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Michigan Primary Care Transformation
Demonstration Project
May 2, 2012Webinar #6
MiPCT Financial Reporting Templates
Carla A. Galligan
Consultant
Agenda
Care Manager Updates
Payer Updates
Financial Template
3
Why Financial Reporting
Financial reporting ensures accountability for the funds received
Reporting will reconcile revenue collected and expenses
Reporting Templates
There are 4 reporting templates:
Revenue and Membership
Care Coordination
Practice Transformation
Incentive
Basic Components of All Templates
Revenue (cash collected)
Membership ( corresponds to cash collected)
Expense
Payers Included in Reporting
Blue Cross Blue Shield of Michigan
Blue Care Network
Medicare
Medicaid Managed Care
Reporting Deadlines
Reports submitted on a quarterly basis for Care Coordination and Practice Transformation
Incentive reporting is for a 6 month period
Data will be submitted electronically.
Details on electronic transmission will be communicated to PO/PHO’s
Reporting Deadlines
PO/PHO’s will be given 30 days after the quarter end to submit reports
Due dates:• May 1, 2012• July 31, 2012• October 31, 2012• January 31, 2013
Data will be submitted electronically
Details on electronic transmission will be communicated to PO/PHO’s
Summary of Payer Member Months and Revenue
Worksheet used to summarize all payer revenues
Care Coordination payments are made directly to PO’s for Medicare and Medicaid Managed Care
Care Coordination payments are made to Practices for BCBSM and BCN
Practice Transformation payments are made to practices for all payers
Care Coordination Template
The care coordination template identifies all revenue and expenses as outlined in Implementation Plan C
Care Coordination Expenses
Care Coordination expenses are amounts spent during the reporting period
Expenses and FTE’s will be cross referenced to Implementation Plan C
Descriptions of Expenses
Compensation, Overtime, Benefits, Training, Education, Certification, Travel, Meeting Costs
Other (explain)
Care Coordination Expense Documentation Requirements
The PO’s/PHO’s must complete the FTE spreadsheet as support for Care Coordination Expenses
The FTE spreadsheet purpose is to reconcile compensation and benefit expense as reported
PO’s/PHO’s will include Implementation C plan FTE data as a data element
Practice Transformation Template
The Practice Transformation template will present revenue and expenses
Practice Transformation Reporting Template
Revenue $5,857,357.50
PRACTICE TRANSFORMATION EXPENSES
COMPENSATION $2,000,000.00 OVERTIME $200,000.00 TRAINING $50,000.00 EDUCATION $7,500.00 CERTIFICATION $8,000.00 CARE MANAGEMENT SOFTWARE $10,000.00 COMPUTER $15,000.00 FAX $50.00 INTERFACE REGISTRY $16,000.00 MINOR EQUIPMENT $500.00 MEETING COST $125.00 PATIENT SURVEY COST $750.00 PRACTICE COACHING $50.00 POSTAGE $150.00 REFERENCE MATERIAL $650.00 RENT/SPACE $900.00 STAFF TRAINING $200.00 SUPPLIES $50.00 TELEPHONE $150.00 TRAVEL $36.00 OTHER $500.00 OTHER $1,000.00 OTHER $2,000.00 OTHER $3,000.00
Total Practice Transformation Cost $2,316,611.00
NET INCOME (LOSS) PRACTICE TRANSFORMATION $3,540,746.50
Practice Transformation Expenses
Practice Transformation expenses are amounts spent during the reporting period.
Expenditures will be cross referenced to Practice Plan Phase 1 item C. Expenditure deviations from the submitted plan are permitted.
Support for FTE’S and Expenses > $5000.00 (single transaction) are required.
Expenses other than Salary and Benefit cost can be assigned on a direct cost or allocation methodology.
Practice Transformation Expenses
The allocation methodology can be used for expenses such as postage, office supplies, telephone etc..
A column has been added to the templates for designation D – Direct, and A‐ Allocation.
Support for FTE expenses will be the same as required for Care Coordination.
PO/PHO’s must complete a supplemental report for single disbursements > $5000.00 .
Excess Medicaid Managed Care Funds
PO/PHO’s will be allowed to roll forward no more than 20% of Medicaid Managed Care excess of revenue over expense for each reporting module (Care Coordination and Practice Transformation)
An allocation methodology will be used to determine expense by payer using membermonths as the basis for the allocation of expense
Excess Medicaid Managed Care Funds
The 20% roll forward will be allowed only if supported by documentation as to why the funds were not expended in the year
Amounts > 20% will be offset beginning February 2013
Practice Incentive Reporting
Practice Incentive reporting is defined as all payments received by the PO’s/PHO’s for Medicare and Medicaid Managed Care only
PO/PHO’s will report funds disbursed to practices
Reporting requirements are by payer and include: Practice name, Location, Amount, Date
Practice Incentive Reporting
PO’s/PHO’s are subject to a maximum retention of 20% of the Total Incentive Dollars received
The retention of the PO/PHO Incentive dollars >20% may require documentation supporting the dollars retained
Questions
Questions on MiPCT Financial Reporting can be submitted to Christine Trimpe at MNO
Overview
Narrative Status Update• Detail will vary by quarter
• 6 and 12 month report require practice level detail• 3 and 9 months, brief PO‐ level overview
• Avoids duplication of SRD and Quarterly PGIP Progress reports
23
Narrative Status Update
Content: based on year 1 requirements and priorities• Care Manager hiring progress and barriers• Infrastructure implementation progress across practices• Electronic registry functionality• Care Management documentation• Transition notifications
• Opportunity to communicate barriers and successes
24
Care Management Activity Reporting
Minimum core data:• Number of encounters per care manager, by payer
Will be required beginning third quarter 2012
Necessary for reporting to participating payers and MDCH
Need to understand PO/practice reporting capacity to minimize burden
25
Submission
Due dates for quarterly reporting• May 1, 2012• July 31, 2012• October 31, 2012• January 31, 2013
Submission: email to [email protected]
26
PDCM Payment Policy Design
Fee‐for‐service methodology – 7 payable codes for services performed by qualified non‐physician practitioners
• Face‐to‐face (individual and group)• Telephone‐based
Payable to approved providers only
• Non‐approved providers billing for these services are subject to recovery
27
PDCM Codes and Fees
28
CODE SERVICEG9001 Initial assessment
G9002 Individual face‐to‐face visit (per encounter)
98961 Group visit (2‐4 patients) 30 minutes
98962 Group visit (5‐8 patients) 30 minutes
98966 Telephone discussion 5‐10 minutes
98967 Telephone discussion 11‐20 minutes
98968 Telephone discussion 21+ minutes
*Net of Incentive amount
Care Management Training Guidelines
• Services provided by Moderate Care Managers are billable once Care Managers complete approved self‐management training
• Services provided by Complex Care Managers are billable once care managers have completed approved Complex Care Management training
• PDCM‐codes should not be billed by untrained care managers
29
Patient Eligibility
The patient must have active BCBSM coverage that includes the BlueHealthConnection® Program. This includes:
• BCBSM underwritten business
• ASC (self‐funded) groups that elect to participate• Medicare Advantage patients
30
Services billed for non-eligible members will be rejected with provider liability.
Patient Eligibility
Checking eligibility:
• Eligible members with PDCM coverage will be flagged on the monthly patient list
• Providers should also check normal eligibility channels (e.g., WebDENIS, CAREN IVR) to confirm BCBSM overall coverage eligibility
31
Services billed for non-eligible members will be rejected with provider liability.
Patient Eligibility
The patient must be an active patient under the care of a physician, PA or CNP in a PDCM‐approved practice and referred by that clinician for PDCM services
• No diagnosis restrictions applied• Referral should be based on patient need
The patient must be an active participant in the care plan
32
Services billed for non-eligible members will be rejected with provider liability.
Provider Requirements: Care Management Team
Individuals performing PDCM services must be qualified non‐physician practitioners employed by practices or practice‐affiliated POs approved for PDCM payments
33
Provider Requirements: Care Management Team
The team must consist of:
• A lead care manager : RN, LMSW, CNP or PA who has completed an MiPCT‐accepted training program
34
Provider Requirements: Care Management Team
Other qualified allied health professionals
LPN, CDE, RD, Nutritionist Master’s Level, Pharmacist, respiratory therapist, certified asthma educator, certified health educator specialist (bachelor’s degree or higher), licensed professional counselor, licensed mental health counselor
35
Provider Requirements: Care Management Team
Each qualified care team member must:
• Function within their defined scope of practice• Work closely and collaboratively with the patient’s clinical care team
• Work in concert with BCBSM care management nurses as appropriate
Note: Only lead Care Managers may perform the initial assessment services (G9001)
36
Billing and Documentation: General Guidelines
• No diagnostic restrictions• All relevant diagnoses should be identified on the claim
• No quantity limits (except G9001) and no location restrictions
37
Billing and Documentation: General Guidelines
• Documentation demonstrating services were necessary and delivered as reported
• Documentation identifying lead CM isn’t required, but documentation must be maintained in medical records identifying the provider for each patient interaction
38