Connect Archives

April 2012

Monday, April 23, 2012

ACO PROGRESS

On March 30th an application for the Accountable Care Coalition of Northwest Florida, LLC was filed with the Centers for Medicare and Medicaid Services (CMS). Accountable Care Coalition of Northwest Florida, LLC is the legal name of the corporation jointly owned by Health First Network, Inc. and Collaborative Health Solutions. The application was filed for participation with CMS in the Medicare Shared Savings Program, specifically for formation and approval of an Accountable Care Organization (ACO). The application was filed for a July 1, 2012 effective date.

We are currently working with CHS on:
- Provider education in office
- Member (patient) communication
- Conflict of Interest and Compliance Programs for the ACO
- Data possibilities for the ACO

You will be seeing and hearing more about some of the above items as we get closer to the approval notification. In the meantime, if you have any questions please contact Charles Brewer or William Whibbs, M.D. and they will be pleased to discuss this with you.

CARE COORDINATION

As medicine has become more complex and more specialized, coordinating any one patient’s care has become a jungle. It is not uncommon to have a patient seeing 5 different physicians in 5 different locations, taking multiple medications from each. Add to that an outpatient surgery or two, P.T., wound care, home health care, and the occasional inpatient stay for any of the above, or even complications from any of the above, and the result is an almost hopeless labyrinth.

The idea of the Patient Centered Medical Home was developed with exactly that level of complexity in mind, and is meant to serve as the hub where all of the loose ends are accounted for, and tied into a pretty bow. Tying that pretty bow is a way to look at care coordination: it’s bringing together all of the diagnosis and treatment strands required for an individual patient, trimming them, reducing unnecessary overlap, and cutting off the ones that either aren’t contributing anything, or may actually be complicating things. This is no small task, and requires a team of providers each focused on certain aspects of care, and all communicating with each other.

While this may be an almost impossible task for a small practice, it can be more easily accomplished by a network of practices sharing resources. We have all seen firsthand the value of case management when it is done right: the patients do better and are happier, and the treating physicians and their staffs are happier as well. And in addition to that, health care resources are used more appropriately, and costs are optimized.

As the physicians in Health First Network move into the arena of Accountable Care, part of the foundation will be maintaining an adaptable and empathetic Care Coordination program that will be available to the patients and their physicians that will encompass initial evaluation and health risk assessment; care transitions at times of hospital or other facility admission and discharge including E.R. visits; education on meds, treatments, diets and the like…the entire spectrum.

While care coordination has always been a great idea, we have reached the point where it is now a necessity. Health First Network and our partner Collaborative Health Solutions are excited to be working on providing these services locally.

LIST OF ACO QUALITY MEASURES

Quality health care is always a high priority for all HFNI Physicians. In light of Health First Network, Inc.’s initiative to become an Accountable Care Organization (ACO) in partnership with Collaborative Health Solutions, implementing and having the ability to report all necessary quality initiatives is critical to assuring the continued provision of quality health care to Medicare Beneficiaries through accountability and public disclosure, and to having the ability to demonstrate quality performance standards are met in order to share in any savings that are created. CMS uses quality measures, also called Physician Performance Measures, in all of its various quality initiatives that include quality improvement, pay for reporting, shared savings and public reporting.

What are Quality Measures?
Quality measures are tools that help to measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.

CMS will continuously measure quality of care standards for every ACO whose application is selected and approved using nationally recognized measures in four key domains:
• Patient/caregiver experience (7 measures)
• Care Coordination/patient safety ( 6 measures)
• Preventive Health ( 8 measures)
• At-risk populations:
- Diabetes ( 6 measures)
- Hypertension ( 1 measure)
- Ischemic Vascular Disease ( 2 measures)
- Heart Failure ( 1 measure)
- Coronary Artery Disease ( 2 measures)

Click the link below for the 33 quality measures.

Related Links


PHYSICIAN EXTENDERS

Health First Network began processing claims for physician extenders under Medicare billing standards on July 1, 2010. Prior to this date, extenders billed using the supervising physician’s provider identification information.

An implication of this process was the requirement that physician extenders had to be credentialed through Health First Network to be able to see, treat, and bill for health plan members assigned to Health First Network physicians.

Each/every Physician extender is required to fill out a Health First Network credentialing application. The completed application is put through a credentialing verification process with an accredited CVO, and is then reviewed by the HFNI Credentials Committee.

Health First Network policies and procedures for credentialing both physicians and extenders are contained in the HFNI Credentials Program Policies and Procedures Manual. In addition to the on-line Credentials Program Manual there are a small number of day-to-day operational credentialing policies and procedures that pertain to specific situations or operational or administrative processes that change frequently with the various health plans. These can be obtained from the HFNI Credentialing Department.

It is the responsibility of every Provider office to notify Health First Network when there are any changes in the status of Health First Network Physicians and/or Physician Extenders. Changes may include exits and terminations, site location changes, practitioners leaving the practice for another office or a move out of the area, retirements, etc. It is critical for offices to keep Health First Network informed of physician and extender(s) status changes within the office. These changes must be updated in the Credentialing and Provider Relations data bases and are then reported to health plans, to the State, and, soon, to CMS. Incorrect or inaccurate information can affect payment, compliance and fraud issues.

Please assist Health First Network in facilitating the flow of accurate and correct credentialing, contracting, composite of geographical network specialty information, and billing and payment information by notifying the Health First Network Credentialing Department and Provider Relations Department of any practitioner status changes in your office.

Related Links


COVENTRY CLAIMS SUBMISSIONS

Effective 1/1/12 Health First Network (HFNI) / MED3000 is no longer responsible for processing claims for the Coventry (Vista) HMO / Open access products.

It is very important that all claims for dates of service December 31, 2011 back are filed to HFNI/MED3000 no later than June 30, 2012.

Coventry (Vista) Healthplan
P. O. Box 10948
Pensacola, FL 32524

All claims received after June 30, 2012 will be denied timely, NO EXCEPTIONS will be made.

Please contact Jenny Caillouet if you have any questions.