Transcript Show me the Money - indianamedicaid.com

Show me the Money
Working together to provide
quality care for MDwise
members
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Indiana Health Coverage Programs
FSSA= Family & Social Services
Administration
OMPP= Office of Medicaid Policy
and Planning
Maximus= Enrollment Broker
FSSA
OMPP
MAXIMUS
Traditional
Medicaid
HP
MDwise
Managed
Behavioral Health
Organizations
Risk-Based Managed Care
MDwise
(Care Select)
ADVANTAGE
590 Program
Hoosier Healthwise
Healthy Indiana Plan
Care Select
MDwise
MDwise
(Care Select)
Anthem Blue Cross
Blue Shield
Enhanced Services Plan
(ESP)
Cenpatico
MHS
Behavioral Health
Magellan Health
Anthem
Services
MHS
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Who is MDwise?
 MDwise is a local, not-for-profit company serving Hoosier Healthwise,
Care Select and Healthy Indiana Plan (HIP) members.
 MDwise believes that everyone deserves to have health coverage.
 MDwise Hoosier Healthwise covers 270,000 children, pregnant women,
and eligible families.
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Who is MDwise?
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What is Risk-Based Medicaid?
 MCE’s are paid a per member per month fee; this is called a capitated rate
 The capitated premium covers the cost of the care for all covered services for
the patients.
 The MCE’s assume financial risk for services of members; thus the name “RiskBased” does not mean the patients are “high risk”.
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Benefit Package
Package A – Standard Plan
Coverage
Full coverage for children, low-income
families.
Package B – Pregnancy Coverage Only Pregnancy-related, postpartum care, family
planning, pharmacy, transportation, urgent
care services for some pregnant women.
Package C – Children’s Health Plan
Preventive, primary, and acute care
services for some children under 19 years
old.
Package P – Presumptive Eligibility
Presumptive eligibility for pregnant women.
(RID # starts with 550)
Package E – Emergency Only
Limited to treatment for medical
emergency conditions.
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NCQA

National Committee for Quality Assurance is the organization that accredits Managed Care
Organizations (MCO’s).
Mission
To improve the quality of health care.
Vision
To transform health care quality through measurement, transparency and accountability.
Values
Our passion is improving the quality of health care.
We stand for accountability throughout the health care system.
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NCQA
created
HEDIS
Healthcare
Effectiveness
Data &
Information
Set
A set of standardized performance measures
• Ensures that consumers have reliable information on the performance of
MCO’s.
• >90% of health plans use HEDIS to measure performance
on important dimensions
of care and service.
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Pay for Performance or P4P are Incentivized
HEDIS Measures
 A contractual activity of MCO’s
 P4P is an incentive to meet quality measures for providers in the
commercial, Medicaid and Medicare insured populations.
 1.0% of the MDwise capitated payment is withheld, and paid to the MCO
when quality goals are met.
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Pay for Performance – P4P
• Supplemental payment based on measured performance against a target
• Incent high quality care by shifting greatest reimbursement to highest
quality providers and plans
• Incent provider offices to increase visits or improve processes.
• Site contests or office contests to improve quality of care.
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Pay for Performance – P4P
• Provider incentives based on claims submissions.
• Provider incentives based on meeting targeted measures.
• Site contests by increasing a measure or bringing in the most members
requiring services in a given measure.
• Provider incentives adding provider staff or equipment that can help
increase a quality measure or quality of care to members.
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HEDIS contains 71 Quality Measures:
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Asthma Medication Use
Persistence of Beta-Blocker Treatment after Heart Attack
Controlling High Blood Pressure
Comprehensive Diabetes Care
Breast Cancer Screening
Antidepressant Medication Management
Childhood and Adolescent Immunization Status
Advising Smokers to Quit & offering assistance to quit….and others
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OMPP Incentivized HEDIS Measures
• Adolescent well-care
• Well-care for children ages 3-6 years
• Well-care for children, 0 – 15 months
• Timeliness of prenatal care
• Frequency of prenatal care
• Timeliness of postpartum care
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7 day follow-up of a behavioral health stay
LDL-C screenings for diabetic members
Cervical cancer screenings
Follow – up care for children prescribed ADHD meds
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How do we Compare?
MDwise
NCQA 90th%tile
74.45%
79.5%
LDL-C
(Diabetes Care)
68.61%
82.5%
Follow-Up after Hospitalization for
Mental Illness (7 Days)
48.22%
64.2%
Cervical Cancer Screening
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How do we Compare?
MDwise
NCQA 90th%tile
89.54%
92.2%
75.67%
72.7%
82.73%
81.0%
Timeliness of Prenatal Care
Timeliness of Postpartum Care
Frequency of Prenatal Care
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How do we Compare?
Six or More Well-Care Visits in the
First 15 Months of Life
MDwise
NCQA 90th%tile
60.83%
73.9%
72.99%
80.3%
53.28%
56.7%
Annual Well-Child Visit Ages 3-6
Annual Well-Child Visit Adolescents
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How we Promote Quality Care
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Provider and staff education
Network Improvement Program (NIP) Team
Billing and process audits
ManagedCare.com
Member education
Reminder Calls about appointments to members
Member incentives:
 Well Child (3 – 6 and 12 – 21)
 Provider incentives
 Disease/Health management services for members with diabetes
 Disease/Health management for members with asthma
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How NIPT Can Help…..
 The Network Improvement Programs Team assists MDwise departments in
the outreach and education of its providers and delivery systems.
 NIP Team Responsibilities:
 Created to take improvement efforts to a higher level
 Educating providers on HEDIS and ROQ standards.
 Providing physicians information about their quality performance
 Diagnose office practices that may result in missed opportunities to provide
care or cause services to not be billed correctly
 Creating and distributing reference/educational materials and tools
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NIP Reports
Measure
Eligible
Members
Current Current %
90th
Numerator
Meets
Percentile
Vol. Mbrs.
Potential % Vol. Needed
Missed Opp.
Meets
for 90th
W34
2,996
1,380
46.1%
79%
1254
87.9%
987
79%
AWC
3,239
747
23.1%
57%
1308
63.4%
1099
84%
Note: Data is based on dates of service 1/1/09-12/31/09 with claims paid through 11/30/09 captured.
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% of Opportunity
Needed
NIP Reports
DS
0
0
% Meet
Criteria
100.0%
Meet
Criteria
LDL-C Screening
F/U Care for Children Prescribed ADHD Meds
Initial Phase
Follow-up After Hospitalization for Mental Il
Follow-up Within 7 Days of Discharge
0
0
0
Timeliness of Prenatal Care
Meet
Criteria
0
% Meet
Criteria
#DIV/0!
100.0%
0
0
0
100.0%
0
0
0
100.0%
0
0
100.0%
Timeliness of Postpartum Care
0
0
Frequency of Prenatal Care >81%
Well-Child Visits in First 15 Mths of Life
Six or More Visits
0
0
% Meet
Criteria
0%
#DIV/0!
0
0
0
#DIV/0!
0
0
0
#DIV/0!
0
0
#DIV/0!
100.0%
0
0
0
100.0%
0
0
0
100.0%
Well-Child Visits - Ages 3-6
0
0
Adolescent Well-Care Visits
0
0
0
% Meet
Criteria
0%
0
0
% Meet
Criteria
0%
0%
0
0
0%
0
0
0%
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0%
0
0
0%
0
0
0%
0
0
0%
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
#DIV/0!
0
0
#DIV/0!
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0%
0
0
0%
0
0
0%
0
0
0%
0
0
% Meet
Criteria
100.0%
0
% Meet
Criteria
0%
0%
0
0
0
0%
0
0
0
0%
0
0
0%
#DIV/0!
0
0
0
#DIV/0!
0
0
0
#DIV/0!
100.0%
0
0
100.0%
0
0
0
0
% Meet
Criteria
0%
0
0
% Meet
Criteria
0%
0
0
% Meet
Criteria
0%
0
0
% Meet
Criteria
0%
LDL-C Screening
F/U Care for Children Prescribed ADHD Meds
Initial Phase
Follow-up After Hospitalization for Mental Il
Follow-up Within 7 Days of Discharge
0
0
100.0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
100.0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
Timeliness of Prenatal Care
0
0
100.0%
0
0
100.0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
Timeliness of Postpartum Care
0
0
100.0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
Frequency of Prenatal Care >81%
Well-Child Visits in First 15 Mths of Life
Six or More Visits
0
0
100.0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
Well-Child Visits - Ages 3-6
0
0
100.0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
0
0
100.0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
Adolescent Well-Care Visits
0
0
100.0%
0
0
0%
0
0
0%
0
0
0%
0
0
0%
Practice
Meet
Criteria
Meet
Criteria
Denom
inator
Meet
Criteria
Denom
inator
Doc5
% Meet
Criteria
Meet
Criteria
Denom
inator
Doc6
Denom
inator
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Criteria
Doc4
0
Measure
Cervical Cancer Screening
Denom
inator
Doc3
0
DS
Meet
Criteria
Doc2
0
Denom
inator
Denom
inator
Doc1
0
Measure
Cervical Cancer Screening
Denom
inator
Practice
Meet
Criteria
Meet
Criteria
Denom
inator
Doc7
Denom
inator
Meet
Criteria
Doc8
Denom
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Meet
Criteria
Denom
inator
NIP Reports
120%
100%
OMPP Target
80%
DS Totals
60%
Practice Totals
40%
20%
0%
CCS
CDC
ADD
FUH
PPC
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FPC
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W34
AWC
Disease/Health Management
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RN’s identify & evaluate members with unique healthcare needs
Develop individualized plan of care
Assist in overcoming barriers to care
Risk assessment
Maintains contact with PMP and member
Implements interventions for identified needs.
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Disease Management Goals
• Empower member with self-management tools, education and awareness
• Promote the Asthma/Diabetes action plan in the home, school, and provider office
• Encourage adherence to the physician’s treatment plan
• Reinforce self-management goals: problem-solving techniques, overcoming barriers,
and establishing goals
• Provide physicians with member specific utilization information including pharmacy,
emergency room, and outpatient visits
• Promote relationship between the member and his/her physician(s)
• Promote healthy lifestyle choices
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Opportunities for Improvement
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Maximize every member interaction to provide preventive and well-care.
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Well care visits for children when they are in for acute care
Schedule the 15th month EPSDT (Early Periodic Screening, Diagnosis, and Treatment)
visit prior to the 15th month of life
LDL-C screens for diabetics when in for acute care
Document all components of prenatal and postpartum care and submit for well-care
visits.
Staff who does scheduling can identify members who need services to schedule
in a timely fashion
Ensure proper billing for services rendered.
Be sure that the documentation is complete
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Converting Acute Visits to Well Visits
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Documentation for Well Child Visits
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Developmental milestones
Review diet and nutrition
Previous problems addressed?
Address obesity and other chronic problems
Ask about smoking, starting at age 10 yrs.
Mental and physical assessment
BMI – record & discuss
Unclothed exam
Provide anticipatory guidance & counseling
Do routine testing (lead, vision, hearing)
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HealthWatch/EPSDT/Bright Futures
Preventive healthcare program
Emphasis is given to early detection
For members from birth to 21 years old
Required care for Medicaid members
Assures availability and accessibility of
required health care resources
 These components of care are a required part of the well-child assessment
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Opportunities
 If a member contacts the primary medical provider’s (PMP’s) office for a
sore throat (sick visit) the office should take the opportunity to provide
preventive care and schedule a well child visit if the member is due for
services.
 If the PMP office receives a list of non – compliant members, the office
should reach out to the members and schedule preventive services.
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Opportunities
 A PMP office could take the opportunity to convert a sick visit into a well
– child visit when the member is in the office for acute care.
 If the PMP office has electronic medical records (EMR), implement alerts
to reflect the non – complaint members in the quality measures.
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Opportunities
 If a member is being seen for an initial prenatal visit or post partum visit,
all the components of a preventive well – child exam are provided. The
appropriate V20.2 or V70.0 can be submitted as a secondary diagnosis
code and count towards the AWC measure.
 If all components of Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) services were provided, remember to submit the appropriate
99381 – 99385 or 99391 – 99395 with the V20.2.
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Opportunities
 If all components of EPSDT were not provided, remember to submit the
appropriate E&M code along with V20.2,V70.0, or V70.3 to ensure the
services count towards the HEDIS measure.
 If EPSDT services were provided along with acute care, be sure to submit
the appropriate EPSDT code along with the E&M code and the 25
modifier to ensure the services are counted towards the HEDIS measure.
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Quiz……..
1.
2.
3.
4.
5.
If the PMP office provides immunizations and well care at the same visit,
can I bill for both?
How do I bill for both services and how do they count towards the
HEDIS measure?
When can I bill for the following combination 99381 and V20.2 as
primary?
If a pregnant adolescent member is seen for prenatal care, how is the
claim coded to count towards the HEDIS measure?
Can a sick visit and a preventive visit be billed and reimbursed n the
same date of service (DOS)?
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Quiz……..
1.
2.
3.
4.
5.
6.
Is MDwise currently at the NCQA 90th percentile for the well – child 3
– 6 measure?
Name 2 examples of provider incentives?
Name 2 examples to promote quality of care within the MDwise
network.
Give an example of a disease management goal?
Give an example for an opportunity for improvement?
What is a goal of the EPSDT program?
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Resources
 MDwise website : www.MDwise.org
 My Wellness Zone: http://mdws.staywellsolutionsonline.com/
 American Academy of Pediatrics http://www.aap.org/
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American Academy of Pediatrics
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Thanks for your hard work!
Questions?
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Handouts
HEDIS poster
Well – Child Mini Poster
Quality PDF
http://www.mdwise.org/about/mdwisequalityprogram09.pdf
EPSDT grid
Network Improvement Program Charts
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