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 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.
Chronic Care Management (CCM): Understand how to capture incremental revenueDiagnotes, Inc.
By now you’ve likely heard that qualifying physicians can receive approximately $42/patient/month from CMS for non-face-to-face care management of patients with two or more chronic conditions. And, in many cases, with the right tracking and reporting, you may be able to capture this revenue for work your team is already doing. In just 30 minutes, you will understand the chronic care management program requirements and see how easy it is to capture and report qualifying activities.
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/
CMS’ Final Rule expands Medicare reimbursement for chronic care management (CCM) services including telehealth. CCM requires at least 20 minutes per month of non-face-to-face care by a care team under a provider. It includes services like remote patient monitoring, medication management, and care coordination. Telehealth can help provide 24/7 access and monitor medical, functional, and psychosocial needs between in-person visits. Providers must meet documentation and patient consent requirements for reimbursement.
Chronic Care Management Coding Guidelines Effective January 1, 2017Manny Oliverez
The Centers for Medicare and Medicaid Services (CMS) recently released new billing requirements for chronic care management services. CMS initiated these latest billing changes in order to improve payment accuracy for CCM services as well as reduce the administrative burden for providers.
Visit Our Website: http://www.CaptureBilling.com/
This SMMC provider webinar talks about the implications for recipients who are eligible for both the Long-term Care and Managed Medical Assistance programs.
This presentation shows providers how to verify a patient's Medicaid eligibility before providing services to them as part of the Managed Medical Assistance program.
The document provides information about verifying recipient eligibility for Florida's Statewide Medicaid Managed Care Long-Term Care Program (SMMC LTC). It emphasizes the importance of accurately checking if a recipient is enrolled in a Long-term Care plan and eligible for services on the date of service before rendering care. It outlines new aid categories for Medicaid Pending and loss of eligibility periods, and how to identify these on eligibility verifications. Providers are instructed to always contact the recipient's Long-term Care plan for authorization and claims submission if they are enrolled.
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.
Chronic Care Management (CCM): Understand how to capture incremental revenueDiagnotes, Inc.
By now you’ve likely heard that qualifying physicians can receive approximately $42/patient/month from CMS for non-face-to-face care management of patients with two or more chronic conditions. And, in many cases, with the right tracking and reporting, you may be able to capture this revenue for work your team is already doing. In just 30 minutes, you will understand the chronic care management program requirements and see how easy it is to capture and report qualifying activities.
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/
CMS’ Final Rule expands Medicare reimbursement for chronic care management (CCM) services including telehealth. CCM requires at least 20 minutes per month of non-face-to-face care by a care team under a provider. It includes services like remote patient monitoring, medication management, and care coordination. Telehealth can help provide 24/7 access and monitor medical, functional, and psychosocial needs between in-person visits. Providers must meet documentation and patient consent requirements for reimbursement.
Chronic Care Management Coding Guidelines Effective January 1, 2017Manny Oliverez
The Centers for Medicare and Medicaid Services (CMS) recently released new billing requirements for chronic care management services. CMS initiated these latest billing changes in order to improve payment accuracy for CCM services as well as reduce the administrative burden for providers.
Visit Our Website: http://www.CaptureBilling.com/
This SMMC provider webinar talks about the implications for recipients who are eligible for both the Long-term Care and Managed Medical Assistance programs.
This presentation shows providers how to verify a patient's Medicaid eligibility before providing services to them as part of the Managed Medical Assistance program.
The document provides information about verifying recipient eligibility for Florida's Statewide Medicaid Managed Care Long-Term Care Program (SMMC LTC). It emphasizes the importance of accurately checking if a recipient is enrolled in a Long-term Care plan and eligible for services on the date of service before rendering care. It outlines new aid categories for Medicaid Pending and loss of eligibility periods, and how to identify these on eligibility verifications. Providers are instructed to always contact the recipient's Long-term Care plan for authorization and claims submission if they are enrolled.
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.
Due to popular demand, the Comprehensive Primary Care Plus (CPC+) team hosted a repeat of the webinar that was originally held on Thursday, April 21, 2016. During this webinar Model team members provided an overview of the model specifically for health IT vendors.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
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The Value-Based Insurance Design (VBID) Model team hosted a webinar on January 28, 2021 from 4:00-5:00 PM EST. During this webinar, presenters provided a brief review of the recently released Calendar Year (CY) 2022 Requests for Applications (RFAs) for the VBID Model and the Hospice Benefit Component. This session also offered attendees an opportunity to ask follow-up 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
Chronic Care Management: 6 Tips for Documentation SuccessManny Oliverez
Take advantage of the Chronic Care Reimbursement opportunity with these tips!
Healthcare providers can be reimbursed for the hours that they spend on the phone, filling prescriptions, and completing paperwork. Medicare now offers reimbursement for doctors who are assisting patients with chronic medical conditions.
The key to reimbursement from Medicare is all in the required documentation for Chronic Care Management (CCM). Here are some tips for documenting for CCM.
Visit Our Website: http://www.CaptureBilling.com/
This presentation covers protections afforded to enrollees and providers participating in the Long-term Care aspect of Florida's Statewide Medicaid Managed Care program.
Chronic Care Management in Post-Acute/LTC SettingPYA, P.C.
PYA Principal Denise Hall and PYA Manager Lori Baker presented an educational session, “Chronic Care Management in Post-Acute/LTC Setting” to members of The Vision Group during The Society for Post-Acute and Long-Term Care Medicine’s (AMDA) Annual Conference.
This webinar defines the "Medicaid Pending" status and serves to educate providers on the needs of individuals in this situation as it relates to the SMMC Long-term Care Program.
This presentation shows the real purpose of the 1Care Technical Working Groups (TWGs).
It is not to consult the stakeholders about what concept to adopt as the government insists. In actual fact, it is to "Translating Government Policy Directions into Value added Research for 1Care".
This presentation also confirms that the TWGs only exist to provide "Evidence to support the 1Care blueprint development".
In other words, the policy has been decided and the government is now using the TWGs to rubber stamp their support for 1Care.
PQRI is the first Medicare program which will directly influence physicians towards value based purchasing (VBP). Value based purchasing is a key mechanism for Medicare to transform itself from being a passive payer to an active purchaser of healthcare by linking payment more directly to performance.
Currently, Medicare Physician Fee Schedule is based on quantity and resources consumed. Soon, this will no longer be the case. Over the next several years, fees will be increasing based on quality and value.
Inside ABC’s of PQRI:
Learning the Basics of PQRI
The Big Picture: Value-Based Purchasing
Engaging a Team
Selecting Measures
Coding on Performance Measures
Collecting Payment and Performance Report
Practice Exercise – Sample Case
Validation
Next Steps by Physicians
This document summarizes insurance eligibility, coverage, and benefits for residential behavioral health settings. It finds that 84% of admissions in 2009 were insurance-based. It describes differences between in-network and out-of-network coverage for major insurance providers, as well as plan types like PPO, HMO, EPO, and POS. The document also outlines eligibility criteria, covered benefits, and patient financial responsibility. Finally, it reviews behavioral health levels of care and pre-admission screening information required.
FAQs chronic care management medicare reimbursement billingGaryRichards30
Care providers across the United States of America are monetizing Medicare chronic care management billing reimbursement codes to increase revenue from their practice. Read on to find answers to all the most commonly asked questions about patient eligibility, the scope of services, CPT codes and payment reimbursement for Medicare CCM.
The CMS Innovation Center hosted a repeat of the Thursday, November 6 ACO Investment Model webinar on Tuesday, November 18, 2014, from 2:30pm-3:30pm EST. The webinar provided guidance on the ACO Investment Model (AIM) application to prospective ACO applicants. The webinar included a review of the model eligibility requirements and an explanation of each application question including the spend plan narrative and spreadsheet.
- - -
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
Cpt codes 99490 99487 99489 all you need to knowGaryRichards30
How can medical professionals benefit from Chronic Care Management CPT Codes 99490 and 99487 and 99489?
Physicians and Non-Physicians can benefit from Medicare’s reimbursement for chronic care services.
Non Physicians include Certified Nurse-Midwife, Physician Assistant, Nurse Practitioner and Clinical Nurse Specialists. The flexibility of remote medical monitoring offers patients and professionals convenience to reach out as per their schedule.
The Medicare and Medicaid EHR Incentive Programs offer financial incentives for the
“meaningful use” of certified EHR technology to improve patient care. Read More.. www.curemd.com
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 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.
The Next Generation ACO Model team hosted an open door forum on Tuesday, March 28, 2017. The Next Generation Model features three payment rule waivers, referred to as benefit enhancements. This open door forum provided an overview of the Model’s three benefit enhancements.
- - -
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
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted an open door forum covering benefit enhancements for the 2017 Next Generation Accountable Care Organization Model. The open door forum was held on Tuesday, April 19 from 4:00pm – 5:30pm EDT.
- - -
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
Health insurance in the US has evolved from primarily covering catastrophic illness to also covering preventative care and services. There are various types of health insurance plans including HMOs, PPOs, and consumer-driven plans. Government plans like Medicare and Medicaid provide coverage for specific groups. Providers must verify a patient's insurance coverage and submit claims according to the insurer's requirements to receive reimbursement.
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.
Due to popular demand, the Comprehensive Primary Care Plus (CPC+) team hosted a repeat of the webinar that was originally held on Thursday, April 21, 2016. During this webinar Model team members provided an overview of the model specifically for health IT vendors.
- - -
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
The Value-Based Insurance Design (VBID) Model team hosted a webinar on January 28, 2021 from 4:00-5:00 PM EST. During this webinar, presenters provided a brief review of the recently released Calendar Year (CY) 2022 Requests for Applications (RFAs) for the VBID Model and the Hospice Benefit Component. This session also offered attendees an opportunity to ask follow-up 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
Chronic Care Management: 6 Tips for Documentation SuccessManny Oliverez
Take advantage of the Chronic Care Reimbursement opportunity with these tips!
Healthcare providers can be reimbursed for the hours that they spend on the phone, filling prescriptions, and completing paperwork. Medicare now offers reimbursement for doctors who are assisting patients with chronic medical conditions.
The key to reimbursement from Medicare is all in the required documentation for Chronic Care Management (CCM). Here are some tips for documenting for CCM.
Visit Our Website: http://www.CaptureBilling.com/
This presentation covers protections afforded to enrollees and providers participating in the Long-term Care aspect of Florida's Statewide Medicaid Managed Care program.
Chronic Care Management in Post-Acute/LTC SettingPYA, P.C.
PYA Principal Denise Hall and PYA Manager Lori Baker presented an educational session, “Chronic Care Management in Post-Acute/LTC Setting” to members of The Vision Group during The Society for Post-Acute and Long-Term Care Medicine’s (AMDA) Annual Conference.
This webinar defines the "Medicaid Pending" status and serves to educate providers on the needs of individuals in this situation as it relates to the SMMC Long-term Care Program.
This presentation shows the real purpose of the 1Care Technical Working Groups (TWGs).
It is not to consult the stakeholders about what concept to adopt as the government insists. In actual fact, it is to "Translating Government Policy Directions into Value added Research for 1Care".
This presentation also confirms that the TWGs only exist to provide "Evidence to support the 1Care blueprint development".
In other words, the policy has been decided and the government is now using the TWGs to rubber stamp their support for 1Care.
PQRI is the first Medicare program which will directly influence physicians towards value based purchasing (VBP). Value based purchasing is a key mechanism for Medicare to transform itself from being a passive payer to an active purchaser of healthcare by linking payment more directly to performance.
Currently, Medicare Physician Fee Schedule is based on quantity and resources consumed. Soon, this will no longer be the case. Over the next several years, fees will be increasing based on quality and value.
Inside ABC’s of PQRI:
Learning the Basics of PQRI
The Big Picture: Value-Based Purchasing
Engaging a Team
Selecting Measures
Coding on Performance Measures
Collecting Payment and Performance Report
Practice Exercise – Sample Case
Validation
Next Steps by Physicians
This document summarizes insurance eligibility, coverage, and benefits for residential behavioral health settings. It finds that 84% of admissions in 2009 were insurance-based. It describes differences between in-network and out-of-network coverage for major insurance providers, as well as plan types like PPO, HMO, EPO, and POS. The document also outlines eligibility criteria, covered benefits, and patient financial responsibility. Finally, it reviews behavioral health levels of care and pre-admission screening information required.
FAQs chronic care management medicare reimbursement billingGaryRichards30
Care providers across the United States of America are monetizing Medicare chronic care management billing reimbursement codes to increase revenue from their practice. Read on to find answers to all the most commonly asked questions about patient eligibility, the scope of services, CPT codes and payment reimbursement for Medicare CCM.
The CMS Innovation Center hosted a repeat of the Thursday, November 6 ACO Investment Model webinar on Tuesday, November 18, 2014, from 2:30pm-3:30pm EST. The webinar provided guidance on the ACO Investment Model (AIM) application to prospective ACO applicants. The webinar included a review of the model eligibility requirements and an explanation of each application question including the spend plan narrative and spreadsheet.
- - -
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
Cpt codes 99490 99487 99489 all you need to knowGaryRichards30
How can medical professionals benefit from Chronic Care Management CPT Codes 99490 and 99487 and 99489?
Physicians and Non-Physicians can benefit from Medicare’s reimbursement for chronic care services.
Non Physicians include Certified Nurse-Midwife, Physician Assistant, Nurse Practitioner and Clinical Nurse Specialists. The flexibility of remote medical monitoring offers patients and professionals convenience to reach out as per their schedule.
The Medicare and Medicaid EHR Incentive Programs offer financial incentives for the
“meaningful use” of certified EHR technology to improve patient care. Read More.. www.curemd.com
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 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.
The Next Generation ACO Model team hosted an open door forum on Tuesday, March 28, 2017. The Next Generation Model features three payment rule waivers, referred to as benefit enhancements. This open door forum provided an overview of the Model’s three benefit enhancements.
- - -
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
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted an open door forum covering benefit enhancements for the 2017 Next Generation Accountable Care Organization Model. The open door forum was held on Tuesday, April 19 from 4:00pm – 5:30pm EDT.
- - -
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
Health insurance in the US has evolved from primarily covering catastrophic illness to also covering preventative care and services. There are various types of health insurance plans including HMOs, PPOs, and consumer-driven plans. Government plans like Medicare and Medicaid provide coverage for specific groups. Providers must verify a patient's insurance coverage and submit claims according to the insurer's requirements to receive reimbursement.
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.
This episode continues our COVID-19 COVID-19 Insights Webinar discussing CMS changes, available grants and loans, existing opportunities in telehealth, and more state openings for elective surgeries.
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
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
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
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.
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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
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.
The CMS Innovation Center hosted an informational webinar March 11, 2014 on the parameters of Models 2-4 of the Bundled Payments for Care Improvement Initiative. This webinar was geared towards physicians, specialty practices and physician group practices.
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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
On Tuesday, April 9 from 2:00 p.m. - 3:00 p.m. EDT the Medicare Advantage Value-Based Insurance Design Model team provided an overview of the model’s main goals and guiding principles, provided a brief review of Medicare Advantage and the Medicare Hospice Benefit, introduced the key model design considerations, and provided a general timeline for the coming months.
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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
The document discusses key concepts in the US health insurance system including payers, providers, members, benefit plans, and workflows. It covers payer types like commercial insurers, Medicare, Medicaid, and plan types including PPOs, HMOs, and EPOs. It also summarizes benefits building, enrollment management, network building, and provider contracting processes.
This document discusses options for rural hospitals and providers to transition to accountable care models. It outlines the challenges rural providers face in existing Medicare Shared Savings Program (MSSP) ACO models due to their reliance on fee-for-service reimbursement and complex attribution models. As an alternative, the document proposes a Rural Clinically Integrated Network (RCIN) model that would allow independent rural providers to clinically integrate and collectively negotiate with payers while maintaining local decision making. Key functions of a RCIN would include promoting evidence-based medicine, facilitating care coordination across settings, and negotiating and managing value-based payer contracts.
The document describes the Comprehensive Primary Care Plus (CPC+) initiative, which aims to strengthen primary care through multi-payer partnerships and alternative payment models. It has three main goals: 1) allow practices to provide more comprehensive care, 2) accommodate practices at different transformation levels, and 3) achieve better care, smarter spending and healthier people. CPC+ will run in up to 20 regions over 5 years, selecting practices to participate in one of two tracks. It emphasizes the importance of aligning Medicare, Medicaid, and commercial payers to support practice transformation.
MACRA consolidated several existing Medicare quality programs and introduced new payment models. It established two tracks for physician payment and quality programs starting in 2017 - MIPS and Advanced APMs. MIPS consolidated existing programs into four categories and allows physicians to gradually increase their participation over multiple years. Advanced APMs provide incentives for participation in alternative payment models and include models like Accountable Care Organizations. MACRA aims to reform Medicare payments to physicians and transition to value-based models.
The document provides an overview of the Comprehensive Primary Care Initiative (CPC Initiative) which aims to establish a new model for purchasing and delivering comprehensive primary care. It discusses the goals of better health outcomes, better care experiences, and lower costs. Practices will receive care management fees and have opportunities for shared savings. They will be required to meet milestones related to care management, access, patient experience, use of data, care coordination, and meaningful use of EHRs. The webinar invites primary care practices to apply and outlines the application process and requirements.
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.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
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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
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.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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).
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptx
PCP Meeting 5/23/2012
1. Michigan Primary Care Transformation
Demonstration Project
Primary Care Physicians and Practice Teams
May 23, 2012
2. Agenda
Demonstration Project Update
• Care Managers
• Transformation Payments
• Participating Payers
• Process and Outcome Metrics
• Pay for Performance
Interesting Facts
Surveys
Comments on transformation activities in Michigan
2
3. Care Management Training
Guidelines
• Services provided by Moderate Care Managers are
billable AFTER Care Managers complete approved
self-management training
• Services provided by Complex Care Managers are
billable AFTER Care Managers have completed
approved Complex Care Management training
• PDCM*-codes should not be billed by untrained
care managers
(PDCM: Provider Delivered Care Management)
3
4. 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
4
5. 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, LVN, CDE, 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
5
6. 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, BCN, or other
participating payer’s care management nurses as
appropriate
Note: Only lead care managers may perform
the initial assessment services (G9001)
6
7. BCBSM 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.
7
8. BCBSM 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.
8
9. BCBSM 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.
9
10. Recent BCBSM Developments
All underwritten groups are participating
Self-Funded groups that have joined:
• URMBT, Zeledyne, Severstal, Magna, Visteon,
Gordon Foods
10
11. BCBSM High Deductible Health Plans
Only members who have a High Deductible Health Plan
with a Health Savings Account will be financially liable
for PDCM services
To identify the amount of cost share, providers can use
Web-DENIS or CAREN IVR to verify if deductible has
been met
• Amount of payment will vary based on where member is at
in fulfilling their deductible requirement
• Patient cost share can be identified by looking in the
patient liability column, similar to what you would see for
any other patient
11
12. BCBSM 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.
12
13. BCBSM 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
13
14. BCBSM 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
14
15. BCBSM 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
15
17. BCN PDCM Payment Policy
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
17
18. 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.
18
19. BCN Patient Eligibility
Provider panels are available through Health e-
Blue web
The patient must be an active patient under the
care of a physician, PA or CNP in a PDCM-
approved practice No diagnosis restrictions are
applied
• Order for PDCM 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.
19
20. Medicaid Patient 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
21. 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
22. Medicaid Payment Calculation
Medicaid payments calculated as Per Member Per
Month (PMPM) based on monthly attribution
counts:
• $1.50 PMPM Practice Transformation paid to
Practice
• $3.00 variable payment based on performance paid
to PO
23. 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
24. 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
25. UMHS CMS Payment Processing and
Distribution to POs
CMS does not have a mechanism to pay POs directly
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
Work is underway and a front-end application has
been built to:
- Reconcile claims with member lists
- Calculate PO payments
26. UMHS CMS Payment Processing and
Distribution to POs
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.
Afterward UMHS will work to get on a regular cycle of
payment distribution.
27. Interesting Facts…
18 MNO PCMH currently participating in MiPCT
35 Primary Care Physicians one referral physician co-
located in PCP PCMH
Participation continues as long as PCMH designation
is maintained
Two practices are being reviewed by BCBSM
Attributed/Assigned population varies monthly
27
28. Interesting Facts: E&M Uplift
Four physician family practice: $91,654
Four physician pediatric practice: $68,546
Two physician adult practice: $48,929
Solo family physician: $10,984
Average amount: $11,777
Medical Network One PCMH: $412,197
28
31. Metrics
Six months:
• Patient registry
• After hours access
• Moderate Care Managers hired, trained and working
• Complex Care Managers hired, trained and working
• Moderate/Complex Care Managers=Hybrid Care Managers
• HEDIS Specific Clinical and Process Measures
31
32. Diabetes
Ages 18-75 Type 1 or 2
1. A1C
2. Poor Control A1c>9
3. Control A1c< 8
4. LDL-C Test
5. LDL-C Controlled < 100 mg/dl
6. BP <140/90
7. Retinal Eye Exam
8. Nephropathy Screen or Evidence of Nephropathy*
32
33. Asthma
Self-Management Plan
Asthma Action Plan
(ages 5-50) Non HEDIS
33
34. Performance Incentive Payment
Process
Health plans contribute $3.00 PMPM to the
incentive program pool
Metrics are assessed every six months and points
are calculated for each PO
POs are ranked by total points and grouped into
payment categories
34
35. Performance Incentive Payment
Process
Entire pool is paid out in variable amounts based
on ranking
PO retains the agreed upon percentage 20%
PO distributes 80% to the PCMH
35