mipct webinar 04/18/2012

Michigan Primary Care Transformation

Demonstration Project

April 18, 2012Webinar #5

Agenda

Context and Overview

Reporting Update

Payer Updates• BCBSM• BCN• Medicaid• Medicare

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BCBSM PDCM Payment Policy Design

Fee‐for‐service methodology – 7 payable codes for services performed by qualified non‐physician practitioners

• Face‐to‐face (individual and group)• Telephone‐based

Payable to approved providers only

• Non‐approved providers billing for these services are subject to recovery

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PDCM Codes and Fees

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CODE SERVICE FEE*

G9001 Initial assessment $112.67

G9002 Individual face-to-face visit (per encounter) $56.34

98961 Group visit (2-4 patients) 30 minutes $14.08

98962 Group visit (5-8 patients) 30 minutes $10.47

98966 Telephone discussion 5-10 minutes $14.45

98967 Telephone discussion 11-20 minutes $27.81

98968 Telephone discussion 21+ minutes $41.17

*Net of Incentive amount

General Conditions of Payment

For billed services to be payable, the following conditions apply:

• The patient must be eligible for PDCM coverage

Non‐approved providers billing for PDCM services will be subject to audit and recoveries

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General Conditions of Payment


• The services must be delivered and billed under the auspices of a practice or practice‐affiliated PO approved by BCBSM for PDCM reimbursement.

• Based on patient need

• Ordered by a physician, PA or CNP within the approved practice

• Performed by the appropriate qualified, non‐physician health care professional employed or contracted with the approved practice or PO

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Care Management Training Guidelines

Services provided by Moderate Care Managers are billable once Care Managers complete approved self‐management training

Services provided by Complex Care Managers are billable once care managers have completed approved Complex Care Management training

PDCM‐codes should not be billed by untrained care managers

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Patient Eligibility

The patient must have active BCBSM coverage that includes the BlueHealthConnection® Program. This includes:

• BCBSM underwritten business

• ASC (self‐funded) groups that elect to participate• Medicare Advantage patients

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Services billed for non-eligible members will be rejected with provider liability.

Patient Eligibility

Checking eligibility:

• Eligible members with PDCM coverage will be flagged on the monthly patient list

• Providers should also check normal eligibility channels (e.g., WebDENIS, CAREN IVR) to confirm BCBSM overall coverage eligibility

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Patient Eligibility

The patient must be an active patient under the care of a physician, PA or CNP in a PDCM‐approved practice and referred by that clinician for PDCM services

• No diagnosis restrictions applied• Referral should be based on patient need

The patient must be an active participant in the care plan

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Provider Requirements: Care Management Team

Individuals performing PDCM services must be qualified non‐physician practitioners employed by practices or practice‐affiliated POs approved for PDCM payments

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The team must consist of:

• A lead care manager : RN, LMSW, CNP or PA who has completed an MiPCT‐accepted training program

• Other qualified allied health professionals:• LPN CDE, certified diabetes educator, RD, Nutritionist Master’s Level, Pharmacist, respiratory therapist, certified asthma educator, certified health educator specialist (bachelor’s degree or higher), licensed professional counselor, licensed mental health counselor

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Each qualified care team member must:• Function within their defined scope of practice• Work closely and collaboratively with the patient’s clinical care team

• Work in concert with BCBSM care management nurses as appropriate

Note: Only lead care managers may perform the initial assessment services (G9001)

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Provider Requirements: Billing and Rendering Provider

RenderingProvider

Billing Provider

Practice‐based Physician, CNP or PA within the PDCM‐approved practice

Physician practice

Physician Organization‐

based

PO‐based billing entity

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BCBSM’s Provider Consulting area is prepared to assist with the enrollment process. Please contact Laurie Latvis at [email protected]

Billing and Documentation: General Guidelines

The following general billing guidelines apply to PDCM services:

• Approved practices/POs only• Professional claim

• 7 procedure codes

• PDCM may be billed with other medical services on the same claim

• PDCM may be billed on the same day as other physician services

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• No diagnostic restrictions• All relevant diagnoses should be identified on the claim

• No quantity limits (except G9001)• No location restrictions• Documentation demonstrating services were necessary and delivered as reported

• Documentation identifying lead CM isn’t required, but documentation must be maintained in medical records identifying the provider for each patient interaction

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G9001: Initiation of Care Management

Payable only when performed by an RN, MSW, CNP or PA with approved level of care management training (i.e., lead care manager)

One assessment per patient per year

Contacts must add up to at least 30 minutes of discussion

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G9001:Initiation of Care Management

Assessment should include:

• Identification of all active diagnoses• Assessment of treatment regimens, medications, risk factors, unmet needs, etc.

• Care plan creation (issues, outcome goals, and planned interventions)

Billed claims must include:

• Date of service (date patient is “enrolled” in care management)

• All active diagnoses identified in the assessment process

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G9001: Initiation of Care Management

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Record documentation must additionally include:

• Dates, duration, name/credentials of care manager performing the service

• Formal indication of patient engagement/enrollment

• Physician coordination and agreement

NOTE: More detailed requirements/expectations applicable to Medicare Advantage patients are under development.

G9002:Individual, Face‐to‐Face

Payable when performed by any qualified care management team member

No quantity limits

Encounters must:

• Be conducted in person• Be a substantive, focused discussion pertinent to patient’s care plan

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G9002:Individual, Face‐to‐Face

Claims reporting requirements:

• Each encounter should be billed on its own claim line

• All diagnoses relevant to the encounter should be reported

Record documentation must additionally include:

• Date, duration, name/credentials of team member performing the service

• Nature of discussion and pertinent details relevant to care plan (progress, changes, etc.)

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Code‐Specific Requirements: 98961, 98962


No quantity limits (for example, if call lasted more than 30 minutes you would bill additional codes for each 30 minute increment)

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Each session must:

• Be conducted in person• Have at least two, but no more than eight patients present

• Include some level of individualized interaction

Each session must:

• Be conducted in person• Have at least two, but no more than eight patients present

• Include some level of individualized interaction23


Claims reporting requirements:

• Services should be separately billed for each individual patient

• Code selection depends upon total number of patient participants in the session

• Quantity depends upon length of session (reported in thirty minute increments)

• All diagnoses relevant to the encounter should be reported

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Additional documentation requirements:

• Dates, duration, name/credentials of care manager performing the service

• Nature of content/objectives, number of patients present

• Any updated status on patient’s condition, needs, progress

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Code‐Specific Requirements: 98966, 98967, 98968 Telephonic

98966 Assessment and management, 5‐10 minutes 98967 Assessment and management, 11‐20 minutes 98968 Assessment and management, 21+ minutes


No more than one per date of service (if multiple calls are made on the same day, the times spent on each call should be combined and reported as a single call)

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Each encounter must:

• Be conducted by phone; be at least 5 minutes in duration

• Include a substantive, focused discussion pertinent to patient’s care plan

Claims reporting requirements

• Code selection depends upon duration of phone call• All diagnoses relevant to the encounter should be reported

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Additional documentation requirements:

• Dates, duration, name/credentials of care manager performing the call

• Nature of the discussion and pertinent details regarding updates on patient’s condition, needs, progress

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BCN Care Coordination Payment

Effective April 1, 2012 and forward, providers need to submit claims for care coordination services rendered

For January 1 to March 31, 2012, BCN will pay a lump sum equal to three times the average monthly care coordination payment• Average monthly care coordination will be calculated using claims validated and billed for July and August 2012 dates of service

• Payment will be made no later than October 31, 2012

BCN PDCM Payment Policy Design

Fee‐for‐service methodology – 7 payable codes for services performed by qualified non‐physician practitioners

• Face‐to‐face (individual and group)• Telephone‐based

Payable to approved/“privileged” providers only

• Non‐approved providers billing for these services are subject to recovery

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BCN PDCM Payment Policy Design

BCN will pay the lesser of provider charges or BCN’s maximum fee

• CNPs or PAs paid at 85% No cost share imposed on members

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BCN PDCM Codes and Fees

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CODE SERVICE

G9001 Initial assessment

G9002 Individual face-to-face visit (per encounter)

98961 Group visit (2-4 patients) 30 minutes

98962 Group visit (5-8 patients) 30 minutes

98966 Telephone discussion 5-10 minutes

98967 Telephone discussion 11-20 minutes

98968 Telephone discussion 21+ minutes

• Use applicable regional fee schedule– Call your BCN provider representative with questions

BCN General Conditions of Payment


• The patient must be eligible for PDCM coverage.

• The services must be delivered and billed under the auspices of a practice or practice‐affiliated PO approved by BCN for PDCM reimbursement.

• Billed in accordance with BCN billing guidelines

Non‐approved providers billing for PDCM services will be subject to audit and recoveries.

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BCN Care Management Training Guidelines

• BCN same as BCBSM

• Services provided by Moderate Care Managers are billable once care managers complete approved self‐management training.

• Services provided by Complex care managers are billable once care managers have completed approved Complex Care Management training.

• PDCM‐codes should not be billed by untrained care managers

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BCN Patient Eligibility

Provider panels are available through Health e‐Blue web• Instructions will be forthcoming detailing how to identify the self‐funded membership not participating in MiPCT

• Providers should also check normal eligibility channels (e.g., WebDENIS, CAREN IVR) to confirm BCN overall coverage eligibility

The patient must be an active patient under the care of a physician, PA or CNP in a PDCM‐approved practice and o diagnosis restrictions are applied• Order for PDCM should be based on patient need

The patient must be an active participant in the care plan

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Provider Requirements: Care Management Team (BCBSM)

Individuals performing PDCM services must be qualified non‐physician practitioners employed by practices or practice‐affiliated POs approved for PDCM payments

Refer to BCBSM slide

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Provider Requirements: Billing and Rendering Provider

RenderingProvider

Billing Provider

Practice‐based Physician, CNP or PA within the PDCM‐approved practice

Physician practice

Physician Organization‐

based

PO‐based billing entity

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The following general billing guidelines apply to PDCM services:• Approved practices/POs only• Professional claim

• 7 procedure codes• PDCM may be billed with other medical services on the same claim• PDCM may be billed on the same day as other physician services• PDCM codes and T codes may not be billed for the same member

• No diagnostic restrictions• All relevant diagnoses should be identified on the claim

• No location restrictions• Documentation demonstrating services were necessary and delivered as reported

• Documentation identifying lead CM isn’t required, but documentation must be maintained in medical records identifying the provider for each patient interaction

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G9001:Initiation of Care Management

Same as BCBSM

Payable only when performed by an RN, MSW, CNP or PA with approved level of care management training (i.e., lead care manager)

One assessment per patient per year

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G9002:Individual, Face‐to‐Face Care Visit

Same as BCBSM


No quantity limits

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98961, 98962Group Education & Training Visit

Same as BCBSM

98961 Education and training for patient self‐management for 2‐4 patients, 30 minutes

98962 Education and training for patient self‐management for 5‐8 patients, 30 minutes

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98966, 98967, 98968Telephone‐based Services

Same as BCBSM98966 Telephone assessment and management, 5‐10 minutes

98967 Telephone assessment and management, 11‐20 minutes

98968 Telephone assessment and management, 21+ minutes

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Medicaid Attribution

Medicaid managed care population only

Attributed member:• Medicaid beneficiary enrolled in a Medicaid Health Plan AND

• assigned Primary Care Provider is affiliated with participating practice/PO

Enrollee Lists

• Attribution process occurs on the first business day of the month

• Medicaid enrollee lists submitted to Michigan Data Collaborative (MDC)

• MDC will post enrollee lists on MDC secure site for retrieval by PO–Automated message from MIShare at UMHS–[email protected] –[email protected]

• PO responsible for transmitting enrollee lists to practices

Payment Calculation

Medicaid payments calculated as Per Member Per Month (PMPM) based on monthly attribution counts:• $3.00 PMPM Care Coordination paid to PO• $1.50 PMPM Practice Transformation paid to Practice

• $3.00 variable payment based on performance paid to PO

Provider Enrollment Required for Payment

PO’s will be enrolled as an MCO in CHAMPS system by DCH.

Practices must enroll as either an individual sole proprietor or as a group in Medicaid CHAMPS system.

PO Enrollment questions: [email protected]

Provider Enrollment questions: 800‐292‐2550

Payment Timing

• Quarterly EFT payments appear as gross adjustment

• Reconcile payment amount with your enrollee list

• Payments released mid month after end of the quarter –April (QTR 1)–July (QTR 2) –October (QTR 3)

• Regularly check the Payment Update Tab on MIPCTdemo.org for new/updated information

• Payment questions: [email protected]

UMHS CMS Payment Processing and Distribution to POs

CMS does not have a mechanism to pay POs directly

• To accommodate this, CMS sends individual line item remittances to UMHS (as they did for practice transformation to the practices).

• Though not ideal, CMS will not change their practice – thus UMHS must receive, reconcile and then distribute payments

UMHS CMS Payment Processing and Distribution to POs

Work is underway and a front‐end application has been built to:

‐ Reconcile claims with member lists

‐ Calculate PO payments

‐ Produce PO payment summary

This will result in a payment delay for the first set of care coordination payments. Goal is to distribute to POs by early June. Earlier if at all possible

Reporting to MiPCT

MiPCT practices are required to provide an accounting for the MiPCT Transformation funds

MNO is responsible for gathering information by April 30

MNO will sign off on all activities regarding care managers and care manager assistants training

MNO will sign off on patient registry documentation: WellCentive will be MU by April 30. Practice will use MiPCT funds to cover enhancement costs ($700)

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Issues in 3 x 5

mipct webinar 04/18/2012

Health & Medicine

provider liability

noneligible members

telephone discussion

g9001initial assessment

net of incentive

laurie latvis