YOUR HEALTHCARE UPDATE • VOLUME 12 • WINTER 2013

At Accountable Health Care IPA, we are supportive of providing access to heath care coverage. Despite what we hear and read in the news, in California, Covered California is well on its way to attract consumer enrollment. Recently, the California Department of Health Services (DHCS) and Covered California announced that applications were started for an estimated 370,000 individuals. These individuals are seeking coverage under the Patient Protection and Affordable Care Act, which offers a low-cost or no-cost Medi-Cal plan. As reported, “…nearly 86,000 were determined to be eligible to participate in subsidized or unsubsidized coverage through Covered California. And 72,007 were determined to be likely eligible for Medi-Cal, with coverage beginning in January 2014.” We are excited and encourage by these results.

We are also proud of our health plan partners which have extended a contract for this program. Our revised Health Plan Partners & Programs section is now updated to give you a view of our contracted partners and programs. With this excitement, we encourage you and your staff to be vigilant on the latest information on the coverage that is surely to make individuals healthier because of you, the Accountable Health Care IPA participating physicians and providers.

Our role in making coverage available for all of the Californians is vital. Because of our commitment in bringing California health care coverage to our regions, we are working with our health plan partners and brokers to facilitate the process and aim for a valuable program. For more information, go to CoveredCA.com.

ST

AT

EM

EN

T CORE VALUE AND AFFIRMATIVE STATEMENT

Accountable Healthcare IPA is a physician owned and directed organization. Our core value is based on reliability and accountability toward providing expedient and quality services for our providers and members with uncompromising integrity, compassion and values. Our team of management profes-sionals foster a culture among our employ-ees that supports interdependency and accountability. Together, we strive to become the leading integrated health services organization dedicated to promoting a member’s personal health status through improved communication, health mainte-nance and coordinated delivery of care.

Utilization management decisions are based only on appropriateness of care

and member’s coverage.

ACCOUNTABLEHEALTH CARE IPA2525 Cherry Ave., Ste. 225Signal Hill, CA 90755Phone: 562.435.3333Fax: 562.981.7431www.ahcipa.com

ST

AT

EM

EN

T CORE VALUE AND At Accountable Health Care IPA, we are supportive of providing access to heath care coverage. Despite what we hear and read in the news, in California, Covered California is well on its way to attract consumer enrollment. Recently, the California

COVERED CALIFORNIAUPDATE

MEDI-CAL NEWS!ACA INCREASE MEDI-CAL PAYMENTS

ELIGIBILITYMeeting at least one of the following qualifications:1. Board certified in a specialty or subspecialty that is recognized by the American Board of Medical Specialties (ABMS),

American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA). OR2. At least 60 percent of total claim volume for the most recently completed calendar year or, for newly eligible physicians, the

prior month, were for E&M (99201 – 99499) and Vaccine Administration (90460, 90461, 90471 – 90474, or their successors) services or local codes that correspond to these E&M and Vaccine Administration codes.

SELF-ATTESTATIONPhysicians must self-attest that they are eligible to receive the payment increase by completing the online ACA Self Attestation Form. For detailed field-by-field instructions about completing the ACA Self Attestation Form, please visit the Medi-Cal website.

SERVICES DEFINEDPrimary care services are defined in HR 4872-24, Section 1202 as:• CPT-4 Evaluation and Management (E&M) codes 99201 through 99499• Services related to immunization administration for vaccines and toxoids-procedure codes 90640, 90461, 90471, 90472,

90473, and 90474.

For the most up-to date information and forms please visit Medi-Cal.ca.gov.

“I am a contracted Primary Care Physician with Accountable Health Care IPA; will I get an automatic increase in payments? When will I get this increase? What services will I get reimbursement for?”These are a few common questions which were asked after the release of the statement made on the Medi-Cal website on April 24, 2013. As many of you may have read from the Medi-Cal website or through word of mouth from a colleague, payments to qualifying Medi-Cal Primary Care Physicians were to be increased. Payments are not automatic and providers must attest to their eligibility. The health plans are solely responsible for this payment and providers are encouraged to, if eligible, seek payments from the enrollee’s health plan.

Amended by House Resolution 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, the Patient Protection and Affordable Care Act (ACA) requires that payments to primary care physicians are to be increased to the Medicare equivalent for certain Evaluation and Management and Vaccine Administration services.

The Centers for Medicare & Medicaid Services (CMS) has approved the Department of Health Care Services State Plan Amend-ment (SPA) related to this rule, therefore allowing the release of the referenced increased payments. The first interim payment issued on the check write will represent estimated increases retroactive to dates of service on or after January 1, 2013. Subsequent weekly interim payments will be issued until final settlement of payment owed is dispersed, as early as July 2014.

ACCOUNTABLEHEALTH CARE IPA2525 Cherry Ave., Ste. 225

From the Accountable Health Care IPA family to you, our valued providers and partners….

Season’s Greetings. In warm appreciation of our association during the past year, we extend our

very best wishes for a happy holiday season!

From the Accountable Health Care IPA family to

A c c o un ta bl eHe a lt h C a r e I PA

“A Healthcare Partnership you can depend on.”

Accountable Health Care IPA is excited to

inform you that incentives are reimbursed for

each annual physical exam performed for

members enrolled in a Medicare Health plan

effective May 1, 2013 as follows:

Medicare Health Plans pay medical groups and IPAs capitation based on the conditions and risk adjustment scores reported. In order for us to maintain competitive capitation rates paid to physicians, we need your assistance in providing complete physical examinations for your members annually.

Physicians must report all conditions of the member and document the progress notes clearly and legibly. Additionally physicians’ evaluation and treatment of their patients’ conditions must report the ICD-9-CM diagnosis codes to highest level of specificity. Completing an annual exam for Medicare patients is imperative, as the diagnoses from the prior year do not automatically continue to the next health status assessment. This can lead to inconsistent reporting of the member’s condition, and lead to lower capitation.

*Submission forms and deadlines vary by health plan. Please contact a Provider Service Representative for further details.

Encounter data is used by health plans to track utilization of services by members. Through encounter data tracking, health plans can determine: pharmacy patterns, prevalence of diseases, co-morbidities, and member’s utilization patterns of certain medical services. Health plans require that our physicians evaluate their members at least 3.5 times a year to participate in most incentive programs. From a broader perspective, complete and timely encounter data submission allows for health plans to have an accurate picture of the range and intensity of services provided to our members. By having our providers submit encounter data we are able to better assess members’ utilization of services and determine appropriate capitation rates to our providers.

Data captured in such submissions is calculated to meet HEDIS, STARS and Risk Adjustment clinical guidelines.

Reimbursement rate for Commercial and Medicare member’s qualified encounter data submission has increased to $2 for dates of service effective October 1, 2013. The following grid outlines rates per member based on visit thresholds according to line of business:

Approved methods are via the Accountable Health Care IPA web-portal or an Accountable Health Care IPA Super Bill. To qualify for the incentive program, please submit encounter data within 30 days from the date of service.

Line of Business

Medi-Cal $1 5 Medicare $2 8 Commercial $2 3

Rate(per encounter)

Visit Threshold(PMPY – per member per year)

Incentives in submitting encounter data: Be a STAR!

MEDICARE ANNUAL EXAMS

*Submission forms and deadlines vary by health plan. Please contact a Provider Service Representative for further details.

Health Plan Health Plan Incentive* Accountable Incentive

Care 1st $125

Molina

$350

$125

Citizens Choice

$350

$125

Brand New Day $300 $125

Encounter data incentiveMedicare/SNP - $30 per valid submissionMedicare - $20 per valid submission

Accountable Health Care IPA is pleased to announce the upgrade to a new provider web portal! eHealth is an on-line web based system that will be available on January 1, 2014. The required registration to access and utilize this system is available to you now. The one-page registration form was designed to be quick and easy to complete. You can access this form via the Provider Portal webpage of our website: ahcipa.com. A representative from the Provider Services Department will be visiting your office in the very near future to show you how to navigate throughout the entire system and answer all of your questions. Feel free to contact Provider Services at (562) 435-3333 with any questions, or see our directory for Provider Services contacts on page four of this newsletter.

Incentives in submitting encounter data: Be a STAR!

New and ImprovedProvider Web Portal

At Accountable Health Care IPA, the desire and commitment toward the members we serve comes in various forms. With the news of typhoon Haiyan, like many, we were saddened and worried by the destruction and eventual human toll. With the people of the Philippines’s in our hearts, and knowing that it would be difficult to do something for the people being so far away, the leadership of Accountable moved into action. On behalf of Accountable Health Care IPA, the executive leaders made a donation to the local chap-ter of American Red Cross. In addition, the amount donated by the employees was matched by Accountable Health Care IPA. We encourage our employees, providers and health plan partners to look into ways that may benefit the Filipino people in their moment of need.

How to help: Got to www.redcross.org or call 1-800-RED-CROSS to donate to typhoon relief.“The American Red Cross shelters, feeds and provides emotional support to victims of disasters; supplies about 40 percent of the nation’s blood, teaches skills that save lives; provides international humanitarian aid and supports military members and their families. The Red Cross is a non-profit organization that depends on volunteers and generosity of the American public to perform its mission.” (Source: American Red Cross website.)

Medicare Star ratings is a government pay-for-performance program for Medicare Advantage and Part D prescription drug plans. The Center for Medicare & Medicaid Services (CMS) uses Star Ratings as an indicator of how well we serve Medicare beneficiaries, especially by improving health outcomes and closing gaps in care.

Medicare Star ratings are determined by the encounter data, claims, and Initial/annual health assessments submitted by contracted Primary Care Physicians.

If you are a Medicare contracted Primary Care Physician and have not received a letter with your current star rating or would like more informa-tion on how to increase your star rating, please contact Ligaya Dolar at (562) 435-3333 Ext. 315, or Beatriz Ramos at Ext. 451.

ACCOUNTABLE

NEW LEADERSHIPNEW LEADERSHIP

LEA

DER

SH

IP C

HA

NG

ES

DAVID SENGWith 12 years of IT experience, David Seng joined Accountable Health Care IPA as our new IT Director and Systems Compliance Officer. He brings excellent experience in system implementation and vast knowledge in the ever-changing world of information systems and technology. He will lead his band of expert “Geek-Squaders” and surely be a shining mega-pixel.

SHARI SHIELDSShari has been in the Healthcare industry for 20 years and has 18 years of Human Resource experience. She is an HR Professional with demonstrated ability to improve organizational effectiveness by collaborating, communicating and executing HR processes and programs across all disciplines that are linked to strategic initiatives of the business. Her goal is to become a business partner with the executive management team as well as all managers and employees across the organization. Shari believes that many people collaborating toward a common goal (excellent customer service, communication and best business practices) can play an important role in the success of the company. Her role will be reviewing policies, procedures and practices to ensure we are operating with the best business practices to ensure the continued growth and success of Accountable Health Care IPA.

AMY LEUKAmy Leuk joined Accountable Health Care IPA as a Manager of Utilization Management Dept in October 2013. Amy comes to us with more than 16 years of experience in managed care. Her experience and extensive utilization management background working for Health Plan and MSOs that includes Universal Care Health Plan, Central Health MSO and HealthSmart MSO will contribute to the continued success of Accountable Health Care IPA.

CHARIA C. BEN, LVNM CPURCharia C. Ben joined Accountable Health Care IPA as Director of Utilization Management in October 2013. She comes in with 19 years experience in Managed Care Utilization Management that includes Universal Care Health Plan and HealthSmart MSO. With her extensive experience in Utilization Management, Charia is optimistic to assure quality of care provided to its members in Accountable Health Care IPA, in conjunction, evaluate the necessity of heath care services, appropriateness, cost effective, and in compliance with all regulations. Her mission is to lead the Utilization Management team in meeting a high expectation and continued success at Accountable Health Care IPA.

JESUS MENDOZAJesus Mendoza joined Accountable Health Care IPA as Supervisor of Customer Service/Eligibility and Capitation Department in May 2013. Jesus oversees the Customer Service/Eligibility and Capitation Department. Jesus comes to us with more than 16 years of experience in managed care and management positions at IPAs and MSOs, that include MedPartners Medical Group, HealthCare Partners Medical Group and HealthSmart MSO.

LINDA SANCHEZLinda Sanchez is the newest member to the Claims Department. She joins our team as the IPA Claims Manager. Linda’s previous background includes working as the Claims Director at HealthSmart MSO, Inc. for 7 years, and Universal Care for 9 years. Her vast knowledge on claims processes will be a great addition to the Department. Linda’s background includes system implementation and the day to day managing of the Claims Crew. We are excited to have Linda as part of the family!

YOLANDA GREER Yolanda Greer joined Accountable Health Care IPA as the Network Relations Manager in November, 2013. She is responsible for managing both the Provider and Business Development Representatives. Yolanda's 18 years of managed care experience attained in clinical settings and also with health plans, IPAs and an MSO, includes key positions held with United Healthcare, UCSD Medical Center and Sharp HealthCare. She is committed and pleased to working closely with all providers and their staff in every capacity, while also contributing to the continual growth of Accountable Health Care IPA’s provider network.

Ligaya Dolar (CPC, CPUR, Risk Adjustment/

P4P/STARS/HEDIS Consultant) presenting on CMS Star ratings at

Beverly Hospital for the AHCIPA Quarterly

meeting onOctober 7, 2013.

Health Plan Partners & ProgramsHealth Care Fraud, Waste, and Abuse is rising higher and higher every year. Examples of Health Care Fraud, Waste, and Abuse include: billing for services not provided, using someone else’s Identity (ID) to obtain benefits or receive payment.

Here are a few helpful tips on how you can help prevent Health Care Fraud, Waste and Abuse:1) Always protect personal identification numbers.2) Follow the CMS anti-fraud: http://www.iceforhealth.org/library/docu-

ments/CMS_Parts_C_and_D_Fraud_Waste_and_Abuse_Training_and_General_Compliance_Training.pdf

3) Speak and encourage patients to:• Protect your Medi-Cal/Medicare and health plan card number by not

giving it anyone except your doctor, clinic, hospital or other health care provider.

• Do not let anyone borrow your Medi-Cal/Medicare and health plan card.

• Never loan your Social Security card to anyone.• Never sign a blank insurance claim form.• Be suspicious of anyone who offers you a free medical screening in

exchange for your Medi-Cal/Medicare or health plan card number.• If it sounds too good to be true, it probably is. Be careful about accept-

ing medical services when you are told they will be free of charge.Yadegarian Herach, M.D.Ruiz Ruben, M.D.Duong Calvin, M.D.Marouni Payam, M.D.Wakslak Menachem, M.D.Zaky Amal, M.D.Godoy P. Ignacio, M.D.Lee M. Terry, M.D.Chung K. Samuel, M.D.Jelen Betty, M.D.Keech Richard, M.D.Mawaheb A. Khaled, M.D.Prado E. Venancio, M.D.Rubinson J. William, M.D.Alavynejad Babak, D.P.M.Custode Eric, D.C.Gallemore P. Ron, M.D.Jotterand H. Veronique, M.D.Kim G. Gene, M.D.Meir Jessica, M.D.Lamorena S. Thelma-Linda S M.D.Liu K. Antonio, M.D.Malamud Ariel, M.D.

Mathis K. Stanley, D.P.M.Mehdikhani Edgar, M.D.Quinonez Rafael, M.D.Spencer Robert, M.D.Tabesh Alireza, M.D.Takahashi R. Stefani, M.D.Maloney L. Patrick, M.D.Taylor Helen, P.A-CThomas Evangela, N.PMarianne Mikhail, M.D.Delshad M. George M M.D.Quijano Edielyn N.P.Bautista I. Daisy, M.D.Aguilera C. Manuel, M.D.Jorge Camilo, M.D.Laktineh Solomon, M.D.Lim Kheng, M.D.Lim Annie, M.D.Rodriguez-Ellis Eva, M.D.Lin L. Hsin, M.D.De Sa Watson, M.D.Gonzalez Manuel, O.DPeters Joseph, M.D.

Wilches Alberto, M.D.Ebrahimi Abdorasool, M.D.Chen Z. Po, M.D.Ezell Jimmy, M.D.Makabali Reynaldo, M.D.Oey Jimmy, M.D.Sohn Hyang, M.D.Aghai M. Mehrdad, M.D.Tran Loan, M.D.Suchov Mordo, M.D.Jekums J. Theodore, M.D.Mehta Manish, M.D.Subhani T. Nabil, M.D.Rogoway M. William, M.D.Casillas Y. Ernest, M.D.Garg K. Santosh, M.D.Menchaca Raymond, M.D.Issa Adly, M.D.Ruiz Phili, M.D.Grubin Martin, M.D.Burnett Keith, M.D.

ACCOUNTABLE HEALTH CARE IPA:COMMITMENT TO PROVIDER SERVICES

If you have questions, comments or suggestions regarding the content of this newsletter, please feel free to contact your assigned Provider Services Representative at (562) 435-3333.

ACCOUNTABLE HEALTH CARE IPA2525 Cherry Ave.. Ste. 225, Signal Hill, CA 90755

Phone: 562.435.3333 • Fax: 562.981.7431 • w ww.ahcipa.com

Anthem Blue Cross Medi-Cal, Covered CA, Commercial, POSBrand New Day Senior PlanCare 1st Health Plan Medi-Cal, Commercial, Senior Plan, CA MediConnectCigna Commercial, POSCitizen's Choice Health Plan Senior PlanHealth Net Medi-Cal, Covered CA, Commercial, POSLA Care Health Plan Medi-CalMolina Health Plan Medi-Cal, Covered CA, Senior Plan, CA MediConnect

AccountableHealth Care IPA

Provider ServicesRepresentativesTeresita Arteaga(562) 435-3333, ext.225Helen Nguyen(562) 435-3333, ext.344Leslie Padilla(562) 435-3333,ext.361

Network Relations ManagerYolanda Greer - Ext. 281

Provider Services CoordinatorHanna Roca - (562) 435-3333, ext.215

Business Development RepresentativesAl George - (562) 435-3333, ext.258Alexis Mejia - (562) 435-3333, ext. 244Ray Antonio - (562) 435-3333, ext. 313Raymond Rivera - (562) 435-3333, ext. 265Elaine Kim - (562) 435-3333, ext. 213Nina Jones - (562) 435-3333, ext. 258Yolanda Greer - (562) 435-3333, ext. 258

Preventing Health Care Fraud, Waste,and Abuse: Your help is needed

REPORTING FRAUDBy working together we can make a difference. If you suspect Fraud report it

today, call the Toll Free number of the Department ofHealth Services Anti-Fraud Line: 1-800-822-6222.

Introducing our newest health plan partner:Discover Why It’s a Brand New Day in Healthcare.Brand New Day is the Medicare product line name of Universal Care Health Plan. Universal Care/Brand New Day is a family run private health plan. Universal Care/Brand New Day has been in operation since 1985 and understands the importance of helping its members through the complex healthcare system. As a family run health plan Brand New Day does not have to answer to Wall Street, we just answer to our members.

Brand New Day has developed a number of unique products and programs that allow you to better address your client’s healthcare needs. Brand New Day has developed a number of benefit plans and specialized programs allowing your clients to choose the program that meets their needs. The Plan has programs for individuals needing a standard Medicare program, special programs for individuals with both Medicare and Medi-Cal (Dual Special Needs Plan or D-SNP) and specialized programs for individuals diagnosed with Diabetes, Dementia, Major Depression, Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, and Paranoid Disorder (Chronic Special Needs Plan or C-SNP). The plan is licensed to service members who live in Los Angeles, Orange, Riverside, San Bernardino, Kern, and Kings Counties.

Customer Service can be called from 8:00 a.m. to 8:00 p.m. Sunday through Saturday (7 days a week) 1-866-255-4795, English, Spanish, Vietnamese, and Khmer, 1-866-321-5955 TTY Users.

http://www.brandnewdayhmo.com/

ACCOUNTABLEHEALTH CARE IPA

ITS NEWESTPROVIDERS

HEALTH CARE IPA

ITS NEWEST