2. Personal
32 years of medical management experience
FACMPE
Healthcare organizations - Small primary care, large
multi-specialty, hospital network, large single specialty
Formed Cockrell and Associates, LLC in 2009
Focus on
Practice management
Network development
3. Incentives Prior to 2010
See more patients
Do more tests – appropriately
Hope fees did not get cut
4. What Happened in 2010
The Accountable Care Act (ACA)
Problems and Concerns but It’s Here to Stay
Financially, the FFS Model Cannot be Sustained
How Do You Argue with High Quality / Low Cost
So Let’s look for Opportunities
7. The Three Levels of Incentives
1. Just cause we like you
2. We like you but we need you to prove you like us
3. We think we like you but you need to prove that we
should like you
8. What Base Do We Use
Cognitive encounters for Primary Care
Major surgery codes for general surgeons
Specialty codes
New measurements
Quality
Cost
9. Primary Care Base for Bonuses
Typically, Primary care bonuses are based on these:
Office/outpatient visits, CPT 99201-99215;
Nursing facility services, CPT 99304-99318;
Domiciliary, rest home, or custodial care services, CPT 99324-
99340; and
Home services, CPT 99341-99350.
In many cases, surgery and other non-diagnostic codes
are included
BCBS list is 20 pages long
11. Medicare
Primary Care Incentive Payment Program
Part of the ACA
Runs from2011 to 2015
10% bonus on to of the fee schedule payment for select
primary care services (earlier slide)
60% of billings must fall in the primary care services
category
12. Medicare
HPSA General
Shortage area
10% bonus
All specialties plus
chiropractors, optometrists, podiatrists, medical tele-
consults
13. Medicare
HPSA - General Surgery
HPSA Surgical Incentive Payment (HSIP)
1/1/2011 – 12/31/2015
Covers major surgical procedures in a geographic HPSA
Additional 10% on top of the regular HPSA bonus
14. We Like You but We Need You to
Prove You Like Us Category
15. Medicare
Transitional Care Management
Effective 1/1/2013
CPT Codes 99495 and 99496
Used to report physician or qualifying non-physician
care management services following a discharge for a
hospital, SNF or CMHC stay
30 day transition period
16. Medicare
Transitional Care Management
Requires
Direct, telephone or electronic contact with the patient or care
giver within two days of discharge
Medical decision making of moderate (CPT 99495) or high
(CPT 99496) complexity
Face to face patient visit within 14 days (CPT 99495) or seven
days (CPT 99496) of discharge
99495 about $150.00
99496 about $200.00
17. BCBS
2012 Primary Care Value-Based Payment Program
Three Elements
Efficiency (5% bonus)
Quantitative (5% bonus)
Qualitative (5% bonus)
18. BCBS
Qualifiers
PMD doctor for at least one year in good standing
Must practice Geriatrics, Family Practice, Internal
Medicine, General Medicine or Pediatric Medicine
Must utilize ETF
Must file claims electronically
Must have 24 hour on call coverage
Must be Board Certified
Must participate in all applicable BCBS of Alabama
Networks
27. Medicare Value Based Modifier
Supports the transformation of Medicare from a
passive payer to an active purchaser of higher
quality, more efficient healthcare
Specific to Fee-For-Service (FFS) Medicare
It’s base is PQRS
Two primary components
Physician Quality and Resource Use Reports (QRURs)
A Value Based Modifier
Mandated to start in 2015 based on 2013 data
28. Medicare Value Based Modifier
2013 – Focused on groups with 25 or more eligible
providers filing under a single tax identification
number (TIN) who will receive QRURs
2015 – Groups with 100 or more eleigible providers
filing under the same TIN will be subject to the
modifier based on their performance in 2013
2017 - Expands to all physicians who participate if FFS
Medicare
29. ACO’s and Shared Savings
Shared savings are starting on the hospital level
Accountable Care Organizations (ACO’s) (excluded
from the Value Based Modifier Program)
Not any real traction in Alabama, yet
Primary care driven but control could be through a
hospital or large specialty network
30. So, why are these last two
considered a positive?
Information is power
It’s time to get our information together now and
Where it’s good – let everyone know
Where it’s not good – fix it
PCMH?
Meaningful Use?
Next up – NCQA is looking at Specialty Centered
Medical Homes (SCMH)
31.
32. Operations
PQRS
Should already be on board
A basis for future programs
Coding
Diagnoses
Document
Credentialing
Don’t be late
Be complete
