Jump to:
- Reimbursement reform related to implementing Patient-Centered Medical Home initiatives
- Priority Health PCMH Reimbursement
- Reimbursement changes effective April 1, 2009
- Value-added services for primary care practices
- Calls to action
Reimbursement reform related to implementing Patient-Centered Medical Home initiatives
Priority Health supports the proposed national model for changing reimbursement, including:
- Payment for services (capitation and fee-for-service)
- Payment for performance (quality and efficiency)
- Infrastructure support (fixed payment per patient based on level of achievement toward PCMH)
Issues considered:
- Infrastructure is critical to pay for practice and physician time spent in activities that traditionally have gone unreimbursed
- Qualifying practices as patient-centered medical homes
- Availability of tools and resources to engage practices in practice transformation
Priority Health PCMH reimbursement
We continually evaluatie our PCMH support.
- On April 1, 2009, we introduced reimbursement changes for all of our PCPs on standard Priority Health contracts (fully-funded HMO, PPO and POS) (see chart below). Medicare, Medicaid, MIChild, and self-funded and shared funded plans are not included in these reimbursement changes.
- Codes for e-visits, telephone visits, after–hours services and group health visits were moved to fee-for-service reimbursement.
- In 2010 we added PIP measures that support PCMH: E-prescribing, registry adoption and meaningful use, optimal diabetes care, Emergency Department visit reduction, and inpatient admission reduction.
- Our PCMH grant program provided funds for pilot programs to test the concepts of PCMH: Access (extended hours, group visits, e-visits, telehealth), care coordination (health coach or team model), and patient engagement (self-management goals, group visits).
- PPC-PCMH NCQA-recognized practices will receive a PMPM infrastructure support fee of $1-$3 for up to a total of 12 months, based on tier of their recognition.
See more details on NCQA recognition support.
Reimbursement changes effective April 1, 2009
The codes in the table below are in the CPT 2009 manual and reimbursement rates for them are established in our standard fee schedule for your region. Call your PHO/PO or the Provider Help Line to request a copy of your current fee schedule.
Review the applicable medical policies below for Priority Health's interpretation of e-visits, after-hours services, and which QHPs we recognize for phone assessments.
| Category |
Reimbursement enhancement |
Capitation payment
(effective April 1, 2009) |
|
Reimburse fee-for-service for alternative visit codes
previously included in captiation |
|
Additional fee-for-service codes for PCPs
on standard Priority Health contracts |
|
Calls to action
-
Consider updating your practice management system (or EMR), superbills or encounter forms to include the new billable codes.
- Educate your billing staff or billing service on their ability to bill for new codes and be paid fee-for-service for them.
- Look at providing enhanced access and including qualified health care professionals and patients as a part of your team.
Last modified
05/07/10
|
