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Michigan Primary Care Transformation Project (MiPCT)

Payment Update and Process Webinar

April 12, 2012

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Agenda

•Context and Overview

•Payer Updates▫BCBSM▫BCN▫Medicaid▫Medicare

There will be an opportunity to ask questions at the end of each payer’s update presentation.

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BCBSM Update

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Recent BCBSM Developments

•All underwritten groups are still participating

•Self-Funded groups that have joined: ▫URMBT, Zeledyne, Severstal, Magna, Visteon,

Gordon Foods•Additional MiPCT payments forthcoming

end of April▫$3.06 PMPM for two months, based on latest

attribution

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BCBSM PDCM Payment Policy Design

• Fee-for-service methodology – 7 payable codes for services performed by qualified non-physician practitioners▫ Face-to-face (individual and group)▫ Telephone-based

• Payable to approved/“privileged” providers only▫ Non-approved providers billing for these services

are subject to recovery • BCBSM will pay the lesser of provider charges or

BCBSM’s maximum fee▫ Subject to PCMH enhanced compensation

provisions▫ Determined by rendering provider identified on

the claim PCMH-designation status uplifts of 10% or 20% CNPs or PAs paid at 85%

• No cost share imposed on members EXCEPT members with Qualified High Deductible Health Plans with a Health Savings Account

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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

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PDCM Codes and Fees

CODE SERVICE FEE*

G9001 Initial assessment $112.67

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

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

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

98966 Telephone discussion 5-10 minutes $14.45

98967 Telephone discussion 11-20 minutes $27.81

98968 Telephone discussion 21+ minutes $41.17

*Net of Incentive amount

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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 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

Billed in accordance with BCBSM billing guidelines• Non-approved providers billing for PDCM

services will be subject to audit and recoveries.

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Care Management Training Guidelines

▫Services provided by Moderate care managers are billable once care managers complete approved self-management training.  

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

▫PDCM-codes should not be billed by untrained care managers

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Patient Eligibility• The patient must have active BCBSM coverage that includes the

BlueHealthConnection® Program. This includes:▫ BCBSM underwritten business▫ ASC (self-funded) groups that elect to participate▫ Medicare Advantage patients

• 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• 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 are applied▫ Referral should be based on patient need

• The patient must be an active participant in the care planServices billed for non-eligible members will be rejected with provider liability.

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Provider Requirements: Care Management Team• Individuals performing PDCM services must be qualified non-

physician practitioners employed by practices or practice-affiliated POs approved for PDCM payments

• The team must consist of:▫ A lead care manager who:

Is an RN, licensed MSW, CNP or PA Has completed an MiPCT-accepted training program

▫ Other qualified allied health professionals: Any of the above, plus… Licensed practical nurse, certified diabetes educator, registered dietician,

masters of science trained nutritionist, clinical pharmacist, respiratory therapist, certified asthma educator, certified health educator specialist (bachelor’s degree or higher), licensed professional counselor, licensed mental health counselor

• Each qualified care team member must:▫ Function within their defined scope of practice▫ Work closely and collaboratively with the patient’s clinical care team▫ Work in concert with BCBSM care management nurses as appropriate

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

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Provider Requirements: Billing and Rendering Provider• PDCM services are only payable to practices or POs approved for PDCM

reimbursement.▫For 2012, MiPCT-participating providers only

• Two potential models▫Practice-based care management team▫Physician-organization-based care management team

• The rendering provider identified on the claim determines the fee.• Rendering and billing providers must be appropriately enrolled with BCBSM.

▫For PO-based arrangement, the PO must obtain an NPI and enroll with BCBSM▫Affiliated clinicians identified as the Rendering Provider on PDCM claims must be registered in connection with the PO entity

RenderingProvider

Billing Provider

Practice-based Physician, CNP or PA within the

PDCM-approved practice

Physician practice

Physician Organization-

based

PO-based billing entity

BCBSM’s Provider Consulting area is prepared to assist with the enrollment process. Please contact Laurie Latvis at llatvis@bcbsm.com

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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▫ No diagnostic restrictions

All relevant diagnoses should be identified on the claim▫ No quantity limits (except G9001)▫ No location restrictions▫ Documentation demonstrating services were necessary and

delivered as reported▫ Documentation identifying lead CM isn’t required, but

documentation must be maintained in medical records identifying the provider for each patient interaction

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Code-Specific Requirements: G9001Initiation of Care Management (Comprehensive Assessment)

G9001 Coordinated Care Fee, Initial Rate (per case)

• 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• 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

• 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.

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Code-Specific Requirements: G9002Individual, Face-to-Face Care Management Visit

G9002 Coordinated Care Fee, Maintenance rate (per encounter)

• 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

• Claims reporting requirements:▫ Each encounter should be billed on its own claim line▫ All diagnoses relevant to the encounter should be reported

• Record documentation must additionally include:▫ Date, duration, name/credentials of team member performing the

service▫ Nature of discussion and pertinent details relevant to care plan

(progress, changes, etc.)

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Code-Specific Requirements: 98961, 98962Group Education & Training Visit

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

• 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)• Each session must:

▫ Be conducted in person▫ Have at least two, but no more than eight patients present▫ Include some level of individualized interaction

• 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

• Additional documentation requirements:▫ Dates, duration, name/credentials of care manager performing the service▫ Nature of content/objectives, number of patients present▫ Any updated status on patient’s condition, needs, progress

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Code-Specific Requirements: 98966, 98967, 98968Telephone-based Services

98966 Telephone assessment and management, 5-10 minutes98967 Telephone assessment and management, 11-20 minutes98968 Telephone 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)

• 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

• Additional documentation requirements:▫ Dates, duration, name/credentials of care manager performing the call▫ Nature of the discussion and pertinent details regarding updates on patient’s

condition, needs, progress

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BCN Update

Recent Developments

• All underwritten groups are still participating

• Presented to some self-fund groups– Informally notified that at least two groups

will participate • Propose paying the $1.50 pmpm for

Performance Transformation to the non-capitated groups quarterly– Calculate the membership monthly

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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

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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 • 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

PDCM Codes and Fees

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CODE SERVICE

G9001 Initial assessment

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

98961 Group visit (2-4 patients) 30 minutes

98962 Group visit (5-8 patients) 30 minutes

98966 Telephone discussion 5-10 minutes

98967 Telephone discussion 11-20 minutes

98968 Telephone discussion 21+ minutes

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

questions

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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.

• 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

• Billed in accordance with BCN billing guidelines• Non-approved providers billing for PDCM

services will be subject to audit and recoveries.

Care Management Training Guidelines (same as BCBSM)

– Services provided by Moderate care managers are billable once care managers complete approved self-management training.  

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

– PDCM-codes should not be billed by untrained care managers

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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 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.

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Provider Requirements: Care Management Team (same as BCBSM)

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

• The team must consist of:– A lead care manager who:

• Is an RN, licensed MSW, CNP or PA• Has completed an MiPCT-accepted training program

– Other qualified allied health professionals:• Any of the above, plus…• Licensed practical nurse, certified diabetes educator, registered dietician,

masters of science trained nutritionist, clinical pharmacist, respiratory therapist, certified asthma educator, certified health educator specialist (bachelor’s degree or higher), licensed professional counselor, licensed mental health counselor

• 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 BCN care management nurses as appropriate

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

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Provider Requirements: Billing and Rendering Provider• PDCM services are only payable to practices or POs approved for PDCM

reimbursement.–For 2012, MiPCT-participating providers only

• Two potential models–Practice-based care management team–Physician-organization-based care management team

• The rendering provider identified on the claim determines the fee.• Rendering and billing providers must be appropriately contracted with BCN as a

PCP–For PO-based arrangement, the PO must obtain an NPI and enroll with BCBSM. BCN will then load the PO –Affiliated clinicians identified as the Rendering Provider on PDCM claims must be registered in connection with the PO entity

RenderingProvider

Billing Provider

Practice-based Physician, CNP or PA within the

PDCM-approved practice

Physician practice

Physician Organization-

based

PO-based billing entity

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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

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Code-Specific Requirements: G9001Initiation of Care Management (Same as BCBSM)G9001 Coordinated Care Fee, Initial Rate (per case)

• 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• Assessment should include:

– Identification of all active and chronic 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

• 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

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Code-Specific Requirements: G9002Individual, Face-to-Face Care Management Visit (Same as BCBSM)

G9002 Coordinated Care Fee, Maintenance rate (per encounter)

• 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

• Claims reporting requirements:– Each encounter should be billed on its own claim line– All diagnoses relevant to the encounter should be reported

• Record documentation must additionally include:– Date, duration, name/credentials of team member performing the

service– Nature of discussion and pertinent details relevant to care plan

(progress, changes, etc.)

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Code-Specific Requirements: 98961, 98962Group Education & Training Visit

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

• Payable when performed by any qualified care management team member

• Current limit is 4 hours per day• Each session must:

– Be conducted in person– Have at least two, but no more than eight patients present– Include some level of individualized interaction

• 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

• Additional documentation requirements:– Dates, duration, name/credentials of care manager performing the

service– Nature of content/objectives, number of patients present– Any updated status on patient’s condition, needs, progress

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Code-Specific Requirements: 98966, 98967, 98968Telephone-based Services

98966 Telephone assessment and management, 5-10 minutes98967 Telephone assessment and management, 11-20 minutes98968 Telephone 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)

• 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

• 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

QUESTIONS?

Contact: James H. Haskins IVjhaskins@bcbsm.com

248-799-6314Or

Regional Provider Affairs Director

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Medicaid Update

Medicaid Attribution

•Medicaid managed care population only•Attributed member:

▫Medicaid beneficiary enrolled in a Medicaid Health Plan AND

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

Enrollee Lists• Attribution process occurs on the first business

day of the month• Medicaid enrollee lists submitted to Michigan

Data Collaborative (MDC)• MDC will post enrollee lists on MDC secure

site for retrieval by PO– Automated message from MIShare at UMHS– mlawr@med.umich.edu – gwenthom@med.umich.edu

• PO responsible for transmitting enrollee lists to practices

Payment Calculation

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

to Practice▫$3.00 variable payment based on

performance paid to PO

Provider Enrollment Required for Payment•PO’s will be enrolled as an MCO in

CHAMPS system by DCH.•Practices must enroll as either an

individual sole proprietor or as a group in Medicaid CHAMPS system.

•PO Enrollment questions: landfairt@michigan.gov

•Provider Enrollment questions: 800-292-2550

Payment Timing • Quarterly EFT payments appear as gross

adjustment • Reconcile payment amount with your enrollee list• Payments released mid month after end of the

quarter – April (QTR 1)– July (QTR 2) – October (QTR 3)

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

• Payment questions: landfairt@michigan.gov

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Medicare Update

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

• 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.

• Afterward UMHS will work to get on a regular cycle of payment distribution.