This document provides information about payment policies and billing guidelines for primary care transformation services through Michigan's Primary Care Transformation Demonstration Project. It discusses payment rates and codes for services like care management visits, group visits, and telephone consultations. Requirements are outlined for care management teams, eligible patients, documentation, and billing. Updates are provided from Blue Cross Blue Shield of Michigan and Blue Care Network on their payment policies and requirements.
This document summarizes information from a presentation about Michigan's Primary Care Transformation Demonstration Project. It discusses care management training requirements, provider requirements including having a qualified care management team, patient eligibility criteria for BCBSM and Medicaid, billing codes and documentation guidelines, metrics that will be measured, and the process for performance-based incentive payments.
This document outlines the agenda and details of a webinar on Michigan's Primary Care Transformation Demonstration Project. It discusses patient identification and eligibility, funding sources, care manager training requirements, payment policies, billing guidelines, and general program delivery conditions. Practices and physician organizations will be paid for providing care management services including assessments, individual/group visits, and phone calls performed by qualified staff like nurses and social workers.
This document discusses Michigan's Primary Care Transformation Demonstration Project. It outlines the agenda for webinar #10, including discussions on Medicaid and Medicare payments, care managers, project committees and metrics. It then provides details on performance metrics and incentives, care manager roles, clinical quality measures, and expectations for participating medical organizations. The webinar aims to update practices on the project and support development of patient-centered medical home capabilities.
This document discusses care plan oversight (CPO) billing for physicians supervising patients receiving home health or hospice care. It defines CPO and how it differs from certification/recertification. Requirements for CPO billing include the physician providing at least 30 minutes of supervision per month and documenting services. Eligible services, documentation methods, and claim filing procedures are outlined. The document encourages agencies to educate physicians on CPO to increase referrals and profits.
Valuation of Physician Practices - David Cranford, Shannon FarrDecosimoCPAs
This document provides an overview of key concepts related to physician practice valuation, including:
- It discusses three common payment methods used by health plans to pay physicians: fee-for-service, discounted fee-for-service, and capitation.
- It outlines various payment adjustments health plans may make like withholds, utilization targets, and bonuses.
- It identifies important revenue and expense items to consider like CPT coding, non-physician staff costs, rent, insurance, and more.
- Key factors that can impact revenues are also outlined such as changes in payor methodologies, payment delays, high deductible plans, and credit balances.
The document provides valuation professionals with background information
On Thursday, September 24, 2015, the Medicare Advantage Value-Based Insurance Design Model team hosted a webinar. Attendees received an overview of the model as well an opportunity for questions and answers about the model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
COVID-19 has changed the landscape of long-term care for the foreseeable future for everyone from ownership to admissions. In this webinar, we will help you understand the changing dynamic with managed care and how to properly manage your cash flow. Hear from industry experts on their best practices and tips for financial management for long-term care professionals.
Understanding the Basics of Physician Billing for "Incident to" ServicesConference Panel
Over the years, the incident has remained a prominent topic of discussion, while shared care has emerged as a relatively new billing opportunity provided by CMS. Many physician offices find themselves perplexed about the appropriate billing methods for these services and how they distinguish from each other. The recent alterations made by CMS to their shared care policy have only added to the existing confusion. It is crucial to minimize the likelihood of audits, paybacks, and potential future reimbursement delays by ensuring accurate billing practices. Inaccurate billing discovered during a payer audit can lead to subsequent pre and post-payment reviews, further exacerbating the reimbursement process. To address these concerns and promote proper reporting, we are organizing a webinar entitled "Physician Billing for 'Incident to' and Shared Care Services," which will comprehensively explain the differences between these services and guide physician billers toward correct billing procedures.
Register,
https://conferencepanel.com/conference/physician-billing-for-incident-to-and-shared-care-services
This document summarizes information from a presentation about Michigan's Primary Care Transformation Demonstration Project. It discusses care management training requirements, provider requirements including having a qualified care management team, patient eligibility criteria for BCBSM and Medicaid, billing codes and documentation guidelines, metrics that will be measured, and the process for performance-based incentive payments.
This document outlines the agenda and details of a webinar on Michigan's Primary Care Transformation Demonstration Project. It discusses patient identification and eligibility, funding sources, care manager training requirements, payment policies, billing guidelines, and general program delivery conditions. Practices and physician organizations will be paid for providing care management services including assessments, individual/group visits, and phone calls performed by qualified staff like nurses and social workers.
This document discusses Michigan's Primary Care Transformation Demonstration Project. It outlines the agenda for webinar #10, including discussions on Medicaid and Medicare payments, care managers, project committees and metrics. It then provides details on performance metrics and incentives, care manager roles, clinical quality measures, and expectations for participating medical organizations. The webinar aims to update practices on the project and support development of patient-centered medical home capabilities.
This document discusses care plan oversight (CPO) billing for physicians supervising patients receiving home health or hospice care. It defines CPO and how it differs from certification/recertification. Requirements for CPO billing include the physician providing at least 30 minutes of supervision per month and documenting services. Eligible services, documentation methods, and claim filing procedures are outlined. The document encourages agencies to educate physicians on CPO to increase referrals and profits.
Valuation of Physician Practices - David Cranford, Shannon FarrDecosimoCPAs
This document provides an overview of key concepts related to physician practice valuation, including:
- It discusses three common payment methods used by health plans to pay physicians: fee-for-service, discounted fee-for-service, and capitation.
- It outlines various payment adjustments health plans may make like withholds, utilization targets, and bonuses.
- It identifies important revenue and expense items to consider like CPT coding, non-physician staff costs, rent, insurance, and more.
- Key factors that can impact revenues are also outlined such as changes in payor methodologies, payment delays, high deductible plans, and credit balances.
The document provides valuation professionals with background information
On Thursday, September 24, 2015, the Medicare Advantage Value-Based Insurance Design Model team hosted a webinar. Attendees received an overview of the model as well an opportunity for questions and answers about the model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
COVID-19 has changed the landscape of long-term care for the foreseeable future for everyone from ownership to admissions. In this webinar, we will help you understand the changing dynamic with managed care and how to properly manage your cash flow. Hear from industry experts on their best practices and tips for financial management for long-term care professionals.
Understanding the Basics of Physician Billing for "Incident to" ServicesConference Panel
Over the years, the incident has remained a prominent topic of discussion, while shared care has emerged as a relatively new billing opportunity provided by CMS. Many physician offices find themselves perplexed about the appropriate billing methods for these services and how they distinguish from each other. The recent alterations made by CMS to their shared care policy have only added to the existing confusion. It is crucial to minimize the likelihood of audits, paybacks, and potential future reimbursement delays by ensuring accurate billing practices. Inaccurate billing discovered during a payer audit can lead to subsequent pre and post-payment reviews, further exacerbating the reimbursement process. To address these concerns and promote proper reporting, we are organizing a webinar entitled "Physician Billing for 'Incident to' and Shared Care Services," which will comprehensively explain the differences between these services and guide physician billers toward correct billing procedures.
Register,
https://conferencepanel.com/conference/physician-billing-for-incident-to-and-shared-care-services
Chronic Care Management - Implemented By TimeDoc - May 2018Dan Wellisch
This is May's presentation of the Chicago Technology For Value-Based Healthcare Meetup - https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
Fundamentals of Bundles for Joint Replacement – Creating the Competitive EdgeWellbe
Medicare is expected to issue the final rule for the Comprehensive Care for Joint Replacement (CJR) initiative soon. As proposed, hospitals in chosen MSAs must be ready to take on this new challenge by January 1, 2016.
The Connecticut Joint Replacement Institute (CJRI) at Saint Francis Hospital has performed more than 20,000 procedures since opening in 2007. CJRI has been on the forefront of bundled payments for joint replacements since implementing their first bundle agreement in 2010. CJRI will share the essential elements to developing a bundle program and the challenges of evolving towards a value-driven, risk bearing model in today’s healthcare environment.
Attendee Takeaways:
– Learn the essential ingredients to develop a successful bundle payment program
– Understand the fundamentals of value-based healthcare
– Learn how to create sustainable bundled payments and maintain a competitive edge in the marketplace
About The Speaker:
Maureen Geary is the Program Director at the Connecticut Joint Replacement Institute in Hartford, Connecticut. Maureen been involved with bundle payments since 2009. CJRI signed their first commercial contract in 2010. She leads strategic initiatives and new product development for the company. Maureen also provides consultative services for orthopedic organizations seeking to develop a bundled product or expand their service line.
Starting an urgent care business requires thorough planning and preparation. Key steps include developing a business plan, choosing a location, securing necessary equipment and supplies, obtaining licenses and certifications, and contracting with insurance companies. Contracting can take 4-6 months to be approved. Once approved, the urgent care center can begin billing and providing services. Ongoing challenges include negotiating rates with insurers, marketing services, and potentially expanding to additional locations or joining a larger network as the healthcare industry continues consolidating. Maintaining strong operations, including use of electronic medical records, is also important for long term success.
CCM Presentation for KYPCA Final Draft-111115Jacqueline Todd
This document discusses chronic care management (CCM) services and billing requirements under Medicare. It defines CCM as care management for patients with two or more chronic conditions expected to last over a year. Key points include: CMS began paying separately for CCM services in 2015; eligible providers can furnish and bill for CCM; at least 20 minutes of CCM services must be provided per month to bill using CPT code 99490; and an electronic health record meeting "CCM Certified Technology" standards is required to document certain elements of the care plan and services.
Skilled nursing homes provide long-term care through support with everyday activities, rehabilitation, and medication and treatment administration. Families of elders considering placing their loved ones in skilled nursing or assisted living must first grasp nursing home billing and coding guidelines in order to determine what type of care they will require and who will pay for it.
Skilled nursing homes provide long-term care through support with everyday activities, rehabilitation, and medication and treatment administration. Families of elders considering placing their loved ones in skilled nursing or assisted living must first grasp nursing home billing and coding guidelines in order to determine what type of care they will require and who will pay for it.
Physicians complete guide to chronic care managementGaryRichards30
Senior citizens with one or more chronic conditions have a hard time managing their health. CMS was spending a lot of money on patient’s insurance who were suffering from chronic conditions. In order to cut down the expenses on hospital admissions, the CMS introduced the Chronic Care Management program. Patients usually visit their physicians for chronic care once or twice a year. With Chronic Care Management program, patient’s health improves due to increased attention and care. They can also spend less time on health issues and more on what they like to do.
NYU Langone Medical Center’s TJA BPCI Experience: Lessons in How to Maximize ...Wellbe
The Bundled Payments for Care Improvement (BPCI) Initiative began generating data in January of 2013. Dr. Iorio will outline the challenges and benefits of implementing BPCI for Total Joint Arthroplasty at an urban, tertiary, academic medical center with a hybrid compensation model. Early results from the implementation of a Medicare BPCI Model 2 primary TJA program demonstrate cost-savings with an improvement in quality of care metrics and continued cost savings through year 3 of our experience. Changes in patient optimization, care coordination, clinical care pathways, and evidence-based protocols are the key to improving the quality metrics and cost effectiveness within the implementation of the Bundled Payment for Care Initiative, thus bringing increased value to our TJA patients.
Maximizing Value in a Bundled Environment – Keys to Success:
• Evidence based, cost effectiveness analysis
• Standardized protocol adoption
• Transparent data
• Perioperative Patient Optimization
• Care management
• Physician-hospital alignment with Gain sharing
• Enhanced pain relief and rehabilitation protocols
• Blood management and rational VTED prophylaxis
About the Speaker:
Richard Iorio, MD, is the William and Susan Jaffe Professor of Orthopaedic Surgery at New York University Langone Medical Center Hospital for Joint Diseases and Chief of Adult Reconstruction at NYU Langone HJD. He co-founded Labrador Healthcare Consulting Services, Responsive Risk Solutions, and the Value Based Healthcare Consortium in 2015. He is a member of the Board of Directors for LIMA, the Lifetime Initiative for the Management of Arthritis. Dr. Iorio is a national expert in physician and hospital quality and safety and a leader in the implementation of alternate payment paradigms in orthopaedic surgery.
Scribes in Primary Care - Inspiring MDs ProductivityErvin Gruia
The document discusses using medical scribes in primary care to improve physician performance and satisfaction. It summarizes a case study that found a significant increase in physician satisfaction, more complete charts, improved clinic revenue and net income, and increased visits per hour when scribes were used. While there was some effort to coordinate staffing, physicians left an average of 1 hour and 41 minutes earlier each day. Proven models are presented that project increased revenue per provider of $1,563.84 per day and decreased time in the office by 41 minutes when scribes are used effectively. Key factors for maximizing the successful use of scribes include adapting workflows, maintaining or increasing patient volumes and appointments, and addressing barriers to change like old behaviors and
Developing Employment Agreement for Quality, Operational Efficiency and Patie...Curtis Bernstein
This document discusses developing employment agreements for physicians that comply with regulations while improving quality and efficiency. It recommends tying physician compensation to productivity, quality metrics, and operational goals. Specific incentives are suggested around quality measures, operational improvements, and medical directorships. Fair market value benchmarks are important to consider to comply with Stark and anti-kickback laws.
The Medicare Care Choices Model aims to expand access to concurrent palliative and curative care for Medicare beneficiaries with serious illnesses. It will test allowing participating hospices to provide supplemental palliative care services to eligible beneficiaries, while receiving curative treatment, in return for a $400 per beneficiary per month fee. Hospices must be Medicare-certified and able to coordinate care. Eligible beneficiaries have advanced cancers, lung disease, heart failure or HIV/AIDS. The model seeks to improve pain and symptom management through 24/7 access to hospice professionals and care coordination over three years. CMS implementation contractors will provide technical support to participating hospices.
CMS hosted an open door forum (ODF) call on Wednesday, April 16, 2014 to allow providers, beneficiary advocacy groups, and other interested parties to learn more about the Medicare Care Choices Model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document provides an overview and agenda for gainsharing arrangements between healthcare providers and considerations for legally structuring such arrangements. It defines gainsharing as contracts where providers share cost savings from increased productivity or efficiency. The goals are improving communication to provide better, lower cost care. Models include demand matching and quality gainsharing. Legal requirements and fair market value must be considered. Demonstration projects in New Jersey and Medicare programs are reviewed that aim to lower costs while maintaining quality.
During this webinar the Direct Contracting Model Options team hosted a webinar on Wednesday, December 18, 2019 from 1:30 p.m.- 3:00 p.m. EST. During this webinar, presenters provided information about benefit enhancements for the Direct Contracting Model Options.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document provides an overview and training on Utah Medicaid hospice care policies for providers. It covers topics such as client eligibility, prior authorization, plans of care, covered services, physician services, pediatric hospice care, health plan and HCBS waiver participants, and reimbursement. Providers will learn about requirements for election of hospice care, documentation needed for prior authorization, covered services under routine hospice care and additional services, and unique policies for pediatric and facility-based clients.
Navigating The Complex World Of Family Practice Billing.pdfRichard Smith
Family practice billing is an essential component of healthcare administration, crucial for ensuring that medical providers are reimbursed accurately and timely for the services they render to their patients. This article provides an in-depth overview of family practice billing, exploring into its significance, common challenges, strategies for effective billing, and the benefits of outsourcing this crucial aspect of healthcare management.
Navigating The Complex World Of Family Practice Billing.pptxRichard Smith
Family practice billing is an essential component of healthcare administration, crucial for ensuring that medical providers are reimbursed accurately and timely for the services they render to their patients. This article provides an in-depth overview of family practice billing, exploring into its significance, common challenges, strategies for effective billing, and the benefits of outsourcing this crucial aspect of healthcare management.
The Medicare Diabetes Prevention Program (MDPP) Model Expansion Medicare Learning Network (MLN) Call was held from 1:30 p.m. – 3:00 p.m. EST on November 30, 2016. During this call, CMS experts provided a high-level overview of the finalized policies in the CY 2017 Medicare Physician Fee Schedule (PFS) final rule (the CY 2017 Medicare PFS final rule includes the expansion of the MDPP Model beginning January 1, 2018), reviewed the steps necessary for enrollment into Medicare as an MDDPP supplier, and answered some of the audiences most pressing questions.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document summarizes the findings from the first year of the Medicare Advantage Value-Based Insurance Design Model (MA VBID). Nine parent organizations tested innovative benefit designs focused on seven conditions. Most commonly, they offered reduced cost sharing for services conditional on participating in care management. While implementation required new workflows, participants saw potential for improving health and reducing costs. Further evaluation will assess impacts on outcomes.
This document advertises a study seeking 20 adults aged 35 or older who are at risk of or living with diabetes, have not had formal diabetes education in the past year, regularly use the internet, and can read and speak English, to complete two 20-minute online surveys for $40 total to help improve a diabetes website, with recruitment occurring through November 15, 2014.
This document contains guidelines for the Patient-Centered Medical Home (PCMH) and PCMH-Neighbor programs run by Blue Cross Blue Shield of Michigan (BCBSM). It outlines 14 domains of function that practices must meet capabilities for, such as patient registries, performance reporting, care management, and coordination of care. The document provides details on the required capabilities within each domain, interpretive guidelines, and requirements for verification site visits. It also addresses how specialists can partner with primary care practices through the PCMH-Neighbor program to better coordinate care for shared patients.
Chronic Care Management - Implemented By TimeDoc - May 2018Dan Wellisch
This is May's presentation of the Chicago Technology For Value-Based Healthcare Meetup - https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
Fundamentals of Bundles for Joint Replacement – Creating the Competitive EdgeWellbe
Medicare is expected to issue the final rule for the Comprehensive Care for Joint Replacement (CJR) initiative soon. As proposed, hospitals in chosen MSAs must be ready to take on this new challenge by January 1, 2016.
The Connecticut Joint Replacement Institute (CJRI) at Saint Francis Hospital has performed more than 20,000 procedures since opening in 2007. CJRI has been on the forefront of bundled payments for joint replacements since implementing their first bundle agreement in 2010. CJRI will share the essential elements to developing a bundle program and the challenges of evolving towards a value-driven, risk bearing model in today’s healthcare environment.
Attendee Takeaways:
– Learn the essential ingredients to develop a successful bundle payment program
– Understand the fundamentals of value-based healthcare
– Learn how to create sustainable bundled payments and maintain a competitive edge in the marketplace
About The Speaker:
Maureen Geary is the Program Director at the Connecticut Joint Replacement Institute in Hartford, Connecticut. Maureen been involved with bundle payments since 2009. CJRI signed their first commercial contract in 2010. She leads strategic initiatives and new product development for the company. Maureen also provides consultative services for orthopedic organizations seeking to develop a bundled product or expand their service line.
Starting an urgent care business requires thorough planning and preparation. Key steps include developing a business plan, choosing a location, securing necessary equipment and supplies, obtaining licenses and certifications, and contracting with insurance companies. Contracting can take 4-6 months to be approved. Once approved, the urgent care center can begin billing and providing services. Ongoing challenges include negotiating rates with insurers, marketing services, and potentially expanding to additional locations or joining a larger network as the healthcare industry continues consolidating. Maintaining strong operations, including use of electronic medical records, is also important for long term success.
CCM Presentation for KYPCA Final Draft-111115Jacqueline Todd
This document discusses chronic care management (CCM) services and billing requirements under Medicare. It defines CCM as care management for patients with two or more chronic conditions expected to last over a year. Key points include: CMS began paying separately for CCM services in 2015; eligible providers can furnish and bill for CCM; at least 20 minutes of CCM services must be provided per month to bill using CPT code 99490; and an electronic health record meeting "CCM Certified Technology" standards is required to document certain elements of the care plan and services.
Skilled nursing homes provide long-term care through support with everyday activities, rehabilitation, and medication and treatment administration. Families of elders considering placing their loved ones in skilled nursing or assisted living must first grasp nursing home billing and coding guidelines in order to determine what type of care they will require and who will pay for it.
Skilled nursing homes provide long-term care through support with everyday activities, rehabilitation, and medication and treatment administration. Families of elders considering placing their loved ones in skilled nursing or assisted living must first grasp nursing home billing and coding guidelines in order to determine what type of care they will require and who will pay for it.
Physicians complete guide to chronic care managementGaryRichards30
Senior citizens with one or more chronic conditions have a hard time managing their health. CMS was spending a lot of money on patient’s insurance who were suffering from chronic conditions. In order to cut down the expenses on hospital admissions, the CMS introduced the Chronic Care Management program. Patients usually visit their physicians for chronic care once or twice a year. With Chronic Care Management program, patient’s health improves due to increased attention and care. They can also spend less time on health issues and more on what they like to do.
NYU Langone Medical Center’s TJA BPCI Experience: Lessons in How to Maximize ...Wellbe
The Bundled Payments for Care Improvement (BPCI) Initiative began generating data in January of 2013. Dr. Iorio will outline the challenges and benefits of implementing BPCI for Total Joint Arthroplasty at an urban, tertiary, academic medical center with a hybrid compensation model. Early results from the implementation of a Medicare BPCI Model 2 primary TJA program demonstrate cost-savings with an improvement in quality of care metrics and continued cost savings through year 3 of our experience. Changes in patient optimization, care coordination, clinical care pathways, and evidence-based protocols are the key to improving the quality metrics and cost effectiveness within the implementation of the Bundled Payment for Care Initiative, thus bringing increased value to our TJA patients.
Maximizing Value in a Bundled Environment – Keys to Success:
• Evidence based, cost effectiveness analysis
• Standardized protocol adoption
• Transparent data
• Perioperative Patient Optimization
• Care management
• Physician-hospital alignment with Gain sharing
• Enhanced pain relief and rehabilitation protocols
• Blood management and rational VTED prophylaxis
About the Speaker:
Richard Iorio, MD, is the William and Susan Jaffe Professor of Orthopaedic Surgery at New York University Langone Medical Center Hospital for Joint Diseases and Chief of Adult Reconstruction at NYU Langone HJD. He co-founded Labrador Healthcare Consulting Services, Responsive Risk Solutions, and the Value Based Healthcare Consortium in 2015. He is a member of the Board of Directors for LIMA, the Lifetime Initiative for the Management of Arthritis. Dr. Iorio is a national expert in physician and hospital quality and safety and a leader in the implementation of alternate payment paradigms in orthopaedic surgery.
Scribes in Primary Care - Inspiring MDs ProductivityErvin Gruia
The document discusses using medical scribes in primary care to improve physician performance and satisfaction. It summarizes a case study that found a significant increase in physician satisfaction, more complete charts, improved clinic revenue and net income, and increased visits per hour when scribes were used. While there was some effort to coordinate staffing, physicians left an average of 1 hour and 41 minutes earlier each day. Proven models are presented that project increased revenue per provider of $1,563.84 per day and decreased time in the office by 41 minutes when scribes are used effectively. Key factors for maximizing the successful use of scribes include adapting workflows, maintaining or increasing patient volumes and appointments, and addressing barriers to change like old behaviors and
Developing Employment Agreement for Quality, Operational Efficiency and Patie...Curtis Bernstein
This document discusses developing employment agreements for physicians that comply with regulations while improving quality and efficiency. It recommends tying physician compensation to productivity, quality metrics, and operational goals. Specific incentives are suggested around quality measures, operational improvements, and medical directorships. Fair market value benchmarks are important to consider to comply with Stark and anti-kickback laws.
The Medicare Care Choices Model aims to expand access to concurrent palliative and curative care for Medicare beneficiaries with serious illnesses. It will test allowing participating hospices to provide supplemental palliative care services to eligible beneficiaries, while receiving curative treatment, in return for a $400 per beneficiary per month fee. Hospices must be Medicare-certified and able to coordinate care. Eligible beneficiaries have advanced cancers, lung disease, heart failure or HIV/AIDS. The model seeks to improve pain and symptom management through 24/7 access to hospice professionals and care coordination over three years. CMS implementation contractors will provide technical support to participating hospices.
CMS hosted an open door forum (ODF) call on Wednesday, April 16, 2014 to allow providers, beneficiary advocacy groups, and other interested parties to learn more about the Medicare Care Choices Model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document provides an overview and agenda for gainsharing arrangements between healthcare providers and considerations for legally structuring such arrangements. It defines gainsharing as contracts where providers share cost savings from increased productivity or efficiency. The goals are improving communication to provide better, lower cost care. Models include demand matching and quality gainsharing. Legal requirements and fair market value must be considered. Demonstration projects in New Jersey and Medicare programs are reviewed that aim to lower costs while maintaining quality.
During this webinar the Direct Contracting Model Options team hosted a webinar on Wednesday, December 18, 2019 from 1:30 p.m.- 3:00 p.m. EST. During this webinar, presenters provided information about benefit enhancements for the Direct Contracting Model Options.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document provides an overview and training on Utah Medicaid hospice care policies for providers. It covers topics such as client eligibility, prior authorization, plans of care, covered services, physician services, pediatric hospice care, health plan and HCBS waiver participants, and reimbursement. Providers will learn about requirements for election of hospice care, documentation needed for prior authorization, covered services under routine hospice care and additional services, and unique policies for pediatric and facility-based clients.
Navigating The Complex World Of Family Practice Billing.pdfRichard Smith
Family practice billing is an essential component of healthcare administration, crucial for ensuring that medical providers are reimbursed accurately and timely for the services they render to their patients. This article provides an in-depth overview of family practice billing, exploring into its significance, common challenges, strategies for effective billing, and the benefits of outsourcing this crucial aspect of healthcare management.
Navigating The Complex World Of Family Practice Billing.pptxRichard Smith
Family practice billing is an essential component of healthcare administration, crucial for ensuring that medical providers are reimbursed accurately and timely for the services they render to their patients. This article provides an in-depth overview of family practice billing, exploring into its significance, common challenges, strategies for effective billing, and the benefits of outsourcing this crucial aspect of healthcare management.
The Medicare Diabetes Prevention Program (MDPP) Model Expansion Medicare Learning Network (MLN) Call was held from 1:30 p.m. – 3:00 p.m. EST on November 30, 2016. During this call, CMS experts provided a high-level overview of the finalized policies in the CY 2017 Medicare Physician Fee Schedule (PFS) final rule (the CY 2017 Medicare PFS final rule includes the expansion of the MDPP Model beginning January 1, 2018), reviewed the steps necessary for enrollment into Medicare as an MDDPP supplier, and answered some of the audiences most pressing questions.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document summarizes the findings from the first year of the Medicare Advantage Value-Based Insurance Design Model (MA VBID). Nine parent organizations tested innovative benefit designs focused on seven conditions. Most commonly, they offered reduced cost sharing for services conditional on participating in care management. While implementation required new workflows, participants saw potential for improving health and reducing costs. Further evaluation will assess impacts on outcomes.
This document advertises a study seeking 20 adults aged 35 or older who are at risk of or living with diabetes, have not had formal diabetes education in the past year, regularly use the internet, and can read and speak English, to complete two 20-minute online surveys for $40 total to help improve a diabetes website, with recruitment occurring through November 15, 2014.
This document contains guidelines for the Patient-Centered Medical Home (PCMH) and PCMH-Neighbor programs run by Blue Cross Blue Shield of Michigan (BCBSM). It outlines 14 domains of function that practices must meet capabilities for, such as patient registries, performance reporting, care management, and coordination of care. The document provides details on the required capabilities within each domain, interpretive guidelines, and requirements for verification site visits. It also addresses how specialists can partner with primary care practices through the PCMH-Neighbor program to better coordinate care for shared patients.
This document provides updates on quarterly reports that must be submitted to Christine and ensure accuracy. It discusses that MiPCT requested MNO attestation of using the registry, having a quality improvement process, and reviewing data. Finally, it addresses education requirements of three 4-hour sessions on CPT and ICD-9 use, and notes that care management numbers have decreased but the care team remains. An extension of MiPCT is unknown and status quo for now.
This document provides information on various programs and services available for breast and cervical cancer screening, family planning, pregnancy and new mother support, pediatric care, and dental care in Macomb and Oakland counties in Michigan. It lists contact information, eligibility requirements, and services offered for programs like BCCCP, WIC, Medicaid family planning services, food pantries, counseling services, and low-cost dental clinics.
The document describes strategies for developing effective healthcare teams. It discusses establishing care teams with interdisciplinary members and providing training. Key elements of team-based care include protocol-driven processes, care management services, managing care transitions, and engaging patients and families. The document also outlines metrics for measuring utilization, clinical quality, and care processes and explains that implementing a bundle of improvement changes through an interdisciplinary team approach leads to better outcomes.
This document outlines the agenda for a MiPCT Demonstration Project meeting, including: introducing new practice team members, comparing G code billing results between practices, discussing care managers and metrics for 2014. It reviews utilization, clinical quality, and process measures that will be assessed. Learning requirements are outlined for care managers and practice teams, including ICD-10 workshops and a learning collaborative. Participating practice teams are listed and an open discussion is invited.
This document summarizes a focus meeting for PCPs that covered several topics: Medicare risk adjustment, risk scoring, and quality star ratings; the Choosing Wisely campaign; advance care planning; and patient-centered medical homes. It provided details on CMS risk adjustment models, proper medical record documentation for risk adjustment, and ways accurate coding can improve reimbursement and lower member premiums. It also reviewed the STAR bonus program metrics and preventive services. Finally, it discussed introducing advance care planning conversations, documenting patient preferences, and applying advance directives when needed.
This document summarizes a PCP focus meeting that covered several topics: Medicare correct coding initiative, Choosing Wisely campaign, advance care planning, patient-centered medical home designations, organized systems of care, optimizing risk adjustment and stars ratings, and advance directives. It provides details on CMS risk adjustment models, required medical record documentation, acceptable provider types and signatures, case studies, and steps for successful advance care planning.
Behavioral Health Specialist Meeting: Keeping You in the Loopmednetone
The document summarizes key points from a meeting between Medical Network One and behavioral health specialists. It introduced Medical Network One and described its history of collaborating with BCBSM on initiatives like the Physician Group Incentive Program (PGIP), Patient-Centered Medical Home (PCMH), and Organized Systems of Care (OSC). It discussed how collaboration between Medical Network One and behavioral health specialists might work, including developing shared goals and responsibilities. The document also provided an overview of the PCMH, PCMH-Neighborhood, and OSC models, and explained how performance is measured using standards like HEDIS.
This document summarizes a new Medicare Advantage Gain Sharing program offered by Blue Cross Blue Shield of Michigan and Blue Care Network. It provides incentives for providers to improve performance in documentation and coding, utilization, costs, and quality measures. Providers can earn a share of financial gains if they meet education and performance criteria, such as attending training, closing diagnosis code gaps, and improving quality scores and readmission rates. The program compares potential earnings to an alternative diagnosis closure incentive program, paying providers the higher of the two amounts. It includes examples of how earnings are calculated based on members' risk scores and expenses.
The document summarizes key points from a PCP cluster meeting held on November 13, 2013 in Monroe, Michigan. The meeting focused on several topics: Medicare correct coding initiative, Choosing Wisely campaign, advance care planning, patient-centered medical home designations, organized systems of care, and risk adjustment. The risk adjustment portion provided details on CMS risk scoring, hierarchical condition categories, documentation requirements, and a case study example. It also discussed the Medicare Advantage STAR bonus program and its quality measures. Finally, the document covered advance care planning and POLST (Physician Orders for Life-Sustaining Treatment) forms.
This document outlines guidelines for collaboration between primary care and specialty care providers to improve patient care. It defines key terms like patient-centered medical home and discusses different types of care transitions including pre-consultation, formal consultation, complete transfer of care, and co-management. The guidelines establish mutual agreements around maintaining accurate records, safe transfers of care, and adopting a referral system. It provides templates for primary care and specialty care expectations in areas like maintaining records, ordering tests, informing patients, and timely communication. The overall goal is to enhance communication and collaboration between providers through coordinated, patient-centered care.
This document outlines a webinar for the Michigan Primary Care Transformation Demonstration Project. It lists the practices in attendance at the webinar and their scheduled dates for best practice showcases. It also details the learning requirements for care managers and practice units in 2014, including required hours and acceptable training activities. Finally, it lists the practices that participated in a learning event in 2013 and those that were absent.
This document outlines details from a webinar on the Michigan Primary Care Transformation Demonstration Project that took place on October 23, 2013. It lists the practices in attendance and their scheduled dates to present their best practices. It also discusses funding, learning requirements, practice visits, the Choosing Wisely campaign, and the State Innovation Model initiative. The webinar covered key details about the project for the participating primary care practices.
This document outlines a webinar for the Michigan Primary Care Transformation Demonstration Project. It lists the practices in attendance at the webinar and their scheduled dates for best practice visits. It also details the learning requirements for care managers and practice units in 2014. Finally, it notes which practices attended a learning event in 2013 and which were absent.
The document advertises the R-Team healthy lifestyle program for kids and teens. The 10-session program teaches healthy eating, exercise, self-esteem and goal setting. Each child receives an individual assessment before starting group sessions. Parents must attend all sessions with their child. Contact and registration information is provided for programs in Madison Heights, Woodhaven and Rochester, Michigan between March 2015 and November 2015.
This document provides information about the Michigan Primary Care Transformation Demonstration Project webinar that took place on September 25, 2013. It lists the practices that attended the webinar and announces an upcoming learning event on September 28th to provide updates to practice teams on new billing codes, advance care planning, and quality improvement processes. It then outlines the schedule for best practice showcases at different practices between September 2013 and April 2014. The document concludes by defining key terms related to the Multi-payer Advanced Primary Care Practice Demonstration, including the purpose and goals of evaluating the demonstration and defining care management.
This document summarizes a webinar for the Michigan Primary Care Transformation Demonstration Project. It lists the attendees of the webinar and recognizes practices that have achieved URAC accreditation or provided appreciation. It outlines quality metrics and goals for care managers, such as engaging patients in care management. It also announces upcoming training events for care managers and practices in July and a challenge to enroll new patients. Time is allotted at the end for open discussion.
The document describes several healthcare organizations' Performance Recognition Programs (PRP) for 2013. It outlines changes made to the programs, including increasing budgets, eliminating pay-as-you-go components, and scoring providers individually on quality measures. Providers can earn payments by meeting quality goals or improving scores by a certain percentage. The programs include measures related to preventative screenings, disease management, and controlling conditions like diabetes and cardiovascular disease. Bonus payments are available for measures like adult BMI tracking and annual medication monitoring.
This referral form provides patient and physician information for referral to Medical Nutrition Therapy and Diabetes Self Management Education. It includes the patient's name, date of birth, contact information, insurance information, and health details like blood pressure, height, and weight. The form indicates a need for either initial or follow-up Medical Nutrition Therapy, and lists possible reasons for referral to Diabetes Self Management Training. Relevant medical details and lab results are requested to better assess the patient's needs. The referring physician's signature and contact information is included.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
3. 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
3
5. 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
5
6. General Conditions of Payment
For billed services to be payable, the following
conditions apply:
• 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
6
7. 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
7
8. 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
Services billed for non-eligible members will be rejected with provider liability.
8
9. 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
Services billed for non-eligible members will be rejected with provider liability.
9
10. 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
Services billed for non-eligible members will be rejected with provider liability.
10
11. 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
11
12. Provider Requirements: Care
Management Team
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
12
13. Provider Requirements: Care
Management Team
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)
13
14. Provider Requirements:
Billing and Rendering Provider
Rendering Billing
Provider Provider
Practice‐based Physician, CNP Physician
or PA within practice
Physician the PDCM‐ PO‐based
Organization‐ approved billing entity
based practice
BCBSM’s Provider Consulting area is prepared to assist with the enrollment
process. Please contact Laurie Latvis at llatvis@bcbsm.com
14
15. 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
15
16. Billing and Documentation:
General Guidelines
• 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
16
17. 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
17
18. 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
18
19. G9001:
Initiation of Care Management
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.
19
20. 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
20
21. 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.)
21
22. Code‐Specific Requirements:
98961, 98962
Payable when performed by any qualified care
management team member
No quantity limits (for example, if call lasted more
than 30 minutes you would bill additional codes
for each 30 minute increment)
22
23. Code‐Specific Requirements:
98961, 98962
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 interaction
23
24. Code‐Specific Requirements:
98961, 98962
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
24
25. Code‐Specific Requirements:
98961, 98962
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
25
26. 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
Payable when performed by any qualified care
management team member
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)
26
27. Code‐Specific Requirements:
98966, 98967, 98968 Telephonic
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
27
28. Code‐Specific Requirements:
98966, 98967, 98968 Telephonic
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
28
29. 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
30. 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
30
31. 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
31
32. BCN PDCM Codes and Fees
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
32
33. BCN General Conditions of
Payment
For billed services to be payable, the following
conditions apply:
• 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.
33
34. 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
34
35. 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
35
36. 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
36
37. Provider Requirements: Billing
and Rendering Provider
Rendering Billing
Provider Provider
Practice‐based Physician, CNP Physician
or PA within practice
Physician the PDCM‐ PO‐based
Organization‐ approved billing entity
based practice
37
38. 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
• 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
38
39. 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
39
40. G9002:
Individual, Face‐to‐Face Care Visit
Same as BCBSM
Payable when performed by any qualified care
management team member
No quantity limits
40
41. 98961, 98962
Group 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
41
42. 98966, 98967, 98968
Telephone‐based Services
Same as BCBSM
98966 Telephone assessment and management,
5‐10 minutes
98967 Telephone assessment and management,
11‐20 minutes
98968 Telephone assessment and management,
21+ minutes
42
43. 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
44. 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
– mlawr@med.umich.edu
– gwenthom@med.umich.edu
• PO responsible for transmitting enrollee lists to
practices
45. 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
46. 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: landfairt@michigan.gov
Provider Enrollment questions: 800‐292‐2550
47. 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: landfairt@michigan.gov
48. 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
49. 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
50. 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)
50