Connect Archives

May 2013

Friday, May 31, 2013


ACO Physician Committees and the ACO Management Committee have been busy reviewing the reports on CMS claims data on our ACO Fee-For-Service Medicare attributed beneficiaries. Analyzing reports and determining which areas need improvement are crucial to meet the triple aim of an ACO – better health; better care; more cost effective care, within our Northwest Florida area. Our ACO Care Coordination and Quality Improvement Committees have begun the work on a Care Coordination and Quality Improvement Plan for 2013 based on the data. A main area of concern is Medicare 30-day readmissions. All area hospitals show readmission percentages above the standard. A focus on causes for readmissions and on the important transition of care from acute care hospital to home, or SNF or Rehab, is a priority at this time for the ACO. High ER utilization is also a concern, particularly as it relates to beneficiaries within certain practices.

Health First Network is asking your help on this. Health First Network’s Accountable Care Coalition of NW Florida now has 3 local RN Care Coordinators. To tackle the high number of readmissions, the ACO needs to be notified when one of your Medicare Fee-For Service patients is admitted to the hospital so the local ACO Care Coordinator can work with hospital staff in the transition from hospital to home, SNF, Rehab or Assisted Living. Please review and sign the attached letter giving the hospital permission to notify Health First Network of your patient’s admission. The information will be forwarded to a Care Coordinator to follow. Signed letters can be sent electronically to Health First Network or faxed to HFNI at Fax # 850-438-0298.

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Medicare Managed Care reimbursement from CMS depends on accurate and complete diagnostic (ICD-9) physician coding. Capturing the most accurate and specific diagnostic codes, on an annual basis, on each Medicare Advantage, ACO, and Medicare Fee For Service patient’s health care conditions is “mission critical” for health plans, for individual physicians practices, for IPA’s and for medical groups. Many are currently receiving radically lower premiums than those to which they are entitled. During 2013, Health First Network, Inc. is initiating a RAPS project to collaboratively work with our physicians to achieve 100% completion of a comprehensive annual exam on each Medicare beneficiary. Please read the letter from Dr. Whibbs.

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CMS views ACO’s as physician groups, and now requires all physicians who are participants (i.e. those who have signed a participating physician agreement) in an ACO to do their PQRS reporting through the ACO. The data will be collected and reported directly to CMS using the GPRO (Group Physician Reporting Option), and the data collection will be done by the ACO. The physicians will not report individually as most have in the past. In fact, by virtue of their participation in the ACO, they will no longer be allowed to report individually. The PQRS bonus money will be calculated using the standard already in place for physician groups (1/2 of 1% of all part B billings for the group), and will then be distributed (ALL of it!!) to the physicians based on their individual part B billings.

The ACCNWFL (Accountable Care Coalition of Northwest Florida) has successfully submitted the PQRS data for our physicians for the year 2012, and will be distributing the bonus as soon as it is received.


Prestige has started enrolling Medicaid beneficiaries in its local managed care plan. Pursuant to Health First Network’s contract with Prestige, these beneficiaries are being assigned to HFNI PCP’s and are being referred to HFNI specialist physicians. Please contact Jenny Caillouet at 850-438-4487 with any questions.


For all Medicaid-enrolled physicians, the Florida Agency for Health care Administration wants to remind you that eligible physicians must self-attest in order to receive the enhanced reimbursement. For information on the web portal attestation or paper attestation process, see the attached AHCA bulletin. While May 31st is the original deadline for retroactive reimbursement and claims reprocessing, it’s not too late to self-attest to be eligible for the increase and the retro claims adjustment.

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To receive full reimbursement allowed by the Affordable Care Act Primary Care Rate Increase for Vaccine Administration, please review the information in the attached AHCA Bulletin. Retroactive Reimbursement is also available during a one-time reprocessing scheduled for June of 2013.

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WellCare Health Plan has notified Health First Network that their vendor will be sending out the attached letters to each of our WellCare Physicians, providing them with a list of members with gaps in Pharmacy-related CMS Star Ratings. HFNI encourages Physicians to review their reports and consider the information on individual non-adherence and quality measures listed on their patients. Since the pharmacy benefit is a significant component of Part C Health Plans, and the primary objective of Part D plans, attention has shifted to Health Plan Pharmacy Departments to deliver winning strategies to improve health plans’ star ratings.

The five-star (STAR) Rating System is a quality and performance scoring method designed by the Center of Medicaid and Medicare Services (CMS), and used for certain health plans offering healthcare services to Medicare beneficiaries. This rating system is used to provide a scored assessment of individual quality components as well as aggregate overall performance of private Part C (Medicare Advantage [MA]) and/or Part D (Prescription Drug Plans [PDP]) plan(s). The Patient Protection and Affordable Care Act and the HealthCare Education and Reconciliation Act of 2010 (the Affordable Care Act) introduced quality-based payments and quality bonus payments (QBPs) as an incentive to encourage these health plans to accelerate the implementation of quality program improvements.

Based on a three-year CMS demonstration project from 2012 to 2014, plans achieving or exceeding the “average performer” rating of 3 stars or better in its overall star ratings will receive bonus payment percentages based on their overall STAR rating. After this demonstration project is completed in 2014, bonus payments will only be awarded to plans with at least 4 stars.

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Health First Network would like to Congratulate both Sacred Heart Health Systems and Baptist HealthCare for being named on the list of the nation’s 100 Top Hospitals® by Truven Health Analytics.

The Truven Health 100 Top Hospitals® study identifies the top U.S. acute-care hospitals by using a set of measures that evaluate performance, excellence in clinical care, patient perception of care, operational efficiency, and financial stability

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The Health First Network Management Team, Richard Tuten, Dr. William Whibbs, Jenny Caillouet and Pat Ast recently attended a community forum, the Community Health Summit, an initiative sponsored by the Partnership for a Healthy Community.

The Mission of the Partnership for a Healthy Community is to periodically conduct comprehensive health status assessments, and to advance, support or promote collaborative initiatives to improve health and quality of life for residents of Escambia County and Santa Rosa County in Northwest Florida.

Community leaders in healthcare, education, economics, and research, came together to discuss findings from the 2012 assessment and to discuss initiatives to address concerns in key areas. Among the facts learned were the following:
1.) The United States ranks at or near the bottom among the world’s 17 developed nations in key areas of health.
2.) Florida ranks in the bottom third of all U.S. states in key indexes of health and well-being.
3.) Based on 230+ health indicators, results for Escambia and Santa Rosa Counties do not compare favorably with those for peer counties (most similar demographically/socio-economically) of the State of Florida as a whole, and the magnitude of difference is cause for public concern.
4.) Escambia County ranks 55th in overall health among Florida’s 67 counties and the Escambia/Santa Rosa areas, last among the state’s 17 Metropolitan Statistical Areas.

A take-away from the Summit was the realization that Community leaders are committed to address these issues to build a healthier community and a healthier economy for residents.


The Gulf Coast Falls Prevention Coalition, a Florida Department of Elder Affairs sub-committee composed of volunteers from local and statewide healthcare agencies, including local Home Health Agencies, Hospitals, Health First Network, the Area Agency on Aging and Escambia Council on Aging, recently held a health fair and health education event on Fall Risk and Health Risk Awareness for Seniors at the East Brent Baptist Church on Davis Highway.

Health Care Screenings that were provided included Vision, Hearing, Osteoporosis, Vascular Screenings, Medication Safety, Diabetic Foot Checks, Blood Pressure, Balance - Sit to Stand and others. Educational materials were available to determine if a senior was at risk for Falls. One in three seniors age 65 and older fall each year.

Taking blood pressures at the event were Pat Ast, RN, Director of Health Services for Health First Network, and ACO Care Coordinators Janet Blough-Black, RN, and Pam Shelton, RN.


Health First Network would like to welcome the most recent physicians to join the Network:
Jeffrey Noon, DC - Chiropractic
Tammy Pruse, DO - Family Practice
Nir Hus, M.D, - General Surgery
Richard Matthews, M.D. - Family Practice

** To determine which health plans each physician is participating in check the “Find A Doctor” section on the HFNI website.