Primary Health Care Renewal In Bc

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Primary Health Care Renewal In Bc

  1. 1. The information contained in this manual is not intended to supercede the information provided in the Medical Services Commission Fee Schedule or in documentation produced by the Medical Services Plan or HealthNetBC Access Services. Primary Health Care Organizations: Operations Manual i Version 1.0 – October 2004
  2. 2. ii Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  3. 3. Table of Contents Table of Contents 1. Introduction ............................................................................................................ 1-3 1.1. About this Guide..................................................................................................................1-3 1.2. What is Primary Health Care (PHC)?..................................................................................1-3 1.3. What is PHC Renewal?........................................................................................................1-4 1.4. What is the Primary Health Care Transition Fund (PHCTF)?...........................................1-5 1.5. What Constitutes a PHCO?.................................................................................................1-6 1.6. Benefits to PHCO Patients..................................................................................................1-6 1.7. Benefits to PHCO Providers ...............................................................................................1-7 1.8. Overview of the Blended Funding Model ..........................................................................1-8 1.9. Contact Information...........................................................................................................1-10 2. Establishing a PHCO ............................................................................................. 2-3 2.1. Overview of the Process .....................................................................................................2-3 2.2. Funding for PHCOs .............................................................................................................2-4 2.3. Site Eligibility Requirements ..............................................................................................2-8 2.4. Developing the Patient Register.........................................................................................2-9 2.5. Interdisciplinary Teams.....................................................................................................2-13 2.6. Estimating the Funding Level (PHCO Site Analysis)......................................................2-14 2.7. Contracts............................................................................................................................2-15 2.8. PHCO Site Set-up...............................................................................................................2-18 2.9. Ongoing Administrative Requirements ...........................................................................2-25 3. Managing a Patient Register................................................................................. 3-3 3.1. Overview...............................................................................................................................3-3 3.2. Registration Data Submission Overview...........................................................................3-3 3.3. Registering a Patient ...........................................................................................................3-8 3.4. Modifying Your Patient Register ......................................................................................3-14 Primary Health Care Organizations: Operations Manual iii Version 1.0 – October 2004
  4. 4. Table of Contents 3.5. De-Registering a Patient .................................................................................................. 3-18 3.6. Monthly Registration Reviews......................................................................................... 3-21 3.7. Verifying Your Patient Register ....................................................................................... 3-28 4. Submitting Claims.................................................................................................. 4-3 4.1. Overview.............................................................................................................................. 4-3 4.2. Basic Claim and Encounter Record Information.............................................................. 4-5 4.3. Submitting Encounter Records ......................................................................................... 4-8 4.4. Submitting Fee-for-Service Claims ................................................................................. 4-10 4.5. Conversion of Fee-for-Service Claims/Encounter Records .......................................... 4-11 4.6. Submitting Call-Out Services .......................................................................................... 4-14 4.7. Third Party Billings........................................................................................................... 4-15 4.8. Direct Patient Billing for Non-Benefit Services .............................................................. 4-16 4.9. Locums .............................................................................................................................. 4-17 4.10. Patients Referred to the PHCO for Pre-Natal Care......................................................... 4-18 4.11. Services Provided to a Newborn ..................................................................................... 4-19 4.12. Submitting Claims for Hospitalized Patients.................................................................. 4-20 4.13. Recording No Charge Referrals....................................................................................... 4-21 4.14. Recording Methadone Treatment for a Registered Patient........................................... 4-22 4.15. Definition of Formal / Informal Case Management for PHCOs ..................................... 4-23 5. Payments ................................................................................................................ 5-3 5.1. Quarterly and Annual Payment and Reconciliation......................................................... 5-3 5.2. Calculations ........................................................................................................................ 5-8 6. Resources............................................................................................................... 6-3 6.1. Enhancing PHCO Service .................................................................................................. 6-3 6.2. Information Resources for PHCOs.................................................................................... 6-4 6.3. Complementary Initiatives ................................................................................................. 6-6 6.4. Health Information for Patients.......................................................................................... 6-9 iv Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  5. 5. Table of Contents APPENDIX A – Local Health Areas................................................................................ 1 APPENDIX B – Information Required for Site Analysis ................................................. 1 APPENDIX C – PHCO Site Analysis Report.................................................................. 1 APPENDIX D – Outflow Reduction Strategies.............................................................. 1 APPENDIX E – Patient Registration Reports................................................................ 1 APPENDIX F – Quarterly/Annual Payment Reports..................................................... 1 GLOSSARY...................................................................................................................... 1 INDEX ............................................................................................................................... 1 Table of Figures Figure 1-1 PHCO Blended Funding Model .................................................................... 1-9 Figure 2-1 PHCO Contractual Arrangements .............................................................. 2-15 Figure 3-1 Monthly Registration Review Schedule ...................................................... 3-22 Figure 4-1 Submission of Fee-for-Service Claims and Encounter Records .................. 4-4 Figure 5-1 Payments Process........................................................................................ 5-3 Figure 5-2 Population-Based Funding ........................................................................... 5-8 Primary Health Care Organizations: Operations Manual v Version 1.0 – October 2004
  6. 6. Table of Contents vi Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  7. 7. SECTION 1 – INTRODUCTION Section Contents SECTION 1 – INTRODUCTION Section Contents 1.1. About this Guide....................................................................................................................1-3 1.2. What is Primary Health Care (PHC)? ...................................................................................1-3 1.3. What is PHC Renewal? .........................................................................................................1-4 1.4. What is the Primary Health Care Transition Fund (PHCTF)?.............................................1-5 1.5. What Constitutes a PHCO?...................................................................................................1-6 1.6. Benefits to PHCO Patients....................................................................................................1-6 1.7. Benefits to PHCO Providers .................................................................................................1-7 1.8. Overview of the Blended Funding Model ............................................................................1-8 1.9. Contact Information ............................................................................................................1-10 1.9.1. Ministry of Health Services......................................................................................1-10 Primary Health Care Branch............................................................................................. 1-10 Medical Services Plan (Teleplan) and the Secure Web Site for Practitioners (HNWeb).. 1-10 1.9.2. Health Authorities ....................................................................................................1-11 Primary Health Care Organizations: Operations Manual 1-1 Version 1.0 – October 2004
  8. 8. Section Contents SECTION 1 – INTRODUCTION 1-2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  9. 9. SECTION 1 – INTRODUCTION About this Guide 1. Introduction 1.1. About this Guide This guide is a reference for Primary Health Care Organizations (PHCOs), Community Health Centres (CHCs), health authorities and other health care providers interested in the set-up and management of primary health care organizations. For the purposes of this manual, the term PHCO includes CHCs. This section of the guide gives an overview of primary health care renewal and the PHCO concept. It also offers contact information useful to both potential and existing PHCOs. Further information is broken into an additional five sections: • Section 2, Establishing a PHCO, describes the overall funding model for PHCOs and the process for setting up a new site. • Section 3, Managing a Patient Register, provides the information PHCOs require to manage the register of patients who use their practice for the majority of their primary health care services. • Section 4, Submitting Claims, provides information on how PHCOs report patient services. • Section 5, PHCO Payments Process, details the processes by which funding payments are made and provides specific information on funding calculations. • Section 6, Resources, gives an overview of the complementary programs, funding opportunities and sources of health information that PHCOs may use to enhance their practice. At the end of the document, there is also a glossary and detailed index. 1.2. What is Primary Health Care (PHC)? Primary health care is the foundation of Canada’s health care system. For most British Columbians, it is the first and most frequent point of ongoing contact with the health care system. The goal of PHC is to keep people healthier longer, by preventing serious illness and injury through education and timely treatment of short-term, episodic problems. It also works to help patients manage chronic illnesses appropriately, so they do not develop unnecessarily into medical crises. Primary Health Care Organizations: Operations Manual 1-3 Version 1.0 – October 2004
  10. 10. What is PHC Renewal? SECTION 1 – INTRODUCTION PHC is the point in the health care system where: • short-term health issues are resolved; • patients with chronic or complex health issues receive ongoing care and are linked to other services in their community; and • health promotion and education efforts are most effective. As expressed in the World Health Organization’s Alma Ata Declaration, Article IV, high-quality PHC should be “based on practical, scientifically sound…methods and technology” and, as such, has the potential to contribute significantly to the sustainability of the health care system as a whole. Universally accessible by all individuals and families, the optimum PHC system delivers health care that is affordable to the community and country and offers quality, front line health care services close to where people live and work. 1.3. What is PHC Renewal? PHC renewal consists of strategies designed to strengthen patient access to health care services, to increase provider and patient satisfaction, and to achieve measurable improvements in health outcomes. A variety of PHC models are being developed across Canada. All offer more consistent, integrated and coordinated care for patients, a more collegial and rewarding working life for doctors and nurses, and more cost-effective care aimed at reducing the need for hospital admissions and promoting effective self-care strategies for patients. In British Columbia, under the Primary Health Care Transition Fund (PHCTF), health authorities were encouraged to pursue PHC initiatives in accordance with the three key PHC goals: • Support a range of practice models such as PHC networks of family doctors in different locations; shared care relationships between family doctors and specialists; augmented roles for nurses; and full service PHCOs based on interdisciplinary teams operating at one site. • Improve health outcomes through measures such as chronic disease registries; integration of clinical practice guidelines aimed at standardizing treatment of certain diseases; targeted disease or population strategies; and targeted high-risk populations. • Education and evaluation through ongoing support for both health care providers and patients as new models of care are implemented. Health care providers need easy access to information and require support to learn more about collaborative practice, team building and change management. Patients need to understand their role as clients of PHCOs and to have access to information and support to enable them to become active managers of their own health. Continued learning from PHC renewal initiatives depends on the establishment of a baseline and the coordination of information gathering to support evaluation at system, project and cross-health authority levels. 1-4 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  11. 11. SECTION 1 – INTRODUCTION What is the Primary Health Care Transition Fund (PHCTF)? 1.4. What is the Primary Health Care Transition Fund (PHCTF)? The PHCTF is an $800 million Health Canada initiative designed to facilitate systemic, long-term PHC renewal by supporting Canada’s provinces and territories in their efforts, over a four-year period (2002-2006), to improve their delivery of PHC services. The common PHCTF objectives agreed to by both the federal and provincial/ territorial governments are: • To increase the proportion of the population having access to PHCOs; • To increase the emphasis on health promotion, disease and injury prevention, and high-quality chronic disease management; • To establish interdisciplinary teams, so that the most appropriate care is provided by the most appropriate provider; • To coordinate and integrate PHC organizations with other services, e.g., in institutions and in communities; and • To expand 24-hour-a-day, seven-day-a-week access to a health care provider for core services. The fund has two components: national and provincial/territorial. The national component is 30 percent of the fund, or $240 million, which is being used to support common approaches to PHC enhancement and to improve PHC for priority populations. The 70 percent provincial/territorial component, or $560 million, has been allocated to the provinces and territories on a per capita basis to advance PHC renewal. British Columbia’s share of the provincial/territorial component is $74 million. The majority of this funding (93 percent) has been provided to the health authorities to plan and implement PHC enhancement initiatives that are appropriate for their regions. British Columbia has focused on working collaboratively with health authorities to achieve key PHC goals. The PHCTF has helped the province to build on the advances made under the Health Transition Fund, which the federal government established in 1997. It was the three-year Health Transition Fund that resulted in the formation of seven Primary Care Demonstration Project (PCDP) sites designed to test new and innovative models of PHC delivery. PCDP sites are now known as PHCOs. Primary Health Care Organizations: Operations Manual 1-5 Version 1.0 – October 2004
  12. 12. What Constitutes a PHCO? SECTION 1 – INTRODUCTION 1.5. What Constitutes a PHCO? A PHCO is a medical practice committed to providing comprehensive primary care services. It promotes interdisciplinary practice by encouraging clinicians to develop and strengthen the natural links between family medicine and other health professionals such as nurses, pharmacists, counselors, respiratory therapists and nutritionists. A PHCO provides extended hours of operation and availability of services and 24-hour-a-day, seven-day-a-week access to a health care provider. PHCOs deliver patient care under a blended funding model. Unlike the fee-for-service only model, blended funding provides a “per person/per day” component that supports the delivery of common (“core”) services to those patients who use the PHCO for the majority of their PHC services. For patients who do not use the PHCO for the majority of their PHC services, the PHCO continues to submit fee-for-service claims. Under the per person/per day funding component (known as “population-based” funding), the PHCO and its patients benefit most when the PHCO delivers targeted PHC services in a manner which promotes patient health, strengthens patients’ self-management strategies and reduces the need for critical interventions. The ongoing financial viability of a PHCO rests on its commitment to make effective use of personnel and to employ innovative patient care strategies to promote and sustain the health of its patient population. Under the blended funding model, each PHCO is assigned a single Medical Services Plan (MSP) payment number to which all payments are allocated. The Ministry of Health Services directs all payments to the health authority or PHCO under this payment number. 1.6. Benefits to PHCO Patients As patients of a PHCO, individuals and families receive improved access to primary health care services 24 hours a day, 7 days a week, and improved access to health care providers during extended practice hours. Patients also benefit from the delivery of coordinated, comprehensive services by the PHCO interdisciplinary team. Through increased health education, promotion of self-care strategies and the implementation of guideline-based disease management protocols, patients secure measurable positive health outcomes, particularly in cases of chronic illness. Patients also benefit from the PHCO’s sound knowledge of the needs of its particular patient population. Aggregate data reports on a PHCOs evolving patient population, issued by the Ministry of Health Services, provide PHCOs and health authorities with regular access to information. This information allows each PHCO to tailor its services, health promotion and health education activities to the particular needs of its patients. Complementary initiatives, such as the Chronic Disease Management (CDM) Toolkit and patient registries, provide further support for targeted services. For information on resources and complementary initiatives, please refer to Section 6. 1-6 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  13. 13. SECTION 1 – INTRODUCTION Benefits to PHCO Providers 1.7. Benefits to PHCO Providers Within an interdisciplinary team, and under the blended funding model, PHCO health care providers experience a measurable positive impact on the quality of their personal and professional lives. For health care providers, the PHCO approach: • promotes stronger links with specialists and with community and institutional services, which facilitates the management of patient care, especially in complex care situations; • creates increased opportunities to develop innovative care plans such as involving patients in educational and self-help groups; • provides, through supporting technologies, the ability to access and update patient medical histories; • provides access, on a regular basis, to ministry analysis of the PHCO’s current patient population and service histories, allowing PHCO health care providers to focus their professional energies for maximum effectiveness; • allows for better vacation and educational leave coverage; and • offers increased income predictability. Primary Health Care Organizations: Operations Manual 1-7 Version 1.0 – October 2004
  14. 14. Overview of the Blended Funding Model SECTION 1 – INTRODUCTION 1.8. Overview of the Blended Funding Model PHCOs receive blended funding: a combination of fee-for-service payments and per patient, per day (population-based) funding. Because population-based funding constitutes the larger portion of its income, a PHCO’s success rests on its ability to deliver health care services efficiently and in a manner which promotes patient health. Population-based funding is paid for patients who use the PHCO for the majority of their primary health care services. These patients, who usually live in the PHCO’s “catchment” area, become registered patients of the PHCO. Commonly provided primary care services (“core” services) and certain additional services (“extended” services) for these patients are covered under the population-based funding. As shown in area of Figure 1-1 on the following page, population-based funding is based on the health status of the PHCO’s registered patients. Each patient is assigned an Adjusted Clinical Group (ACG) which indicates their “illness burden.” In conjunction with patient age and gender information, ACGs allow the Ministry of Health Services to analyze each patient’s past need for primary care health services. The ministry conducts ACG assignments each year to reflect patients’ evolving need for service. Using the MSP Claims History, the value of the services that patients assigned a specific ACG are likely to require is used to calculate an appropriate Daily Rate for those patients. As shown in area of Figure 1-1, the appropriate ACG Daily Rate is multiplied by the number of days a patient is registered to the PHCO. The result is the gross annual funding amount for the patient. This is the amount that will be paid to the PHCO (usually through the health authority) providing the patient does not receive core services from another practice in the PHCO’s catchment area. If a registered patient does receive a core service from another practice within PHCO catchment area, the value of the fee-for-service claim submitted by the other provider is deducted from the annual funding amount. This deduction is known as a “service outflow.” To prevent service outflows from resulting in less than zero population-based funding for a patient, a Stability Fund has been established. If, at year-end, service outflows have caused the funding for a patient to drop below zero, the Stability Fund is used to “top up” the funding to zero. PHCOs continue to receive fee-for-service, third party and other payments (as shown in area of Figure 1-1). Fee-for-service claims are submitted for patients who are not registered to the PHCO and for any services not categorized as “core” services. As indicated in areas , and of Figure 1-1, the formation and funding of a PHCO is a team effort involving the Ministry of Health Services, the health authority and the PHCO itself. For more information on the role of the Ministry of Health Services and the health authority, please refer to Section 1.9. 1-8 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  15. 15. 1 3 4 Patients PHCO Payment Health Authority Used to calculate Interdisciplinary Teams Identifying Health Needs ACG Daily Rates* Contract * Version 1.0 – October 2004 Entire Patient Population Covered by BC Medical 0100 (2-59): $ 0.25 SECTION 1 – INTRODUCTION Planning Appropriate Programs and Services Services Plan 2400 (2-59): $ 0.21 Billing and Data Submission 4110 (60-69): $ 0.63 Catchment area for PHCO Managing the Delivery of Health Services 5110 (70-79): $ 0.38 e iice 5340 (00-01): $ 0.84 r rv Patient Register for PHCO e Se iice rs * Rates by age groups. e rv r ve liv Rates used in 2002/2003 2400 5100 fS Communication o o De e pe 0100 Primary Health Care Organizations: Operations Manual Ty T Payment Payment Contract * 0200 4110 4330 1200 5340 5100 Ministry of Health Services 2 1100 1500 5310 Data Collection / Reporting 5070 2600 1710 1762 * Some existing PHCO sites have contracts directly with the Ministry Figure 1-1 PHCO Blended Funding Model Population-Based Funding 5 Blended Funding 6 ACG Categories per Patient Service Outflows (-$) The number of days the patient is A registered with PHCO Population-Based Funding 1. Age ACG 2. Gender Multiplied by 1 of 82 Plus 3. Diagnostic Information B The Patient’s ACG Daily Rate Less Fee-For-Service Funding C Any deductions for core services received Plus outside the PHCO but within the PHCO catchment area (to a minimum population-based funding of $0 per Third Party, Self-Pay, Out of Province, etc. patient, per year). Overview of the Blended Funding Model 1-9
  16. 16. Contact Information SECTION 1 – INTRODUCTION 1.9. Contact Information Formation of a PHCO under the PHCTF is a team effort involving the PHCO, health authority and the Primary Health Care Branch of the Ministry of Health Services. Following is a brief description of the role of each entity with which PHCOs will interact and the appropriate contact information. 1.9.1. Ministry of Health Services Primary Health Care Branch Through the Primary Health Care Branch (part of Clinical Innovation and Integration, Ministry of Health Services), the ministry provides direction and support, implements PHC policies and strategies in accordance with provincial goals and standards, and monitors performance. The Primary Health Care Branch ensures that a potential PHCO meets the criteria for operation under the blended funding model. The branch conducts an analysis of the proposed site and its potential patient base. This provides the financial projections that the proposed PHCO and the health authority require to determine if the site would be a viable undertaking. PHCOs may also contact the ministry for assistance with matters relating to education, office re-design or assessment, change management, etc. For general information on PHCO set-up and operation, visit the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc. For more specific information, contact: Beverlee Sealey Manager, Primary Health Care Organizations and Networks Primary Health Care Branch Ministry of Health Services Telephone: 250-952-1290 Fax: 250-952-3486 E-mail: Beverlee.Sealey@gems3.gov.bc.ca Medical Services Plan (Teleplan) and the Secure Web Site for Practitioners (HNWeb) Submission of PHCO claims and patient registration information is effected through Teleplan and HNWeb. Teleplan is administered through the Medical Services Plan. HNWeb is administrated through HealthNetBC Access Services within the Ministry of Health Services. As with the existing fee-for-service system, PHCOs submit claims and patient encounter records through the MSP Teleplan system. Patient registration information can be submitted either through Teleplan or through HNWeb. If you require assistance with Teleplan, call the Teleplan Support Centre in Victoria at 250-952-2668, or, from elsewhere in British Columbia, at 1-800-663-7206. 1-10 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  17. 17. SECTION 1 – INTRODUCTION Contact Information Teleplan information is also available on the Medical Services Plan Web site at www.healthservices.gov.bc.ca/msp/infoprac/teleplan.html. If you require assistance with HNWeb, contact the Ministry of Health Services Help Desk at 250-952-1234 or send an e-mail to hlth.hnetconnection@gems1.gov.bc.ca. 1.9.2. Health Authorities The health authorities identify health needs, plan appropriate programs and services and manage the delivery of services in their health regions. As part of their overall planning for regional PHC enhancement, health authorities make the final determination of a site’s viability, deliver blended funding to the individual sites and administer the allocation of PHCTF funds to PHC enhancement initiatives within their regions. Health care providers interested in the PHCO model should contact their local health authority as a first step. If you are unsure of the appropriate contact within your local health authority, please contact the Primary Health Care Branch at the phone number or e-mail provided in Section 1.9.1 above. Primary Health Care Organizations: Operations Manual 1-11 Version 1.0 – October 2004
  18. 18. Contact Information SECTION 1 – INTRODUCTION 1-12 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  19. 19. SECTION 2 – ESTABLISHING A PHCO Section Contents SECTION 2 – ESTABLISHING A PHCO Section Contents 2.1. Overview of the Process .....................................................................................................2-3 2.2. Funding for PHCOs .............................................................................................................2-4 2.2.1........Overview................................................................................................................2-4 2.2.2........Adjusted Clinical Groups........................................................................................2-4 Assigning Individual Patients to an ACG ...................................................................... 2-5 2.2.3........Payment for PHCO Services .................................................................................2-5 2.2.4........Adjusted Clinical Group Daily Rate........................................................................2-6 2.2.5........Service Outflows....................................................................................................2-6 2.2.6........Calculation of Population-Based Funding ..............................................................2-7 2.3. Site Eligibility Requirements ..............................................................................................2-8 2.3.1........Essential Components...........................................................................................2-8 2.4. Developing the Patient Register.........................................................................................2-9 2.4.1........Overview................................................................................................................2-9 2.4.2........Virtual Patient Registers and Community Service Profiles.....................................2-9 2.4.3........Catchment Areas ...................................................................................................2-9 Use of Catchment Areas in Developing the Initial Patient Register............................ 2-10 2.4.4........Determining the Proposed Initial Patient Register ...............................................2-10 PHCOs Based on an Existing Practice....................................................................... 2-11 PHCOs Not Based on an Existing Practice ................................................................ 2-11 2.4.5........PHCO-Proposed Patients....................................................................................2-12 2.5. Interdisciplinary Teams.....................................................................................................2-13 2.6. Estimating the Funding Level (PHCO Site Analysis)......................................................2-14 2.6.1........Overview..............................................................................................................2-14 2.6.2........Estimated Service Outflows.................................................................................2-14 2.6.3........Site Analysis Report ............................................................................................2-14 2.7. Contracts............................................................................................................................2-15 2.7.1........Relevant Agreements—British Columbia Medical Association ............................2-15 2.7.2........Performance Agreements—Ministry and Health Authorities ................................2-15 2.7.3........Contracts—Ministry and Health Authorities .........................................................2-16 2.7.4........Blended Funding Contracts—Health Authorities and PHCOs..............................2-16 Blended Funding Contracts ........................................................................................ 2-16 2.7.5........Incentive Programs..............................................................................................2-16 Ongoing Incentives..................................................................................................... 2-16 Time Limited Incentives under the Primary Health Care Transition Fund .................. 2-17 Primary Health Care Organizations: Operations Manual 2-1 Version 1.0 – October 2004
  20. 20. Section Contents SECTION 2 – ESTABLISHING A PHCO 2.8. PHCO Site Set-up...............................................................................................................2-18 2.8.1........Site Set-Up Checklist...........................................................................................2-19 2.8.2........Making Contract Arrangements ...........................................................................2-20 2.8.3........Applying for an MSP Practitioner Number ...........................................................2-20 2.8.4........Applying for a Single Payee Number for the PHCO.............................................2-21 2.8.5........Assigning Practitioner Payments to the PHCO ....................................................2-21 2.8.6........Applying for Transfer of Payments to a Single Bank Account..............................2-22 2.8.7........Applying for Teleplan Service (Opted-In).............................................................2-22 2.8.8........Applying for Additional Facility Numbers..............................................................2-22 2.8.9........Upgrades Required to a PHCO’s Teleplan-Compliant Software..........................2-22 2.8.10......HNWeb - Secure Web Site for Practitioners ........................................................2-23 2.8.11......Designating PHCO Contacts ...............................................................................2-24 2.8.12......PHCO Listserv.....................................................................................................2-24 2.9. Ongoing Administrative Requirements ...........................................................................2-25 2.9.1........Modifications to PHCO Registration of a Practitioner or Locum...........................2-25 Adding a Physician/Practitioner to the PHCO............................................................. 2-25 Deleting PHCO Registration of a Physician/Practitioner/Locum................................. 2-25 2-2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  21. 21. SECTION 2 – ESTABLISHING A PHCO Overview of the Process 2. Establishing a PHCO 2.1. Overview of the Process Organizations interested in forming a PHCO must work with the local health authority. If the health authority wishes to pursue the possibility, the Ministry of Health Services and the health authority work with the proposed PHCO to see if it would be a viable business undertaking under the blended funding model. The blended funding model is a combination of population-based (per patient, per day) funding and fee-for-service payments. The ministry’s Primary Health Care Branch first ensures that the proposed site meets the basic requirements for operation as a PHCO. If these requirements are met, the next step is to estimate the level of funding that the health authority or PHCO would receive for the PHC services delivered by the PHCO. To do this, an initial patient register (or “list”) is developed and patients on the register are categorized according to their “illness burden.” Categories, known as Adjusted Clinical Groups (or ACGs), allow the Primary Health Care Branch to estimate the level of medical services funding those patients have required in the past. Each ACG is associated with a daily rate. By applying these daily rates to patients proposed for the initial patient list, the ministry can estimate population-based funding for those patients and then compare it to the actual historical fee-for-service income for those patients. If, based on this analysis, the health authority decides to implement the PHCO, site set-up can begin. The necessary contractual, administrative and technical structure is put in place to: • enable the health authority to direct payments to the PHCO rather than to individual practitioners; and • enable the PHCO to manage its patient register and submit patient encounter records and fee-for-service claims. Primary Health Care Organizations: Operations Manual 2-3 Version 1.0 – October 2004
  22. 22. Funding for PHCOs SECTION 2 – ESTABLISHING A PHCO 2.2. Funding for PHCOs 2.2.1. Overview Unlike the fee-for-service system which pays physicians per service, a large portion of PHCO income consists of lump sum per patient, per day funding that covers the majority of a patient’s primary care services for a period of time. This population-based funding is predicated on the health status of each patient. Common (“core”) primary care services and identified “extended” services to patients who use the PHCO as their main source of primary care (“registered patients”) are included in this population-based funding. The list of core and extended services is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html#data. All other services (those not designated as core services) to registered patients and all services to non-registered patients continue to be paid on a fee-for-service basis. This combination of population-based and fee-for-service funding is called “blended funding.” To determine the appropriate initial level of population-based funding, the Primary Health Care Branch works with the PHCO and health authority to draw up an initial patient list. The branch analyzes the level of funding that the listed patients have required in the past by grouping patients according to their past use of services and then assigning a daily rate for patients within each group. 2.2.2. Adjusted Clinical Groups Adjusted Clinical Groups (ACGs) are health status categories defined by morbidity, age and gender. ACGs are based on the premise that the level of resources necessary to deliver appropriate health care to a population depends on the “illness burdenquot; of that population. The ACG system, developed by Johns Hopkins University, is widely used to determine the morbidity profile of patient populations, to assess provider performance and to pay health care providers based on the health needs of their patient population. For PHCO purposes, each ACG (and age group within the ACG) is associated with a funding level that reflects the average value of the fee-for-service items that patients in the ACG received in the previous year. Information on the ACG Case Mix System is available on the Johns Hopkins University Web site at www.acg.jhsph.edu/homepage.htm. 2-4 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  23. 23. SECTION 2 – ESTABLISHING A PHCO Funding for PHCOs Assigning Individual Patients to an ACG Over time, a patient may develop a variety of conditions. Within the province of British Columbia, this information is captured by properly coded diagnoses in the fee-for-service claims or encounter records submitted through Teleplan to the Medical Service Plan (MSP) Claims System. Under the Johns Hopkins ACG Case-Mix System, ICD-9 diagnostic codes are mapped to 32 Aggregated Diagnosis Groups (ADGs). Each ADG is a grouping of ICD-9 codes that are similar in terms of severity and likelihood of persistence of the health condition. The ADGs for a patient, combined with the patient’s age and gender, are used to assign the patient to one of 93 ACGs, of which the Ministry of Health Services uses the 82 that are relevant to primary health care. ACG assignments take place each year when the majority of MSP claims for a fiscal year have been received. Note: New patients or patients who have been insured by MSP for less than 275 days during the fiscal year (including newborns) are assigned to a separate group determined solely by age and gender. Additional funding is provided for patients diagnosed with HIV/AIDS. If your PHCO serves patients diagnosed with HIV/AIDS, please advise the Primary Health Care Branch (refer to Section 2.8 for contact information). An adjustment to your site set-up will be made to allow you to set a “Special Needs” administrative code for these patients. Note: The ministry does not disclose the ACG assignment of a specific patient. 2.2.3. Payment for PHCO Services Not all services to registered patients are paid through population-based funding. Analysis by the Medical Services Plan (MSP) revealed that about 90% of fee-for-service claims for PHC services were associated with 97 core services (as of February 2004). These core services, such as 0100-General Office Visit, are those that would be commonly provided by a PHCO. Payment for services not typically provided by primary care physicians—for example, emergency treatment, anesthesia, minor surgery, and obstetrics—are paid on a fee-for-service basis. The core services are a collection of existing fee-for-service items supplemented by a limited number of additional services referred to as “extended services.” Extended services are specifically designed to reflect the work of PHCO practitioners including, for instance, case conferencing, telephone follow-ups and patient education on a variety of topics. The list of core and extended service codes is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html. Primary Health Care Organizations: Operations Manual 2-5 Version 1.0 – October 2004
  24. 24. Funding for PHCOs SECTION 2 – ESTABLISHING A PHCO PHCO services are reported in the following manner: • Core services and extended services for registered patients are funded through population-based funding (the delivery of such services to registered patients is referred to as a “patient encounter”). • All other services, to both registered and non-registered patients, are reported and paid as fee-for-service. This includes services that are not insured by MSP (such as Workers’ Compensation Board, Insurance Corporation of BC) and services to patients who are not insured by MSP. 2.2.4. Adjusted Clinical Group Daily Rate The Adjusted Clinical Group Daily Rate, also known as the “ACG Means”, is the amount of daily funding provided for each PHCO patient within a particular ACG morbidity category and age group within that ACG. Once a year, usually in July, the Primary Health Care Branch calculates the ACG Daily Rate for all patients in the province. Using ACG assignments from two years before the current year and claims data from one year before the current year, the ACG Daily Rate is calculated as follows: • For all patients assigned to a specific ACG, all fee-for-service claims for core PHCO services are totaled. • This total is then divided by the number of MSP-insured days for the patients. This provides the mean rate per patient/per MSP-insured day for that ACG (the ACG Daily Rate). To calculate the ACG income for a patient, the patient’s ACG Daily Rate is multiplied by the number of days the patient is registered with the PHCO. Actual population-based funding for a patient will be the calculated ACG income less any deductions for service outflows, as described in Section 2.2.5. The specific ACG Daily Rate for each ACG is published on the Primary Health Care Branch Web site (www.healthservices.gov.bc.ca/phc/infosites.html) each year. 2.2.5. Service Outflows In the normal course of business, PHCOs experience service outflows. A service outflow occurs when a patient receives a core service from a general practitioner outside the PHCO but within the PHCO’s pre-defined catchment area (which sets the boundaries for patient registrations and service outflows). Payments for such services are deducted from the population-based funding for that patient. Note: PHCOs may choose to operate under a “network agreement” with another PHCO. When such an agreement exists, service outflows do not occur when a patient registered with one PHCO receives core services from the other PHCO. 2-6 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  25. 25. SECTION 2 – ESTABLISHING A PHCO Funding for PHCOs To make certain that the minimum annual population-based funding that a PHCO receives for a registered patient for a complete fiscal year is not less than zero, a Stability Fund has been established. For more information on the Stability Fund, refer to Section 5.2.4. Each month, the ministry conducts a registration review for each PHCO. During this monthly review, the ministry will propose that patients associated with service outflows be de-registered from the PHCO if they meet certain criteria. The final decision on whether to de-register a patient is made by the PHCO. Similarly, the ministry may propose that a patient be registered with the PHCO based on specific criteria. For more information on the criteria for proposed registrations and de-registrations, please refer to Section 3.6.4. 2.2.6. Calculation of Population-Based Funding The total population-based funding for the PHC services delivered through a PHCO is the total for all patients of: The number of days a patient was registered with the PHCO multiplied by Patient’s ACG Daily Rate less Deductions for core service outflows (to a minimum population-based funding of $0 per patient per year). Primary Health Care Organizations: Operations Manual 2-7 Version 1.0 – October 2004
  26. 26. Site Eligibility Requirements SECTION 2 – ESTABLISHING A PHCO 2.3. Site Eligibility Requirements Based on its experience with existing PHCOs, the Primary Health Care Branch has developed a set of criteria that PHCOs should meet in order to run a sustainable and viable practice. The criteria are in keeping with the principles developed under the Primary Health Care Transition Fund. 2.3.1. Essential Components The following characteristics are considered essential to the provision of effective, appropriate PHC services. A PHCO should: • Operate under the blended funding model administered by the local health authority. • Establish a group practice (sharing responsibility for patient care, patient records, on-call responsibilities, work space and support staff). • Work as an interdisciplinary team. • Have established, regular office hours for clinical services (a minimum of 35 hours per week). • Provide some extended hours of clinical practice. • Provide 24-hour-a-day, seven-day-a-week access to core services either by having physicians share on-call hours or by participating in an on-call group. • Provide the full scope of PHC services including acute episodic care, continuing (proactive) care of chronic illness, management and coordination of comprehensive care (i.e., referral to specialists and other providers, case management, case conferences), patient advocacy, health promotion, case finding/screening, disease/injury prevention, patient education, counseling and palliative care. • Be integrated with community services. • Implement mechanisms to assure quality of service (such as setting health goals for their patient population, case finding, using clinical protocols, inviting peer review and patient input, etc.). It is also recommended that a PHCO have: • approximately one physician per 1500 patients, and • a minimum of three physicians in the same location. 2-8 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  27. 27. SECTION 2 – ESTABLISHING A PHCO Developing the Patient Register 2.4. Developing the Patient Register 2.4.1. Overview After confirming that the proposed PHCO meets the basic criteria, the Primary Health Care Branch, in consultation with the PHCO and health authority, identify the potential patient base. Patients who use the PHCO for the majority of their PHC services and who live within the PHCO catchment area will be proposed to be registered with the PHCO and be funded under population-based funding. Patients who do not use the PHCO for most of their medical services will not be proposed for registration. Services to these non-registered patients will continue to be billed as fee-for-service. For information on catchment areas, refer to Section 2.4.3, below. 2.4.2. Virtual Patient Registers and Community Service Profiles A PHCO’s potential patient base is usually developed using a virtual patient register. The Primary Health Care Branch works with the health authority and PHCO to select the appropriate method for the initial analysis. A virtual register, often used for practices with an established patient population, is based on the MSP claims history of individual patients. The claims history indicates the patients most likely to use the PHCO as their main source of primary care. Sometimes, the first step is to develop a community service profile. A community service profile may be developed from a list of patients who live within a defined geographic area. This area is defined in consultation with the proposed PHCO and should accurately reflect the areas in which potential patients live. 2.4.3. Catchment Areas A catchment area serves two purposes: • It assists in developing the initial patient register for sites without an established patient base. • It defines, on an ongoing basis, the boundaries for patient registration and service outflows. For more information on service outflows, refer to Section 2.2.5. Primary Health Care Organizations: Operations Manual 2-9 Version 1.0 – October 2004
  28. 28. Developing the Patient Register SECTION 2 – ESTABLISHING A PHCO Use of Catchment Areas in Developing the Initial Patient Register When the initial patient register is based on a community service profile, the Primary Health Care Branch consults with the health authority and PHCO to identify the areas from which a patient could reasonably be expected to use the PHCO as their main source of primary medical care. A carefully defined catchment area promotes a stable patient register and, therefore, a stable funding level. A PHCO catchment area usually consists of: • the local health area in which the PHCO is located, and • any adjacent local health areas from which patients may be expected to use the practice as their main source of primary medical care. B.C. health boundaries consist of six health authorities (5 regions +1) and 16 health service delivery areas. The 16 health service delivery areas are further divided into 89 local health areas. Refer to Appendix A for a map of British Columbia’s health areas. 2.4.4. Determining the Proposed Initial Patient Register Careful determination of the proposed initial patient register promotes PHCO success by reducing subsequent service outflows that may affect funding levels, especially in the early months of operation. If the PHCO is to be based on an existing practice, the Primary Health Care Branch examines the MSP claims history of patients who have attended the practice in the past and who live within the catchment area. The proposed PHCO is asked to provide the Primary Health Care Branch with, among other information, practitioner numbers for each practitioner whose patients will be considered for the patient register and the Teleplan Payee Number (also known as the MSP “Payment Number”) of the existing clinic. For a complete list of the information that may be required for accurate development of the initial patient register, please refer to Appendix B. If the PHCO is not based on an existing practice, primarily geographical information on patients is used. The Primary Health Care Branch and the proposed PHCO may also refine the initial patient register by looking at the claims history of patients of any PHCO practitioner who has worked for another practice within the geographic area. Note that only patients insured by MSP can be added to the patient register. For MSP eligibility information, visit the MSP Web site at www.healthservices.gov.bc.ca/msp/infoben/eligible.html#enroll. 2-10 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  29. 29. SECTION 2 – ESTABLISHING A PHCO Developing the Patient Register PHCOs Based on an Existing Practice If the initial patient list is for a PHCO based on an existing practice, all patients who have received one or more core services from the practice in the previous three years are reviewed. The remaining list is divided into non-registered and registered patients. Non-registered patients are identified as patients who: • are “transient” patients—those who live outside the practice’s catchment area or who only occasionally receive medical care from the practice. • have received three consecutive core services outside the practice. • have received less than 50% of their last seven core services from the practice during the previous three years. • are not registered with MSP. • are now deceased. • are already registered with another PHCO. Registered patients—those most likely to use the PHCO as their main source of primary care—are identified as patients: • whose two most recent core services during the previous three years were from the practice. • whose most recent service during the previous three years was from the practice and who have received 51% or more of their core services (to a maximum of seven services) from the practice during the previous three years. The proposed lists of registered and non-registered patients are used, in consultation with the PHCO, to determine the final patient register. PHCOs Not Based on an Existing Practice To develop an initial patient list for a potential PHCO that is not based on an existing practice, the Primary Health Care Branch may start by identifying all patients who live within the PHCO catchment area. MSP claims history may not provide a patient’s most current address, so the initial list may also include patients who have received services in the area. The Primary Health Care Branch reviews the MSP claims history of each patient for the previous three years. The following patients are removed from the list: • Patients who have recently moved out of the catchment area. • Patients whose two most recent core services in the previous three years occurred outside the catchment area. Primary Health Care Organizations: Operations Manual 2-11 Version 1.0 – October 2004
  30. 30. Developing the Patient Register SECTION 2 – ESTABLISHING A PHCO • Patients who live in the catchment area but who have had no claims in the catchment area. • Patients who live in the catchment area but who are already registered with another PHCO. The following patients are added to the list: • Patients who have moved into the catchment area within the past three years but who have not yet received services from any practice. The resulting information is compiled into three lists that, in consultation with the proposed PHCO, are used to determine the final patient register. The lists are of: • Patients who have an address in the catchment area. • Patients who would qualify for registration if they lived in the catchment area. • Patients recommended for the register by the PHCO or health authority. 2.4.5. PHCO-Proposed Patients The PHCO and the health authority are given the opportunity to review the initial patient lists and advise the Primary Health Care Branch of any misclassification of patients or of patients missing from the list. The PHCO and health authority may propose the registration of any patient who meets basic registration requirements. Normally, only patients who live in the PHCO catchment area can be registered. Note: PHCO-proposed additions to the register may result in increased service outflows. Although an estimated service outflow amount is factored into the initial PHCO funding level, actual outflows may result in reductions to population-based funding. For more information on service outflows, refer to Section 2.2.5, and Appendix D, Outflow Reduction Strategies. 2-12 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  31. 31. SECTION 2 – ESTABLISHING A PHCO Interdisciplinary Teams 2.5. Interdisciplinary Teams The interdisciplinary team approach promotes more efficient, effective patient care and enhances the professional life of both physicians and other PHCO practitioners. Physicians continue to deliver all services (including those not defined as core services), to registered, non-registered and transient patients. Normally, non-physician practitioners cannot bill MSP for services provided to patient. However, under a special agreement with MSP, non-physician PHCO practitioners are assigned a specialty code and a unique MSP billing number. These practitioners can then deliver and report (via the Teleplan system) both core and extended services to PHCO registered patients. For more information on the assignment of MSP billing numbers to non-physician PHCO practitioners, refer to Section 2.8.3. Be aware, however, that MSP accepts and pays fee-for-service claims only if a physician delivers the service. Furthermore, an encounter record cannot be converted to a fee-for-service claim (or vice versa) unless a physician is identified as the primary practitioner. Conversion of claims may be necessary as a result of: • the inadvertent submission of a fee-for-service claim for a core or extended service to a registered patient; or • the inadvertent submission of an encounter record for a service not defined as a core or extended service to a registered patient, or any service to a non-registered patient; or • the backdating of a patient’s registration date. For more information on the conversion of claims, refer to Section 4.5. PHCOs can report multiple practitioners for a single encounter record. However, to permit any necessary conversion of claims, the ministry recommends that, whenever a physician is involved in a patient encounter, he or she be listed as the primary practitioner. For more information on reporting multiple practitioners, refer to Section 4.2.3. Primary Health Care Organizations: Operations Manual 2-13 Version 1.0 – October 2004
  32. 32. Estimating the Funding Level (PHCO Site Analysis) SECTION 2 – ESTABLISHING A PHCO 2.6. Estimating the Funding Level (PHCO Site Analysis) 2.6.1. Overview When the Primary Health Care Branch conducts the site analysis, it uses the initial patient register to build a financial picture of the PHCO and compares it to the historical fee-for-service revenues of the practitioners (and, if applicable, the existing practice). The Site Analysis Report, described in Section 2.6.3, provides the proposed PHCO with valuable information on expected funding levels. 2.6.2. Estimated Service Outflows To provide the most accurate funding projection, the Primary Health Care Branch includes estimated service outflows in the Site Analysis Report. PHCOs should have a firm understanding of service outflows, as described in Section 2.2.5, before reviewing the report. 2.6.3. Site Analysis Report The Site Analysis Report provides a clear financial picture for the proposed PHCO. The Patient Analysis section provides a detailed breakdown of the patients reviewed in the site analysis. It indicates the number of patients eligible and ineligible for registration under each of the specific registration criteria. Careful review of this section of the report by the PHCO and health authority is required as the total number of registered patients identified in this section forms the basis for the Income Analysis section. The Income Analysis section of the report provides: • a breakdown of the projected ACG income for the PHCO, including estimated service outflows (which results in the projected total population-based funding) and third party payment income (e.g., Insurance Corporation of BC and Workers Compensation Board billings); and • a comparison of the PHCO’s projected blended funding plus third party payment income with fee-for-service plus third party payment income. An example of this report is provided in Appendix C. 2-14 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  33. 33. SECTION 2 – ESTABLISHING A PHCO Contracts 2.7. Contracts Payment PHCO Health Authority Contract * Interdisciplinary teams Contract * Payment Communication Ministry of Health Services * Some existing PHCO sites have contracts directly with the ministry. Figure 2-1 PHCO Contractual Arrangements 2.7.1. Relevant Agreements—British Columbia Medical Association The two main agreements relevant to the delivery of services through PHCOs are the Second Master Agreement and the Working Agreement. The Second Master Agreement establishes the framework for negotiation and consultation. The Working Agreement is the economic agreement between the province and doctors. It sets out the provisions for fees, on-call payments and physician benefits, including disability and malpractice insurance, education funds, RSP contributions and maternity leave. It addresses all matters of common interest to physicians. Additional information on these agreements is available on the MSP Web site at www.healthservices.gov.bc.ca/msp/legislation/mscagree.html. 2.7.2. Performance Agreements—Ministry and Health Authorities Each health authority has signed performance agreements with the Ministry of Health Services that hold them accountable for the delivery of patient care, health outcomes and how health dollars are spent. These agreements define expectations, performance deliverables and service requirements in the areas of emergency care, surgical services, home and community care, and mental health services. For additional information on these agreements, visit the Health Authorities Web site at www.healthservices.gov.bc.ca/socsec. Primary Health Care Organizations: Operations Manual 2-15 Version 1.0 – October 2004
  34. 34. Contracts SECTION 2 – ESTABLISHING A PHCO 2.7.3. Contracts—Ministry and Health Authorities For each new PHCO, the Ministry of Health Services and the health authority enter into a contract. 2.7.4. Blended Funding Contracts—Health Authorities and PHCOs Historically, payment for physician services has been made on a fee-for-service basis. As such, each service has a specific fee associated with it and the level of income a physician earns relates directly to the number and complexity of services he or she provides. Under a fee-for-service contract, MSP accepts claims for MSP benefit services provided by practitioners who are enrolled with MSP and in good standing with the licensing body governing their profession. MSP pays practitioner claims in accordance with the provisions of the Medicare Protection Act and Regulations, the relevant payment schedule, and MSP claims policies and procedures. The fees in the payment schedules are established through consultation between Medical Services Commission and the respective professional associations. For PHCOs, however, the health authority enters into a blended funding contract with each individual PHCO. Blended Funding Contracts PHCOs operate under a combined fee-for-service and population-based funding arrangement, combining the duties and related income from both fee-for-service and alternative payment models. As such, PHCOs will have clear, written policies in place in the form of a blended funding contract. The policies within the contract clearly distinguish the services claimed under each payment model. Under a blended funding contract, PHCOs cannot claim population-based funding for physician expenditures that have been, or will be, billed to MSP by a physician as fee-for-service. 2.7.5. Incentive Programs Ongoing Incentives Incentives such as the Full Service Family Practice Incentive Program, and rural health programs such as the Rural Retention Program, may offer additional funding to qualifying practices or physicians. For more information on these and other incentives, please refer to Sections 6.3.2 and 6.3.3. 2-16 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  35. 35. SECTION 2 – ESTABLISHING A PHCO Contracts Time Limited Incentives under the Primary Health Care Transition Fund Health Canada’s Primary Health Care Transition Fund supports activities that promote the renewal of primary health care. Incentives under the fund are time limited (funds cannot be used as ongoing funding) and Health Canada has defined the costs that are eligible for support under the transition fund. Specific distribution of the fund is administered at discretion of the health authority. For more information on specific incentives that may be offered, contact the local health authority. If you are unsure of the appropriate contact within your local health authority, please contact the Primary Health Care Branch at the phone number or e-mail address provided on page 2-18. Primary Health Care Organizations: Operations Manual 2-17 Version 1.0 – October 2004
  36. 36. PHCO Site Set-up SECTION 2 – ESTABLISHING A PHCO 2.8. PHCO Site Set-up To expedite set-up of your site, the Primary Health Care Branch coordinates the implementation of the reporting, billing, payment and information technology infrastructure for your new PHCO. Mail or fax all forms (including Medical Services Plan forms) and information itemized in Sections 2.8.2 through 2.8.12 to: Beverlee Sealey Manager, Primary Health Care Organizations & Networks Primary Health Care Branch Ministry of Health Services Telephone: 250-952-1290 Fax: 250-952-3486 E-mail: Beverlee.Sealey@gems3.gov.bc.ca 2-18 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004
  37. 37. SECTION 2 – ESTABLISHING A PHCO PHCO Site Set-up 2.8.1. Site Set-Up Checklist 1. Before site set-up can begin, a contract must be in place between the Ministry of Health Services and the relevant health authority, and between the health authority and the PHCO. Refer to Section 2.8.2, Making Contract Arrangements. 2. All PHCO practitioners (both physicians and non-physicians) must register with MSP if they have not already done so. Refer to Section 2.8.3, Applying for an MSP Practitioner Number. 3. The PHCO must apply for a new single Payee Number (MSP Payment Number) for the PHCO. Refer to Section 2.8.4, Applying for a Single Payee Number for the PHCO. 4. MSP payments for each individual PHCO practitioner must be assigned to the PHCO’s Payee Number. Refer to Section 2.8.5, Assigning Practitioner Payments to the PHCO. 5. The PHCO must apply to have MSP transfer semi-monthly payments to a single PHCO bank account. Refer to Section 2.8.6, Applying for Transfer of Payments to a Single Bank Account. 6. The PHCO must apply to submit claims electronically to MSP through Teleplan. Submitting claims through Teleplan ensures the capture of the diagnostic information that is essential for accurate ACG assignment of patients. Refer to Section 2.8.7, Applying for Teleplan Service (Opted-In). 7. PHCOs that will provide services at more than one location will require additional Facility Numbers. Refer to Section 2.8.8, Applying for Additional Facility Numbers. 8. The PHCO must ensure that its billings/claims submission software is compliant with Teleplan specifications for the submission of information regarding core and extended services and patient registration data. Refer to Section 2.8.9, Upgrades Required to a PHCO’s Teleplan-Compliant Software. 9. The PHCO must be set-up to use HNWeb (the Secure Web Site for Practitioners) that allows PHCOs to view patient registration information and receive patient registration and financial reports from the ministry. Refer to Section 2.8.10, HNWeb - Secure Web Site for Practitioners. Primary Health Care Organizations: Operations Manual 2-19 Version 1.0 – October 2004

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