How reimbursement is changing for PCMH

Reimbursement reform related to implementing Patient-Centered Medical Home initiatives

• 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 introduced reimbursement changes for all of our PCPs on standard Priority Health contracts (fully-funded HMO, PPO and POS) effective April 1, 2009 (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.
• PIP incentives included incremental changes in 2009. In 2010 there will be additional PIP measures that support PCMH.
• Our PCMH grant program is providing funds to recipients to test the concepts of PCMH.
  
  • Phase one grant program: We awarded $725,000 to five West Michigan PHO/POs representing 16 practices from November 1, 2008, through October 31, 2009.
  • Phase two grant program: We awarded $1.25 million to 10 PHO/PO/independents representing 16 practices across the state. This pilot will run from October 1, 2009 through March 31, 2011.
• PPC-PCMH NCQA-recognized practices will receive a PMPM infrastructure support fee of $1-$3, based on tier of their recognition.
  
  • This support fee will be paid to practices certified in 2009 or 2010. It will be paid for up to 12 months. PMPM payment is based on the practice’s fully-funded Priority Health members.
  • For more information on the PPC-PCMH NCQA certification, visit the NCQA website.
    

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)	Increase by $0.30 PMPM
Reimburse fee-for-service for alternative visit codes previously included in captiation	99078, Group health education Read more about billing for group visits in this manual 99441-99443, Telephone visits, physician 99050, 99051 and 99053, After-hours services Read more about billing for after-hours services in this manual Read the After-Hours Services policy (72KB PDF)
Additional fee-for-service codes for PCPs on standard Priority Health contracts	98966-98968, Telephone visits, non-physician, qualified health care provider Read the QHP policy (55KB PDF) 99444, Online medical visits or "e-visits" Read more about billing for telephone and e-visits in this manual Read the Online Evaluations policy (65KB PDF)





Value-added services for primary care practices

If you want more information on these and other programs, please contact your provider account executive (PAE).



Category	Initiative
Transformation	TransforMedSM* will help practice redesign efforts and assist in implementing collaborative learning opportunities for five practices within the existing Priority Health pilot program.
Evaluation	Priority Health has contracted with the Michigan State University College of Human Medicine to perform a comprehensive evaluation of pilot programs.
Collaboration	Priority Health has assigned a full-time staff professional to lead the implementation of plan initiatives.



*TransforMed is a wholly owned subsidiary of the American Academy of Family Practice. The organization is a leader in transforming family medicine and primary care, by using and refining a core group of best practices identified by the Future of Family Medicine.



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.