Listed below are questions and answers from the ISMA's teleseminar Q & A section on Wednesday, March 28, 2007.
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1. What is pay for performance (P4P?
2. What are P4P catch phrases?
3. How are determinations made?
4. I am an anesthesiologist or radiologist, does P4P affect me? 5. What insurers are using a P4P program?
6. What should I do?
7. Where can I find information about the various plans?
8. What if I don't care for the determination made regarding my care?
9. What is the Medicare P4P program?
10. What Medicare services are included in the PQRI program?
11. How do I participate in the PQRI program?
12. Is Indiana Medicaid doing anything related to P4P?
A: The P4P concept is to reward/pay physicians based on the quality of care provided to patients instead of the current concept of paying based on the volume of care.
A: Tiered Network: A tiered network assigns physicians into two or more separate tiers. Patients may still see physicians not included in the tiered network.
Narrow Network: A narrow network is a small or select network of physicians within a larger physician network. Patients are limited to seeing only those physicians included in the network.
PQRI: Physician Quality Reporting Initiative This is the Medicare quality program.
Claims Data: Claims data refers to the claims payment history held by payers on claims submitted for reimbursement for services provided to their insureds.
Episode Treatment Grouper (ETG): A computer program developed by Symmetry Health Data Systems to assign quality and efficiency measures based on claims data for episodes of care.
Episode of Care: An episode of care includes all physician, pharmacy, inpatient, and outpatient services provided to an individual for a given episode of illness.
A: The majority of commercial payers utilize ETG Software to make determinations regarding quality and cost effectiveness of care. Each payer may have different measures for inclusion in their program. Therefore, a physician may be considered to be providing quality care by one payer’s standards, but not be considered as providing quality according to another payer’s standards. Regardless of the criteria, commercial payers are relying on claims data.
A: P4P may not directly affect your reimbursement at this time. However, the ETG software looks at all physician charges related to an episode of care. This means your charges as an ancillary physician will be used in determining inclusion/exclusion of the primary physician in a network.
A: Currently, the ISMA is aware of programs either developed or being used by Aetna, Humana, United Healthcare, Anthem/Wellpoint, and Cigna.
A: Check your status on the Web site of each of your large commercial insurance plans. You may not know it, but quality and cost effectiveness ratings may already be available to the public.
A: Immediately contact your provider representative to begin an investigation of the data used to make a decision. Offices are finding payers are very slow in producing the data and can take several months. The sooner you start requesting data, the sooner you will be able to conduct your own internal review and potentially dispute the insurance company’s determination.
A: The Medicare program is called the Physician Quality Reporting Initiative (PQRI). It provides a 1.5% bonus of all paid services for a given time period. This requires reporting of either level II CPT codes or G Codes on your claim for certain services provided to Medicare beneficiaries.
A: The measures used by Medicare were developed by the AMA Physician Consortium for Performance Improvement. Find more information about the Consortium. Learn about the measures being utilized by the Medicare program.
A: In the Request for Services (RFS) issued in 2006, the State required Managed Care Organizations to include information regarding P4P. The contracts were effective January 1, 2007. The ISMA is not currently aware of any programs currently in place. However, the RFS included suggested areas such as decreasing Emergency Department (ED) utilization, blood lead screening, etc. Medicaid will focus on primary care issues.
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