Q1 physician & practice news digest 2024

Happy New Year and thank you

David Rzeszutko, MD, MBA
Vice President, Medical and Clinical Operations

Every year presents a fresh opportunity to reflect and appreciate the work we’ve accomplished together to improve the health of our communities. Thank you for your support in 2023; we look forward to another year of working together.

While 2024 is well underway, our priorities remain the same – to drive better health outcomes for your patients, our members.

Mental health treatment when members need it most
Winter is a challenging season for mental health, and we want to ensure our members have access to the care they need. Most of our commercial and Medicare member health plans include intensive outpatient behavioral health services through our Community Care Management (CCM) program. CCM helps members navigate the transition back to their homes after receiving inpatient or partial hospitalization psychiatric care to support their recovery and reduce readmissions.

Through CCM, we offer our members critical, time-sensitive support until they feel ready to access traditional outpatient care. The program staff, including masters-level therapists, provide short-term support and monitoring to high-risk individuals, particularly those who:

  • Were discharged from a high level of care (psychiatric inpatient, partial hospitalization, or crisis residential care) and require intensive support.
  • May be at risk of requiring hospitalization, without intervention.
  • Need additional support beyond what traditional outpatient therapy can offer.

Learn how CCM goes beyond traditional outpatient care, about member eligibility and coverage options – including how to make a referral and more.

Thank you for your continued commitment to the health and wellbeing of your patients, our members. We look forward to another year of partnership and wish you all the best this year.

Dr. David C. Rzeszutko

Billing & coding tips

prism tips
Choosing a claim inquiry dropdown option

Clinical edits vs other related claims When contacting us about a claim, always choose the most appropriate and specific inquiry dropdown option in prism. Choosing incorrectly can increase your response time by 15 days or more as we work to route your inquiry to the appropriate team. Below is a closer look at two dropdown options that are frequently selected incorrectly:

When you have multiple claims with the same issue

We’re in the process of posting 2024 fee schedules, with individual and commercial fee schedules already online. We continually monitor the state and national benchmarks for fee schedule updates, making all required updates in our system within 30 days of a change.

We don’t retroactively adjust any claims paid while we’re loading new rates into our system. To make sure your claims are processed and reimbursed under new rates, you can choose to hold them until you see the new fee schedules posted in prism.

Check for 2024 fee schedules
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Medicare & Medicaid quality

Together, we can close your patients’ gaps in care. From preventative screenings to managing chronic conditions, we’re here to support you.

Get our latest Medicare & Medicaid quality newsletter to learn about member campaigns and resources, how to maximize your 2024 PIP incentives and more.

Download the guide

Incentive programs

We appreciate your partnership as we work to provide the right care, at the right time, in the right place and at the right cost. We’re continually evolving our incentive programs to help us achieve these goals and to recognize the hard work you do to keep our members healthy. Below you’ll find key incentive program updates and deadlines for the first quarter of 2024.

2024 PCP Incentive Program (PIP)

Our 2024 PIP program is a continuation is the 2023 model, with a few adjustments including:

  • Two new pediatric focus measures
  • A simplified payout methodology for the focus measures
  • A new social determinants of health (SDoH) screening measure
  • Updated care management measure, with the addition of CPT codes for touchpoint credit and a simplified link to quality

Additionally, as announced last September, Patient Profile and the PIP_70 report will retire on Feb. 1, 2024 as part of our Digital First data strategy. We’ll continue accepting Patient Profile and PIP_70 reports for gap closures for 2023 dates of service through Jan. 31. We’ve been working closely with ACNs to ensure a smooth transition and effective gap closure for the 2024 performance year.

We encourage you to work with your ACN to ensure your hard work is captured through this Digital First strategy.

See our PIP 2024 manual
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2024 Disease Burden Management (DBM) program

We know the hard work you put into population health and chronic condition management in your practices. We want to make capturing important information about your patients easier and more efficient so you can focus your time on what matters most – your patients, our members.

Based on your feedback, we retired our Advanced Health Assessment (AHA) and Persistency programs effective Dec. 31, 2023. We’ll continue accepting claims with 2023 dates of service through Feb. 29, 2024, to ensure complete final payouts for both programs. To continue our partnership focused on improving patient outcomes, we’ve launched the 2024 Disease Burden Management program (DBM). You can find information on eligibility, incentives and program details in our DBM manual.

Note: to be eligible for this program, you must be affiliated with an ACN.

2024 DBM program manual
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We’re committed to ensuring you have all the tools you need to be successful in our programs. We recently held a webinar with valuable information on how to be successful in the new program.

Watch the webinar

Provider Roster Application (PRA) The monthly PRA attestation schedule continues in 2024. ACNs participating in the following programs must attest to their PCP rosters monthly:

  • PIP
  • DBM
  • Alternative Payment Models (APM)

To get the 2024 attestation calendar and details about how to effectively use PRA (including batch attestations and creating groups / subgroups for your roster), see our updated PRA manual.

Get the 2024 PRA manual
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Important incentive program dates

Mark your calendars for these upcoming deadlines for the 2024 program year:

  • Jan. 31 – Supplemental data submission deadline for Patient Profile, Report 70, MiHIN and HL7. Files submitted after this date won’t be in year-end settlement.
  • Feb. 28 – Claims submission and adjudication deadline. All 2023 claims must be billed and adjudicated by the Priority Health system by this date.

Latest news

Check out our latest news items on our Provider news & education page.