Patient Attribution. An Introduction for PCPs & Staff Nov. 4, 2016

Transcription

1 Patient Attribution An Introduction for PCPs & Staff Nov. 4, 2016

2 Agenda Importance of Member Attribution Choosing PCP Upon Enrollment Process for Changing PCPs HMSA s Claims Attribution Logic Using Cozeva for Panel Management 103

3 Importance of Member Attribution Patient attribution part of Pay for Quality and Patient-Centered Medical Home from the beginning Greater importance Monthly Payment Transformation payment = Base PMPM Rate X Attributed Members Performance (quality) max potential = Performance PMPM X Attributed Members each month (or member-months ) Reminder: Payment Transformation global payment is paid based on Member Attribution from one month earlier. (February 2017 payment is based on January 2017 member attribution) 104

4 Choosing PCP Upon Enrollment For three plans, HMSA members select a PCP upon enrollment HMSA s HMO plans: Select an HMO health center and a PCP within the health center HMSA s QUEST Integration: Select a PCP or clinic HMSA s Akamai Advantage: Encouraged to select a PCP The name of the member s PCP is stored in HMSA s member data base and printed on their ID card New PCP selection process for Payment Transformation uses a Patient Attestation Form 105

5 Patient Attestation Form Form is only for Payment Transformation PCPs 106

6 Process for Changing PCP: HMO, QUEST and Akamai Advantage Please ensure patients are informed and agree they want you as their primary care provider. Explain your role as their PCP and Patient Attestation Form Member completes form and signs. Follow instructions on form so change is documented by HMSA: HMO members: must fax form to HMSA QUEST Integration members: must fax form to HMSA Akamai Advantage: must fax form to HMSA HMSA s internal processes will attach member to PCP for purposes of patient attribution count for HMO and QUEST 107

7 Process for Changing PCP: PPO [and Akamai Advantage] Please ensure patients are informed and agree they want you as their primary care provider. Explain your role as their PCP and Patient Attestation Form Member completes form and signs PPO members, including Fed 87: file in your medical record In Cozeva, for PPO and Akamai Advantage, add member for patient attribution count by selecting Add the patient to the P4Q program or Payment Transformation Program 109

8 How to Add a PPO or Akamai Advantage Patient Fill out all necessary information in the form and click Search Click the circle next to the member s name to confirm the system found the correct member Click the first box to confirm the medical need t access the member s information Click second box, Add patient to P4Q or Payment Transformation program

9 HMSA s Attribution Logic Step 1: Apply line of business rules HMO and QUEST: Attribute member to the PCP the member selected upon enrollment (should match HHIN and member ID card) PPO and Akamai Advantage: Attribute member to PCP who most recently added that patient to panel in Cozeva. Patient must sign attestation form to confirm relationship with PCP. Step 2: If no member selection (e.g., PPO), HMSA looks at claims for face-to-face encounters over 16 months and attributes the member to the PCP: Seen most frequently; or, In case of a tie, seen most recently. Step 3: If no member selection and no claims history at all, patient is not attributed to any PCP 112

10 Cozeva Changes vs. HMSA Attribution For PPO and Akamai Advantage: PCP changes made through Cozeva will trump HMSA claims logic attribution. Considered active confirmation of the PCP-patient relationship. That s why informed patient consent and the Patient Attestation Form are important HMO and QUEST Integration: Critical that the form be faxed back to HMSA so our systems and member ID card can be updated. HMSA s system will attribute member to new PCP. 113

11 Cozeva Reports Patient Counts By line of business on Dashboard page: Total at the top of the Registry page: 114

12 Panel Management Current = PT or P4Q patient count Added = Patient added by PCP after affirming PCP selection; patient transferred and accepted New = Member added through enrollment or claims logic Declined = PCP declined member Left = Member removed because coverage ended; patient died; patient added by another PCP or attributed to another PCP by claims logic 115

13 Panel Management Other Member for whom the provider is NOT the member s PCP (not included in that PCP s member count for Base PMPM, Performance or Engagement measures) Patient recently seen for urgent care or consult Provider is not claiming to be the PCP. Provider did not check the box, Add the patient to P4Q program or Payment Transformation program 116

14 Adding Patients Once a PPO or Akamai Advantage member is added to a PCP s panel via Cozeva, or HMO/QUEST member is added through fax to HMSA, HMSA will not allow claims logic to reassign the member to another provider If one PCP has already submitted an Add Patient request for a PPO member for that month, no other provider will be able to add the member in the same month Attribution to the new PCP stays until another PCP adds the member to his panel Use professional judgment in adding patients 117

15 Adding a Patient in Cozeva Reporting Member s Subscriber ID number on Cozeva, using the member ID card For HMSA PPO, HMO, and Akamai Advantage members: Use one letter followed by 12 digits. Include all leading zeroes. Do not include the BlueCard prefix of the first three letters. Example: If the card says XLHR , enter R For HMSA QUEST Integration: Use 10 digits. Include all leading zeroes. Do not include the BlueCard prefix of the first three letters. Example: If the card says XLQ , enter