Reimbursement for PCMH

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 evaluate 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). PriorityHSA^SM, Medicare, Medicaid, MIChild, and self-funded and shared funded plans are not included in these reimbursement changes. Call your PHO/PO or the Provider Help Line to request a copy of your current fee schedule.
• 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).
• For 2011, reimbursement for PCMH recognition, designation or credential is included in our 2011 Partners In Performance (PIP) program.

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.