Connect Archives

February 2012

Wednesday, February 15, 2012

HFNI AND THE ACO

Health First Network has reached an agreement with Universal American (NYSE - UAM) through its subsidiary Collaborative Health Solutions to form an Accountable Care Organization (ACO). An ACO is a provider based organization authorized by the Centers for Medicare and Medicaid Services (CMS) to provide care for Medicare beneficiaries. To directly quote the CMS website, the purposes of an ACO include:

"...help doctors, hospitals and other health care providers better coordinate care for Medicare patients."
"...create incentives for health care providers to work together to treat an individual patient across care settings."
"...reward ACO's that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first."

This is a very exciting development for the physicians in Health First Network. It not only places them in the forefront of health care reform, it gives the physicians the ability to make their own determinations of how care is to be coordinated and delivered to patients. Added to this is the fact there is opportunity for the physician to earn a share of any savings achieved with no downside risk.

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ADMINISTRATIVE CHANGES IN COVENTRY (VISTA)

You should have previously received notification from Coventry (Vista) concerning the changing but continued relationship between HFNI and Coventry. Basically, our contract changed from one which is “at risk” to a messenger model. Under a messenger model HFNI does not have the same responsibilities. For a copy of the correspondence from Coventry detailing the change please click on the link below. Please note this change had no effect on the Coventry (Vista) Healthy Kids contract.

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SIMPLY HEALTHCARE

Health First Network has finalized a new contract with Simply Health to provide a managed Medicaid product to Escambia and Santa Rosa counties. The new contract with Simply Health will be a messenger model contract. HFNI is not at financial risk. We are going to perform some network development functions, meaning your current credentials with HFNI will serve for the Simply Health product as we are delegated this function. HFNI has a separate agreement that medical management will be done locally by HFNI personnel.

CREDENTIALING REQUIREMENT CHANGES FOR 2012

There are several additional provider requirements now required by Federal and State statutes that HFNI will be asking Providers to meet beginning in January of 2012. Several standards pertain to language and wording in physician contracts and subcontract provisions. The Credentialing standards will apply for all Providers submitting new initial credentialing applications to Health First Network and for all HFNI Providers submitting re-credentialing applications. These requirements are mandated by AHCA contracts and/or Federal Law. Compliance with these statutes is not optional.

Simply stated, because Health First Network Physicians care for beneficiaries covered under both Medicaid and Medicare Advantage Programs, Health First Network, Inc., is required to comply with all applicable federal and state laws, regulations and CMS instructions pursuant to statutes listed in these federal and state regulations. Some of these contract provisions were not a standard part of HFNI Provider contracts. Health First Network submitted these to our Corporate Attorney for review and recommendations. Recommendations have been received back and are under review for inclusion in HFNI Joinders. For credentialing standards, there are three disclosure requirements required by law that are bundled together. These three disclosure requirements have to do with: ( A) ownership and management; (B) business transactions; and (C) Crimes related to any Provider’s involvement in any program under Medicare, Medicaid, or the title XX program since the inception of those programs.

In order to comply with Federal Law (42 CFR 420.200-420.206 and 455.100-455.106) and Medicaid Program Integrity requirements, health plans and Provider Organizations with Medicaid or Medicare business are required to obtain information regarding the ownership and control of entities with which the health plan or provider network contracts for services for which payment is made under the Medicaid or Medicare Program or any line of business that provides healthcare for federal employees. The Centers for Medicaid and Medicare Services (CMS) require Health First Network, Inc., and its subsidiaries to obtain this information to demonstrate that Health First Network is not contracting with an entity that has been excluded from federal health programs, or with an entity that is owned or controlled by an individual who has been convicted of a criminal offense, has had civil monetary penalties imposed against them, or has been excluded from participation in Medicare or Medicaid.

A form related to this these issues will be included in application packets for initial credentialing applications and re-credentialing packets. A copy of this form is attached below.

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PROVIDER SURVEY RESULTS

Every year or two, Health First Network does a Provider Survey to determine how the organization is doing in regards to serving its members. The two-part Provider Satisfaction Survey was divided into two sections: Health First Network Customer Survey which contained questions specific to the services provided by Health First Network. The second part, MED3OOO Customer Survey, contained questions specific to the services Health First Network contracts with MED3OOO to provide to your office.

We are pleased to share this year’s results:

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