Gateway to Practitioner Excellence GPE 2017 Medicaid & Medicare Recognizing and Rewarding Excellent Practices Improving the Health of Gateway Members
PRACTICE ELIGIBILITY (see PCMH slide #27 for separate eligibility requirements) Primary Care Practices Medicaid (MA) and Medicare (MC) Family Practice, Internal Medicine, Pediatrics 50 member panel size per Line of Business (LOB) (as of 12/31/2016) (PA only) No minimum panel size for NC, KY and OH Obstetrical Care Providers (OCPs) Medicaid only No minimum panel Dental Practices Medicaid only No minimum panel Paid through United Concordia Dental (UCD) 2
DETAILS Qualifying practices = individual practices/groups with >50 members per product (MA or MC) as of 12/31/2016. At this cut point >85% of Gateway membership is impacted (Pennsylvania only) Each practice will be eligible for quarterly widget payments per LOB End of Year payments are based on MA and MC membership as of 12/31/2016 with minimum 10 members per scored measure Additional incentive dollars can be earned by increasing membership throughout year End of Year payments align with national benchmarks (NCQA Quality Compass and STAR ratings) PCMH promotes access, availability and quality but is not required to participate in the GPE program 3
2017 GPE PROGRAM COMPONENTS MEDICAID HEDIS GAP CLOSURE Well Child Visits 1 - $10 6 visits by 15 mo - $10 3-6 yo annual - $10 12-21 yo annual Controlling High BP 2,3 - $10 BP <140/90 Diabetes 2,3 - $10 HbA1c < 9 Asthma Outpatient Care 2 - $10 outpatient visit - $20 Asthma Control Test (ACT) performed on DOS Reducing ER Utilization - $10 Tele post-discharge nurse 1 - $15 Tele post-discharge prov 1 - $25 Visit post discharge 1 - $15-$25 after hours visit Maternity Care - $200 Tri 1 visit + ONAF - $100 8 prenatal visits - $75 postpartum visit Reducing Readmissions - $190 TCM visit within 7 days or - $130 TCM visit within 14 days or - $40 E&M visit within 7 days or - $20 E&M visit within 14 days MEDICARE HEDIS GAP CLOSURE Diabetes Care -$20 Eye Exam 1 -$20 Nephropathy tx 2 -$20 HbA1c < 9 2,3 Primary Care - $10 Adult BMI - $10 Rheumatoid Arthritis Rx - $10 Colorectal Screen - $10 BP <140/90 2,3 Woman Care - $20 BMD test or osteo Rx after fracture - $20 Mammogram Reducing ER Utilization - $10 Tele post-discharge nurse 1 - $15 Tele post-discharge prov 1 - $25 Visit post discharge 1 - $15-$25 after hours visit Care of the Older Adult - $30 Functional status assessment - $10 Pain assessment - $10 Med reconciliation Reducing Readmissions - $190 TCM visit within 7 days or - $130 TCM visit within 14 days or - $40 E&M visit within 7 days or - $20 E&M visit within 14 days PCMH Certification Payments (pmpm) by Level: MA $3.00 II, $4.00 III; MC $4.00 II, $8.00 III 1 One incentive payment per member per year 2 One incentive payment per member per quarter 3 Additional $5 for electronic submission 4
MEDICAID MEASURES 5
ANNUAL WELL CHILD VISITS Ages 0 through 15 months of life - $10 Perform 6 comprehensive Well Child visits by 15 months of life Submit claims for payment Bonus paid to PCP attributed to member at age 15 months Ages 3-6 years of age - $10 Perform at least 1 comprehensive Well Child visit Submit a claim for payment Bonus paid to PCP attributed to member at end of quarter for which gap was closed Ages 12-21 years of age - $10 Perform at least 1 comprehensive Well Child visit Submit a claim for payment Bonus paid to PCP attributed to member at end of quarter for which gap was closed Bonus paid for closing ONE open care gap, however Gateway Health strongly encourages practitioners to align checkups with the periodicity schedule. Modifier 25 may be used when an unrelated and significant separately identifiable evaluation and management (E/M) is furnished on the same day as a preventive service. 6
ASTHMA MANAGEMENT Denominator: members 5 to 64 years of age who were identified as having been prescribed at least one controller medication in 2016 and/or 2017. Three options for payment: 1. A visit where the principal diagnosis is asthma OR $10 2. A well visit that includes any diagnosis of asthma OR $10 3. Option 1 or Option 2 in addition to a completed Asthma Control Test (ACT) and submitted to Gateway electronically through the NaviNet Secure Messaging Portal. -1 incentive payment per member per quarter $20 7
MEDICAID OB Obstetrical Program has three bonus opportunities: 1. First Trimester Prenatal Care Bonus = $200 - ONAF submission within 5 days of intake - Claim submitted using codes listed in table below - All three codes must be reported together on the same claim form Code Description Amount Any E & M code for prenatal care 99201-99205 99211-99215 plus U9 modifier in the first position and pregnancy dx codes 1 T1001-U9 99429-HD Prenatal Office visits Initial Assessment (ONAF) First Trimester Prenatal Incentive code Per contracted rate Per contracted rate $200 1 FQHCs should bill T1015 in addition to the E & M codes per contract 8
MEDICAID OB Obstetrical Program opportunities continued: 2. Prenatal Visits = $100-8 prenatal visit during pregnancy Non- FQHC: FQHC: E&M Code (99201-99215), U9 modifier (must follow the code in the 1st position), & all other services performed in the visit T1015, E&M (99201-99215), U9 Modifier (must follow the code in the 1 st position), & all other services performed in the visit Pregnancy Dx code Pregnancy Dx code 3. Post Partum Visit = $75 Date of service MUST be between 21-56 days after delivery Examples of valid postpartum codes include, but are not limited to, encounters for postpartum care: EXAMPLES of Postpartum Care Codes CPT I Codes ICD-10 dx codes CPT II 58300, 57170 Z39.2, Z39.1, Z01.411, Z01.419 0503F This is not an all-inclusive list Of Note: Bonus payments are in addition to normal contracted payment for services Members must be seen by a Provider to bill for first trimester incentive Primary care physicians who perform OB services are eligible for bonuses 9
CONTROLLING HIGH BLOOD PRESSURE Members 18-85 years of age with a diagnosis of hypertension and whose BP was < 140/90 mm Hg The $10 incentive bonus is paid for ONE new date of service in each quarter of 2017 via submission of CPT II codes on the encounter claim. The maximum payout is four times per program year per member for: Systolic Values 3074F: <130 mmhg 3075F: 130 139 mmhg Diastolic Values 3078F: < 80 mmhg 3079F: 80-89 mmhg A compliant systolic AND compliant diastolic must be submitted An additional $5 is paid if submitted electronically One incentive payment per member per quarter 10
DIABETES CARE: HbA1c Members 18-75 years of age who have been diagnosed with Diabetes The $10 payout to PCPs is for each controlled member in each quarter. The incentive bonus is paid for ONE new date of service per quarter. HbA1c levels 9% via evidence of submission of CPT II codes on the encounter claim must be received. The maximum payout is four times per program year per member: CPT II Code HbA1c Level 3044F Value < 7 3045F Value 7-9 An additional $5 is paid if submitted electronically 11
EMERGENCY ROOM UTILIZATION Any member who has an ER visit during 2017 is included. Payments are rewarded if a visit occurs within 15 days of ER visit OR if a visit occurs within 15 days of receipt of the monthly ER provider list via NaviNet. (One payment per member per year) Two options for payment Option #1: Telephone Assessment & Evaluation Code Description Bonus Rate 98966-68 Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service of procedure within the next 24 hours or soonest appointment. 99441-43 Telephone evaluation and management services provided by a physician to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. Any face-to-face provider encounter with a physician, nurse practitioner or physician assistant within 15 days of ER visit or within 15 days of receipt of the monthly ER report provided through NaviNet $10 $15 $25 12
EMERGENCY ROOM UTILIZATION (cont) Option #2: After-Hours Service Codes Code Description Non-FQHC FQHC 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (holidays, Saturday or Sunday) 99051 Services provided in the office during regularly scheduled evening, weekend, or holiday office hours. (These are hours that are posted as regular hours but fall outside of standard business hours) $50 plus a bonus of $25 = total $75 $75 $35 plus a bonus of $15 = total $50 $50 13
REDUCING PREVENTABLE READMISSIONS: Following In-Patient Stay Members who have had an acute non-behavioral Health inpatient stay Transition care management services with high medical decision complexity (face-toface visit within 7 days of discharge) Any face-to-face visit within 7 days of discharge excluding 99496 Transition care management services with moderate medical decision complexity (face-toface visit within 14 days of discharge) Any face-to-face visit within 14 days of discharge excluding 99495 Transition Management Codes Payment 99496 $190* *TCM reimbursement varies by zone and is based on the contracted rate (Medicare FQHC excluded). Note: Non-FQHC will get paid through normal claims submission process $40 99495 $130* $20 14
MEDICARE MEASURES 15
BREAST CANCER SCREENING Women ages 50-74 years of age who have NOT had a bilateral mastectomy or two unilateral mastectomies A $20 payout will be made for a mammogram in 2017 A claim for the mammogram must be received by Gateway Codes may be submitted by any provider, but incentive bonus is only payable to the PCP 16
COLORECTAL CANCER SCREENING Members age 50-75 years of age who do not have colon cancer or have not had a total colectomy The payout amount $10 per member per year for submission of any one of the following CPT codes: 82270- fecal occult blood by immunoassay 82274- take home test screening, guaiac for colorectal cancer screening GO328: colon cancer screen for fecal occult blood test G0105- colonoscopy high risk G0121: colonoscopy not high risk G0104: flex sigmoidoscopy G0464 & 81528: FIT-DNA Test Codes may be submitted by any provider, but incentive bonus is only payable to the PCP 17
CARE OF THE OLDER ADULT Members who are 66 years of age or older. Care of the Older Adult has three bonus possibilities: Functional status assessment - $30 1170F -functional status assessment; Pain Assessment - $10 1125F- pain severity quantified; pain present or 1126F- pain severity quantified; no pain present; Medication List/Review - $10 (Two options for this element) A review of meds by prescribing practitioner or clinical pharmacist (1160F) AND medication list documented (1159F) OR G8427-professional attestation to documenting in the medical record they obtained, updated, or reviewed the patients current medications 18
OSTEOPOROSIS MANAGEMENT FOLLOWING A FRACTURE Female members 67-85 years of age who have had a fracture A $20 incentive will be paid when one of the following are documented within 6 months of a fracture: A bone mineral density test (BMD) is completed or A qualifying prescription to treat osteoporosis is dispensed as determined by pharmacy claims This measure excludes fractures of the face, skull, finger or toe 19
DIABETES CARE: NEPHROPATHY TESTING Members 18-75 years of age who have been diagnosed with Diabetes and do not have chronic renal failure The payout amount allocated to PCPs is $20 for submission of one of five CPT II codes for nephropathy testing: 3060F Positive microalbuminuria test result documented and reviewed 3061F Negative microalbuminuria test result documented and reviewed 3066F Documentation of treatment for nephropathy 4010F ACE/ARB therapy prescribed or currently being taken 3062F - Positive macroalbuminuria test result documented and reviewed - Codes may be submitted by any provider, but incentive bonus is only payable to the PCP - One incentive payment per member per year 20
DIABETIC CARE: EYE EXAM Members 18-75 years of age who have been diagnosed with Diabetes The payout amount allocated to PCPs is $20 for submission of one of four CPT II codes for Diabetic Retinal Eye Exam (DRE): 2022F DRE with interpretation by an Ophthalmologist or Optometrist 2024F 7 standard field stereoscopic photos with interpretation by an Ophthalmologist or Optometrist 2026F Eye imaging validated to match diagnosis from 7 standard field stereoscopic photos 3072F low risk for retinopathy (no evidence of retinopathy in the prior year) - Codes may be submitted by any provider, but incentive bonus is only payable to the PCP 21
DIABETES CARE: HbA1c Members 18-75 years of age who have been diagnosed with Diabetes The $20 payout to PCPs is for each controlled member in each quarter. The incentive bonus is paid for ONE new date of service per quarter. HbA1c levels 9% via evidence of submission of CPT II codes on the encounter claim must be received. The maximum payout is four times per program year per member: CPT II Code HbA1c Level 3044F Value < 7 3045F Value 7-9 An additional $5 is paid if submitted electronically 22
CONTROLLING HIGH BLOOD PRESSURE Members 18-85 years of age with a diagnosis of hypertension and whose BP was < 140/90 mm Hg The $10 incentive bonus is paid for ONE new date of service in each quarter of 2017 via submission of CPT II codes on the encounter claim. The maximum payout is four times per program year per member for: Systolic Values 3074F: <130 mmhg 3075F: 130 139 mhg Diastolic Values 3078F: < 80 mmhg 3079F: 80-89 mmhg A compliant systolic AND compliant diastolic must be submitted An additional $5 is paid if submitted electronically One incentive payment per member per quarter 23
DMARDS FOR PERSONS WITH RA Members 18 years of age or older with a diagnosis of Rheumatoid Arthritis EXCEPT those who are pregnant or have HIV A $10 incentive will be paid for a DMARD dispensed in 2017 as determined by pharmacy claims Codes may be submitted by any provider, but incentive bonus only payable to the PCP 24
ADULT BMI Members 18 74 years of age are included EXCEPT those who are pregnant $10 payout is made for a BMI claim using Diagnosis codes in 2017 (refer to BMI coding form provided) BMI percentile (for members age 18-19) BMI Value (for members age 20-74) See the BMI ICD-10 code handout for details 25
EMERGENCY ROOM UTILIZATION Any member who has an ER visit during 2017 is included. Payments are rewarded if a visit occurs within 15 days of ER visit OR if a visit occurs within 15 days of receipt of the monthly ER provider list via NaviNet. (One payment per member per year) Two options for payment Option #1: Telephone Assessment & Evaluation Code Description Bonus Rate 98966-68 Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service of procedure within the next 24 hours or soonest appointment. 99441-43 Telephone evaluation and management services provided by a physician to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. Any face-to-face provider encounter with a physician, nurse practitioner or physician assistant within 15 days of ER visit or within 15 days of receipt of the monthly ER report provided through NaviNet $10 $15 $25 26
EMERGENCY ROOM UTILIZATION (cont) Option #2: After-Hours Service Codes (no limit applies to Option 2) Code Description Non-FQHC FQHC 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (holidays, Saturday or Sunday) 99051 Services provided in the office during regularly scheduled evening, weekend, or holiday office hours. (These are hours that are posted as regular hours but fall outside of standard business hours) $50 plus a bonus of $25 = total $75 $75 $35 plus a bonus of $15 = total $50 $50 27
REDUCING PREVENTABLE READMISSIONS: Following In-Patient Stay Members who have had an acute non-behavioral Health inpatient stay Transition care management services with high medical decision complexity (face-toface visit within 7 days of discharge) Any face-to-face visit within 7 days of discharge excluding 99496 Transition care management services with moderate medical decision complexity (face-toface visit within 14 days of discharge) Any face-to-face visit within 14 days of discharge excluding 99495 Transition Management Codes Payment 99496 $190* *TCM reimbursement varies by zone and is based on the contracted rate (Medicare FQHC excluded). $40 99495 $130* $20 Note: Non-FQHC will get paid through normal claims submission process 28
PCMH Primary Care Practices Must be FFS Must have 50+ members (MA+MC combined) PMPM payment based on PCMH Certification from accrediting body Level II = $3.00 (Medicaid) and $4.00 (Medicare) Level III = $4.00 (Medicaid) and $8.00 (Medicare) Status changes due 45 days prior to effective months No retro pmpm payments to this program 2011 and 2014 NCQA eligibility amendments are accepted Accrediting Bodies: NCQA URAC TJC AAAHC PCMH certification in itself does not provide GPE eligibility 29
END OF YEAR PAYMENT CALCULATIONS Medicaid End of Year Payments End of year payments will be determined based on residual GPE funds. This is in addition to quarterly GPE payments and practices must be at the 50 th, 75 th, and 90 th percentiles Quality Compass Benchmarks. Only those measures from the 2017 GPE program with 10 or more qualified members will be considered for End of Year payment Medicare End of Year Payments End of year payments will be determined based on residual GPE funds. This is in addition to quarterly GPE payments and practices must be at a 3.75 STAR rating. Only those measures from the 2017 GPE program with 10 or more qualified members will be considered for End of Year payment 30
MEDICAID END OF YEAR PAYMENT STRUCTURE Overall End of Year Performance NCQA Quality Compass Percentile Base Bonus Modifier Final Bonus <50% 0 N/A 50% to <74% 1*$X* # Compliant Members in Measure >75% to <89% 1.5*$X* # Compliant Members in Measure >90% 2 *$X* # Compliant Members in Measure TBD* TBD* TBD* *End of year payout is made on a per measure level in 2017 and based on residual DHS GPE funds. Providers must reach or exceed the 50 th percentile as determined by the NCQA Quality Compass National Benchmark to be eligible for final bonus Qualifying Measures: Controlling High Blood Pressure, Comprehensive Diabetes Care (HbA1c Control), Well Child Visits (15 months, Years 3-6, and Adolescent) Providers must have 10 qualifying members in a measure to participate in the year end bonus 31
Medicare End of Year Payment Structure Overall End of Year Performance NCQA Quality Compass Percentile <3.75 STARS Base Bonus Modifier Final Bonus 0 N/A 3.75 to 4 >4 to 5 1*$X*# Compliant Members in Measure 1.5*$X*# Compliant Members in Measure TBD* TBD* *End of year payout is made on a per measure level in 2017 and based on residual GPE funds. Providers must reach or exceed 3.75 STARs as determined by the CMS STARs cut points. Qualifying Measures: Adult BMI, Breast Cancer Screening, Controlling High BP, Comprehensive Diabetes Care (HbA1c Control, DRE and Nephropathy TX), Care of Older Adults, Colorectal Screening, DMARDs for members with RA, Osteoporosis Management in Women with a Fracture Providers must have 10 qualifying members in a measure to participate in the year end bonus 32
PAYMENT SCHEDULE The following payment schedule applies to both Medicaid and Medicare: Quarterly Payments 2 nd quarter 2017 for dates of service 1/1 3/31 paid through 3/31 3 rd quarter 2017 for dates of service 1/1 6/30* paid through 6/30 4 th quarter 2017 for dates of service 1/1 9/30* paid through 9/30 1 st quarter 2018 for dates of service 1/1 12/31* paid through 12/31 End-of Year Bonus payments to go out no later than June 30, 2018 *claims previously paid from the prior quarter will be excluded 33
PRACTICE RESOURCES Reporting New PCP Dashboards Both lines of business. Includes open and closed gaps Quarterly Practice Scorecards Monitor progress towards year end overall practice performance Gateway P4P Ready Reference Guide (ONAF, ACT, TCM how-tos) NaviNet Secure Messaging & Document Exchange Practice Reference Guide HEDIS measures and details CPT II Reference Guide & BMI Diagnosis Codes Provider Engagement Team (Clinical Transformation Consultants) ProviderEngagementTeam@gatewayhealthplan.com 34