Presentation is loading. Please wait.

Presentation is loading. Please wait.

High Intensity Care Management November 4, 2014 Webinar.

Similar presentations


Presentation on theme: "High Intensity Care Management November 4, 2014 Webinar."— Presentation transcript:

1 High Intensity Care Management November 4, 2014 Webinar

2 Additional 2014 Clinical Model Elements 2 Clinical Model Goal Outreach to 100% of patients on the “accepted” list within 90 days of finalizing list (outreach defined as initial attempt to reach patient via telephonic or in-person verbal contact) Completion of in-person care management assessment within 3 months of successful outreach for at least 50% of Accepted Members patients, and for 100% of Accepted Members within 6 months Completion of in-person comprehensive health care assessment [for those patients who have not yet received an annual wellness visit in the current calendar year] within 3 months of successful outreach for at least 50% of patients, and for 100% of patients within 6 months Quarterly review/update of care plan for engaged patients Hospital to home transition phone follow-up for 30 days for engaged patients; frequency of phone calls dependent upon patient needs SNF to home transition initial contact within hours of discharge for engaged patients SNF to home transition follow-up w/PCP (or specialist, as appropriate) within 7 days of discharge for engaged patients SNF to home transition phone follow-up for 30 days, minimum of one call following discharge for engaged patients; frequency of phone calls dependent upon patient needs The following elements of the clinical model cannot be tracked/measured via the claims system, but are identified as important goals within the clinical model. Physician Organizations should track these metrics. Metrics will be discussed at joint meetings, in addition, Physician Organizations may be asked to submit data to BCBSM.

3 Phase 1 Launch Full Launch HICM Common Clinical Model Components Subset of Core Model Core Model Comprehensive Clinical Model 1.24/7 phone access to clinical decision-maker with electronic access to pt record ●●● 2. Comprehensive health care assessment by PCP, NP, or PA with full diagnoses capture, advance planning (75% w/in 2 months; all w/in 4 months; in-home for homebound) – top priority for July 1, 2014 start ●●● 3. In-home health care assessment by PCP, NP, or PA for homebound ●● 4. Daytime home visits by RN, MSW or Care Manager (minimum quarterly), including in-home assessments ●● 5. Patient-specific comprehensive care plan (updated at least quarterly) ●●● 6. Care management team includes pharmacist and nutritionist ●● 7. Access to in-home PT and OT ●●● 8. Care transitions management – Hospitals ●●● 9. Care transitions management – SNFs ● 10. Access to palliative care team ● 11. Access to hospice ●●● 12. Transportation for non-emergent medical visits and Rx Remote patient monitoring (weight, BP, glucose) Standardized staff training ●●● 15. Review of all patients on monthly patient lists, common outreach script (2 nd outreach by PCP as needed); POs maintain disposition information on all patients on monthly list ●●●

4 Medicare Advantage STAR Recognition Program

5 Medicare STAR Ratings  The CMS star rating program is a pay-for-performance program for Medicare Advantage plans  Plans will now receive revenue based on outcomes and the quality of their performance  The higher the quality ranking, the higher the payments and the more competitive the plan is in the marketplace  This is an attempt by CMS to create a new paradigm to bend the cost curve

6 What’s Measured 6  STAR ratings measure a Plan’s performance in delivering quality outcomes  STAR ratings are based on 53 key quality measures (36 related to Medicare and 17 related to prescription drug coverage) across the five following domains (subset of HEDIS measures)

7 What do CMS STARS Rating Measure  Staying Healthy: screenings, tests, and vaccines  Managing chronic (long term) conditions  Ratings of health plan responsiveness and care  Member complaints, problem getting services, and choosing to leave the plan  Health plan customer service 7

8 What’s It Look Like 8 Clinical quality and outcomes HEDIS Plan administrative performance and compliance Member assessment of their health (Health Outcomes Survey) Member perceptions of Plan, providers and care CAHPS

9 2014 Provider Outreach Activities  Diagnosis coding education where DDDS is not part of practice  HEDIS/STARS for all targeted providers  Activities include: Address and close HEDIS/STARS treatment opportunity gaps Address and close Enterprise and BCNA risk adjustment diagnosis gaps 9

10 2014 Provider Outreach Activities  Activities include: Support HEB education and sign-up Support provider staff on scheduling member appointments Provide education to providers Provide reference tools and materials to providers Retrieve medical records related to treatment opportunity gaps if necessary 10

11 2014 Provider Outreach Activities  Activities include: Retrieve medical records for BCNA risk adjustment diagnosis gaps, BCNA only Complete focus-driven activities as specified Report on outreach activities completed by practice unit/providers 11

12 Provider Recognition Program 12

13 Measure Codes Adults’ Access to Preventive/ Ambulatory Health Services (AAP) CPT® codes to identify preventive/ ambulatory health services: Office or other outpatient services: , , Home services: , Nursing facility care: , 99315, 99316, Domiciliary, rest home or custodial care services: , Preventive medicine: , , , 99411, 99412, 99420, HCPCS: G0402, G0438, G0439, S0620, S0621 Ophthalmology and optom­etry: 92002, 92004, 92012, General medical examination: ICD-9-CM diagnosis codes: V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Adult Body Mass Index (ABA) Assessment CPT®: , , , , , , , , 99411, 99412, 99420, 99429, 99455, HCPCS: G0402, G0438, G0439 ICD-9-CM Codes to identify BMI: V85.0-V85.5 Exclusions: Members with a diagnosis of pregnancy in the measurement year or the year prior to the measurement year. ICD-9-CM: , V22, V23, V28 Breast Cancer Screening (BCS) Claims Coding Reference 13

14 MeasureCodes Annual Monitoring for Patients on Persistent Medications (MPM) Monitoring for ACE Inhibitors or ARBs, Digoxin*, and Diuretics: Drug serum concentration for serum potassium: CPT®: 80051, Drug serum concentration for serum creatinine: CPT®: 82565, Drug serum concentration for blood urea nitrogen: CPT®: 84250, *Drug serum concentration for Digoxin: CPT®: Monitoring for Anticonvulsants: Drug serum concentration for phenobarbital: CPT®: Drug serum concentration for carbamazepine: CPT®: 80156, Drug serum concentration for phenytoin: CPT®: 80185, Drug serum concentration for valproic acid and divalproex sodium: CPT®: Lab panel codes: CPT®: 80047, 80048, 80050, 80053, Claims Coding Reference 14

15 Claims Coding Reference 15 MeasureCodes Breast Cancer Screening (BCS) CPT®: HCPCS: G0202, G0204, G0206 ICD-9-PCS: 87.36, Exclusions: Members with a bilateral mastectomy. Any of the following meet criteria for bilateral mastectomy: Bilateral mastectomy ICD-9: 85.42, 85.44, 85.46, Unilateral mastectomy CPT®: 19180, 19200, 19220, 19240, ICD-9-PCS: 85.41, 85.43, 85.45, Two unilateral mastectomies *50 and modifier codes indi­cate the procedure was bilateral and performed during the same operative session. Cholesterol Management for Patients with Cardiovascular Conditions (CMC)  CPT®: 80061, 83700, 83701, 83704, Plus  CPT® II: 3048F, 3049F, 3050F

16 Claims Coding Reference  Claims Coding Reference 16 MeasureCodes Colorectal Cancer Screening (COL) FOBT Fecal occult blood test between (FOBT) 1/1/2013 and 12/31/2013:  CPT®: 82270,  HCPCS: G0328 Flexible sigmoidoscopy between 1/1/2009 and 12/31/2013:  CPT®: , ,  HCPCS: G0104  ICD-9-PCS: Colonoscopy between 1/1/2004 and 12/31/2013:  CPT®: , 44397, 45355, , 45391,  HCPCS: G0105, G0121  ICD-9-PCS: 45.22, 45.23, 45.25, 45.42, AND/OR Chart documentation of previously performed colorectal cancer screening tests. Exclusions: Members with a history of either of the following:  Colorectal cancer  HCPCS: G0213-G0215, G0231  ICD-9-CM: 153, , 154.0, 154.1, 197.5, V10.05  Total colectomy  CPT®: ,  ICD-9-PCS:

17 HEDIS Coding Reference  HEDIS Claims Coding Reference 17 MeasureCodes Comprehensive Diabetes Care (CDC) – Eye Exam CPT®: 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , CPT® II codes: 2022F, 2024F, 2026F, 3072F HCPCS codes: S0620, S0621, S0625, S3000 Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year. ICD-9-CM: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. ICD-9-CM: , 251.8, 648.8, , 962.0

18 HEDIS Claims Coding Reference 18 MeasureCodes Comprehensive Diabetes Care (CDC) – HbA1c CPT®: 83036, PLUS CPT® II: 3044F, 3045F, 3046F Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year. ICD-9-CM: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. ICD-9-CM: , 251.8, 648.8, , Comprehensive Diabetes Care (CDC) – LDL-C CPT®: 80061, 83700, 83701, 83704, PLUS CPT® II: 3048F, 3049F, 3050F Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year. ICD-9-CM: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. ICD-9-CM: , 251.8, 648.8, , 962.0

19 MeasureCodes Comprehensive Diabetes Care (CDC) – Nephropathy Screening CPT®: 82042, 82043, 82044, PLUS CPT® II: 3060F, 3061F, 3066F, 4010F ICD-9-CM: 250, , , 753, 791 Exclusions: Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria: A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year. ICD-9-CM: A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. ICD-9-CM: , 251.8, 648.8, , Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) ICD-9-CM codes to identify rheumatoid arthritis: 714.0, 714.1, 714.2, HCPCS codes to identify pharmacy claims for DMARD in the measurement year: J0129, J0135, J0718, J1438, J1600, J1745, J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J9310 Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) COPD: Chronic bronchitis: 491 Emphysema: 492 COPD: 493.2, 496 CPT® codes to identify spirometry testing: 94010, , 94060, 94070, 94375, HEDIS Claims Coding Reference 19

20 MeasureCodes Osteoporosis Management in Women Who Had a Fracture (OMW) Codes to identify bone mineral density test: CPT®: 76977, , 78350, HCPCS: G0130 ICD-9-CM: AND/OR pharmacy claims for osteoporosis drug therapy: HCPCS: J0630, J0897, J1000, J1740, J3110, J3487, J3488 HEDIS Claims Coding Reference 20

21 Open Discussion 21


Download ppt "High Intensity Care Management November 4, 2014 Webinar."

Similar presentations


Ads by Google