Michigan Primary Care Transformation Project

1. Michigan Primary Care Transformation Project Webinar #2: Funding model, Care management models And Implementation plan November 28, 2011

2. Agenda • BCBSM/BCN Care Management Billing • PO/PHO Billing for Care Management • Integrated Health Partners • Medical Network One • Question and Answer Session

3. BCBSM MiPCT Payments for Care Management/Care Coordination • January – March 2011 • $3pmpm based on total commercial members attributed to MiPCT participating practices • Payments being processed; should arrive by November 30 • April 1, 2012 • Begin new care management/care coordination reimbursement methodology

4. BCBSM Care Management/Care Coordination Reimbursement Policy • Reimbursement will be based on fee-for-service – no bundling or pending of claims • 7 identified HCPCS (G-codes) and CPT codes • Codes billed with $0.00 charges • BCBSM will pay established fee for each code • PGIP withhold applies to PDCM fees • No quantity/frequency restrictions applied to services except G9001 • Services delivered must be necessary and relevant to patient success • BCBSM customers expect net savings will be achieved • G9001 limited to one per year per patient • No cost share imposed on member

5. HCPCS and CPT Codes • Initial patient evaluation • G9001: Coordinated Care Fee, initial rate (per case) • Individual follow-up visit (face-to-face) • G9002: Coordinated Care Fee, maintenance rate (per visit) • Group education and training for patient self-management • 98961: Face-to-face with the patient, each 30 minutes; 2-4 patients • 98962: Face-to-face with the patient, each 30 minutes; 5-8 patients • Telephone assessment and management service • 98966: 5-10 minutes of medical discussion • 98967: 11-20 minutes of medical discussion • 98968: 21+ minutes of medical discussion

6. Conditions for Payment • For billed services to be payable, the following conditions apply: • The patient has the BlueHealthConnection benefit and is eligible for PDCM coverage • The Primary Care Physician practice and affiliated PDCM care management team have been approved by BCBSM for PDCM reimbursement. • All services delivered are individualized based on the physician-directed care plan and patient need, and are directly tied to patient-specific care goals • The patient has agreed to the care plan and to be actively engaged in the process • Each service is delivered by the appropriate qualified, non-physician health care professional functioning under the direction of a certified care manager. • G9001 must be performed by an RN or MSW • Other codes may be performed by any of the professionals currently allowed for T-Codes • Sufficient documentation is maintained in the patient record

7. When POs employ care managers • POs do have options for billing for care manager services (coming in next presentation) • Key points to keep in mind • Preferred care management model involves in-person patient interactions • Research shows in-person interventions more effective than 100% phone-based • Travel teams can be effective if meet regularly with practice unit team and have in-person sessions with patients

8. Billing Guidelines When submitting claims: • Recommend billing $0.00 for PDCM services to avoid patient co-pays • Report all relevant diagnoses • Identify the Primary Care Physician as the Rendering Provider. • Identify the practitioner (name and credentials) performing the services in the Remarks Field. Question: • Can your billing systems handle sending us a claim with $0 and we return with a payment of $100? Does this automatically credit the member? Note: services may be billed on the same claim as medical.

9. Proposed Fees

10. Training Schedule • Webinars for billing staff • Billing manual

11. PO/PHO Billing for Care Management Part I: Integrated Health Partners

12. Planning for G-Code Implementation Integrated Health Partners Ruth Clark Lesley Anne M. Durant

13. G-Code Implementation • National Provider Identifiers for POs and PHOs • Liability • Billing

14. National Provider Identifier (NPI) • Developed by CMS in 1993 to standardize identification of providers for billing purposes • Mandated by HIPAA Administrative Simplification provisions in 1996 • Final Rule for providers published in 2004 adopting NPIs and defining providers

15. NPI – Final Rule • Adopts the NPI as the standard identifier mandated by HIPAA for health care providers for use in the health care system • Establishes the implementation specifications for obtaining and using the NPI

16. Final Rule Definitions • Health Care Provider is defined as a “provider of services” or a “provider of medical or health services” as defined in section 1861 of the Social Security Act, and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business. • Excludes entities that do not provide “health care” as defined in the Act (i.e. taxi services, respite services, etc.) • Excludes entities that only bill and do not provide services (i.e. billing services, value added networks, repricers, etc.) • Health Care is defined as care, services, or supplies related to the health of an individual. Includes, but is not limited to: • Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and • Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.

17. POs and PHOs as Health Care Providers • Care Management services provided by RNs do not fall under the Act’s specific definitions of “provider of services” or “provider of medical or health services” in section 1861 • However, Care Management services would fall under the final rule’s definition of “Health Care” • Therefore, an RN performing Care Management services would be “any other person who furnishes…health care in the normal course of business” and thus an individual health care provider • Furthermore, an entity that employs such individuals and bills for the services would be an organizational health care provider for purposes of the Final Rule

18. Applying for a NPI • Individual: • Each licensed RN, MSW or other provider as defined in the Final Rule may apply for a Type 1 NPI number • Organization: • Look at organization’s ownership structure • Is PO or PHO a stand alone “legal entity?” • If yes, PO/PHO may apply for a Type 2 NPI number • If no, PO/PHO must apply as a “subpart” of a larger organization (i.e. hospital) • Taxonomy: • PO/PHO would use “Case Management” taxonomy code to identify the types of services being provided (see http://www.wpc-edi.com/codes/taxonomy)

19. Liability • Each organization should check with its insurer regarding its malpractice liability coverage • Activities will likely be covered under an employee Errors and Omissions (E&O) rider

20. Billing • IHP is using a custom designed, web-based software program to submit electronic billing • PHO/PO can purchase pre-designed, commercial billing software • PHO/PO can contract with billing service • Any billing software must be HIPAA 5010 compliant

21. PO/PHO Billing for Care Management Part II: Medical Network One

22. New Billing Codes: A Ding in the Healthcare Universe

23. Planning Phase: Slow…Go Slower • Contact accountant and legal • Liability coverage for all entities (RN’s behavior health can supplement liability coverage through own professional organization) • Create separate business unit (DBA) within PO • Business unit applies and receives an NPI • Business unit is linked to PO (existing corporation) with a separate EIN

24. MNO Community Care Travel Team:Ready, Aim, Fire • Policies and procedures • Job descriptions: staffing for transformation and success • Building a high performing team: no silos here • Preparing for the job interview: team interviews • Initial competency assessment • Ready to hire…hired • Onboarding…training including shadowing

25. Phase One: Small Step • Introduce CCTT services available to Physician and Medical Practice Team • Engage all parties: this is crucial • Talk about mutual roles and responsibilities • Discuss commitment to patient/family/caregiver and other healthcare professionals • Ready to engage? • Contract between Physician and CCTT

26. Phase Two: Ready to Roll • HIPAA Business Agreement executed • Revisit the relationship question…how does the physician see his/her role in this new process • Remind the Physician and Medical Practice Team to begin identifying the patient population requiring moderate level oversight (Care Team assists) • Repeat the commitment that all patients identified will be seen

27. Phase Three • Patients are identified by PCP, practice team member, or another clinician • Physician writes order for CCTT services • Patients may opt-out of CCTT services • Knowledge/skills and competency assessment of entire care team completed at minimum annually and more frequently if gap in training and delivery of program identified (comparing clinicians)

28. Phase Four • Practice Unit selects day and time most suitable for elementary training and education of Practice Unit staff • After successful training, Practice Unit identifies “Care Guide” who selects day and time most suitable for CCTT onsite visits and also for telephonic meetings • CCTT and “Care Guide” work in partnership to identify patients who would benefit from services

29. Phase Five • Begin with one physician, one patient, one day, with one CCTT clinician • Assess what worked and what didn’t work • Establish next steps • As capacity is reached new CCTT staff brought on

30. MNO CCTT: Evaluator, Educator, Coach, Mentor and Manager • Care coordination: initial and maintenance • Face to face self management by a qualified, non-physician health care professional using a standardized curriculum • Telephone assessment and management by a qualified non-physician health care professional • Medical nutrition therapy, assessment, intervention, and re-assessment • Diabetes self-management education

31. Tips from the Field • Behavior health is first point of contact • Other Allied Health Professionals added as needed • As capacity is reached additional staff are retained • Team conference to assess individual’s progress • CCTT support varies but on average 6-9 months • Effectiveness of face-to-face encounters increases with telephonic support

32. Tips from the Field • Use population registry, daily census reports and paid claims extensively • Medical management team “managed care” • Adult and pediatric care plan template designed within EMR • Population registry integrated with EMR to generate “Care Plan” available to CCTT and physicians • RelayHealth key to communication and ongoing support among the community of caregivers

33. Engaging the Patient and Caregiver • Explanation of the services provided prior to the patient’s first encounter • Explain the benefits of the program • On-call billing team not only for CCTT matters but also to help patients and caregivers navigate the maze associated with services provided an individual with a chronic condition

34. Next Steps

35. Question and Answer Session