 Claims Example: Akamai 28
Claims Example: Summary 29
2017 Claims Example: Coordination RTP shows what primary plan paid. HMSA, as secondary plan, applied withhold to $17.82 in the coordination = included in the global payment 30
QUEST Integration Claims QUEST Integration claims = included in monthly global payment. Claim will be shown on RTP with an indicator of WHD for services that are being withheld FFS payment (paid under global payment; no additional payment in this report) QUEST Integration Aged, Blind and Disabled (ABD) claims = paid fee for service. Claim will shown on RTP with an indicator of FFS (usual processing and payment) 31
QUEST Integration Claims (RTP) Paid under global payment WHD WHD 32
QUEST Integration ABD Claims (RTP) Paid FFS 33
Claims Servicing Continue to use current resources for claims inquiries, including: HHIN Customer Relations Oahu - (808) 948-6330 Neighbor Islands - 1 (800) 790-4672 toll-free QUEST Integration Provider Service Oahu - (808) 948-6486 Neighbor Islands - 1 (800) 440-0640 toll-free 34
Getting Ready Continue to do well in the legacy Pay for Quality program. Your performance in 2017 will affect your advance payment in 2018. Prepare yourself and your team for the Performance measures. Discuss workflows, responsibilities and claims reporting with all team members Review the PCP toolkit and training modules so your team will feel confident about Payment Transformation 35
Success Strategies Office Workflows Pre-visit Planning: Review schedule of future visits and check Cozeva for any outstanding care gaps Flag gaps on face sheet, encounter forms, superbill, or EMR alerts, etc. Medicare patients with RCCs, print patient s RCC list from Cozeva Check for any reports from specialists that may need to be addressed (e.g. colorectal, breast, cervical screenings, etc.)
Success Strategies Office Workflows Patient Check-In/Intake: Clinical Depression & Anxiety Screener (age 18 and older) PHQ 4 Patient Assessment/Chief Complaints/Vitals ( HT, WT, BMI, BP, TEMP, etc) If BP reading is too high (above 139/89), repeat BP Document appropriate codes for BMI & BP Tobacco Screening (age 18 and over) Ask about smoking status Document in medical record and appropriate codes for smoking status
PCP Toolkit Simple, easy-to-use toolkit posted in Provider Resource Center with these resources https://hmsa.com/portal/provider/zav_pel.aa.pay.100.htm Understanding your PMPM band Patient attribution Patient Satisfaction survey samples Screening tools Performance measure codes and claims filing guidance Report to Provider samples and sample provider reports and cover letters Brochures for patients explaining Payment Transformation 38
Learning Resources Self-paced, recorded learning modules (go to hmsa.com, select Provider Portal and Training, scroll down to Payment Transformation) 6 modules (ranging from 10 to 27 minutes) covering these topics: understanding the PMPM band; short intro to Payment Transformation; overview of Payment Transformation; patient attribution; performance measures; and monthly payment and claims Watch with your team to prepare together 39
HHIN 2017 Payment Transformation Guide New! Click here Click here Click here 40
End Session 3 41
Reporting Performance Measures Reference
Success Strategies: Pediatrics Children Newborn through age 15 months Measure Well-child visits in the first 15 months By age 2 birthday Childhood immunizations by age 2 By age 1 birthday By age 2 birthday By age 3 birthday Age 3 to 17 Age 3 to 17 Age 3, 4, 5 and 6 Birth to age 20, per state EPSDT schedule (QUEST Integration) Developmental screening in first 3 years of life, annual CSHCN Screener, every 3 years Weight assessment and counseling for nutrition and physical activity Well-child visit annually EPSDT form submission 43
Success Strategies: Pediatrics Children Ages 12 to 21 Ages 12 to 17 By age 13 birthday All patients, with each visit All patients Measures Adolescent well-care visit Screening for symptoms of clinical depression and anxiety [Patient Health Questionnaire-2, -4, -9, -Adolescents] Immunization for adolescents Patient Experience survey Check on well-being of all patients in panel at least once a year [annual patient survey administered to sample of patients] 44
Success Strategies: Adults Adults Ages 18 and older Ages 18 and older Ages 18 and older Ages 18 and older Ages 18 to 74 Ages 18 to 75 Ages 18 to 85 Women ages 24 to 64 Women ages 52 to 74 Ages 51 to 75 Measures Flu vaccine Tobacco cessation and follow-up Screening for symptoms of clinical depression and anxiety RealAge assessment completed Body mass index assessment All 4 diabetes measures Controlling blood pressure Cervical cancer screening Breast cancer screening Colorectal cancer screening 45
Success Strategies: Adults Adults Ages 65 and older Ages 65 and older All patients Measures Advance care planning Review of chronic conditions Check on well-being of all patients in panel at least once a year [annual patient survey administered to sample of patients] 46
Important Reminders about Reporting Measures All codes on claims submitted to HMSA, whether claim line is approved or denied, are captured for numerator credit in Cozeva Some CPT codes used in reporting may trigger member copayments Please consider coding options that will minimize impact on your patients 47
Reporting Adult Measures New! Measure Procedure Code ICD-10 Code Influenza vaccine (ages 18 and older). Does not have to be administered by PCP Influenza vaccine CPT codes --Standard trivalent flu vaccine 90658 --Preservative-free flu vaccine 90654, 90656, 90661, 90662 --Nasal spray flu vaccine 90672 --Quadrivalent flu vaccine 90686, 90688 --HCPCS codes: Q2034-Q2039 (suggested) Z23 Encounter for immunization New! Supplemental reporting on Cozeva will be allowed for flu shots. Medical record evidence must include: name and title of individual who gave shot; date of administration; vaccine product and route of administration. 48
Reporting Adult Measures New! Measure Influenza vaccine (ages 18 and older). When patients report they got their flu shots Procedure Code 4037F Influenza immunization ordered or administered 4274F Influenza immunization administered or previously received Supplemental Data Documentation Requirements for 4037F and 4274F Medical record evidence must include the date the physician administered the vaccine or the date the physician confirmed with the patient that they received the vaccination during the measurement year 49
Reporting Adult Measures New! Measure Procedure Code ICD-10 Code Screening for symptoms of clinical depression and anxiety (ages 18 and older) 96127 Brief emotional/ behavioral assessment (e.g., depression inventory, ADHD scale), with scoring and documentation, per standardized instrument G0444 with mod 59 Annual depression screening, 15 minutes 3725F Screening for depression performed *Z13.89 Encounter for screening for other disorder *Credit will be given based on 96127. No member copayment when code combination 96127 + Z13.89 is used for ACA-compliant plans For Akamai Advantage members: use G0444 with mod 59 New! Depression screening may be done by PCP via telephone, if appropriate, but must be fully documented in medical record 50
Reporting Adult Measures New! Measure Procedure Code ICD-10 Code Tobacco screening and cessation counseling (ages 18 and older) Non-tobacco user: G9459 Currently a tobacco non-user [for members 20 years and younger] or G9275 Documentation that patient is a current non-tobacco user or 1036F Current tobacco non-user New! Tobacco screening may be done by the PCP via telephone, but must be fully document in medical record 51
Reporting Adult Measures New! Measure Procedure Code ICD-10 Code Tobacco screening and cessation counseling (ages 18 and older) Option 1: 1 proc code Tobacco user: G9458 Patient documented as tobacco user and received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco cessation program) if identified as a tobacco user [for members 20 years and younger] (suggested*) Z72.0 Tobacco use or Z87.891 Personal history of nicotine dependence *Credit given based on the G9458. These ICD-10 codes are optional. If G9458 is used for patients over 20 it will deny at the claim line level with a message about patient age, but credit still given in Cozeva 52
Reporting Adult Measures Measure Procedure Code ICD-10 Code Tobacco screening and cessation counseling (ages 18 and older) Option 2: 1 proc code + 1 DX code Tobacco user: 99406 Smoking and cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes 99407 Smoking and cessation counseling visit; intensive, greater than 10 minutes + New! Z72.0 Tobacco use *Z87.891 Personal history of nicotine dependence *F17.200 Nicotine dependence, unspecified, uncomplicated *F17.210 Nicotine dependence, cigarettes, uncomplicated * No copayment when these code combinations are used with ACA-compliant plans Time-based G0436 and G0437 not recognized after dates of service 9/30/16 53
Reporting Adult Measures Measure Tobacco screening and cessation counseling (ages 18 and older) Option 3: 2 DX codes Procedure Code ICD-10 Tobacco user: Z72.0 Tobacco use or Z87.891 Personal history of nicotine dependence + Z71.6 Tobacco abuse counseling 54
Pediatric Measures and Due Dates New! Birthday rule: Measures with due dates determined by child s birthday Well-child visits before age 15 months (birthday plus 90 days) Childhood immunizations second birthday Developmental screenings before the child s first, second or third birthday Calendar-year rule: Measures that count only if completed in that calendar year Well-child visits in third to sixth years of life any visit during the measurement year will count (can be before or after birthday), but at least 9 months since previous well-child visit Adolescent well-care any visit during the measurement year will count but at least 9 months since previous well-care visit 55
Reporting Pediatric Measures Measure Procedure Code ICD-10 Code Developmental screening in 12 months before child s 1 st, 2 nd, and 3 rd birthdays CSHCN Screener (Ages 3-17, done every 3 years) 96110 + HA modifier Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument Screening done; positive finding for chronic or special health care needs: E/M CPT code + HA modifier + Z87.898 Screening done; negative finding: E/M CPT code + HA modifier * No copayment when code combination used with ACA-compliant plans HA HCPCS code modifier = Child/adolescent program (suggested) * Z00.129 Encounter for routine child health examination without abnormal findings * Z00.121 Encounter for routine child health examination with abnormal findings Z87.898 Personal history of other specified conditions 56
Reporting Pediatric Measures Measure Procedure Code ICD-10 Code Adolescent well-care visit (ages 12-21) 99384-99385 Initial comprehensive preventive medicine evaluation and management new patient [age-based] 99394-99395 Periodic comprehensive preventive medicine reevaluation and management established patient [age-based] (suggested*) Age 15 and older: Z00.00 General adult medical examination without abnormal findings Z00.01 General adult medical examination with abnormal findings Through age 17: Z00.129 Routine child health examination without abnormal findings Z00.121 Routine child health examination with abnormal findings *No copayment when code combination used with ACA-compliant plans 57
Reporting Pediatric Measures Measure Procedure Code ICD-10 Code Screening for symptoms of clinical depression and anxiety (ages 12-17) 96127 Brief emotional/behavioral assessment (e.g., depression inventory, ADHD scale), with scoring and documentation, per standardized instrument or G0444 Annual depression screening, 15 minutes or 3725F Screening for depression performed 58 New! * Z13.89 Encounter for screening for other disorder *No copayment when code combination 96127 + Z13.89 used with ACAcompliant plans New! Depression screening may be done by PCP via telephone, but must be fully documented in medical record
BMI Reporting Age 3-17 Age 18-20 Age 21-74 BMI Percentile + Nutrition Counseling + Physical Activity Counseling BMI Percentile BMI Value 59