1. MGMA – Tuscaloosa
April 24, 2013
William F. Cockrell, FACMPE

2. Personal
 32 years of medical management experience
 FACMPE
 Healthcare organizations - Small primary care, large
multi-specialty, hospital network, large single specialty
 Formed Cockrell and Associates, LLC in 2009
 Focus on
 Practice management
 Network development

3. Incentives Prior to 2010
 See more patients
 Do more tests – appropriately
 Hope fees did not get cut

4. What Happened in 2010
 The Accountable Care Act (ACA)
 Problems and Concerns but It’s Here to Stay
 Financially, the FFS Model Cannot be Sustained
 How Do You Argue with High Quality / Low Cost
 So Let’s look for Opportunities

5. Today’s, and
Tomorrow’s, Opportunities
 Medicare
 Medicaid
 BCBS
 Electronic Medical Records / Meaningful Use
 Operations
 Future

7. The Three Levels of Incentives
 1. Just cause we like you
 2. We like you but we need you to prove you like us
 3. We think we like you but you need to prove that we
should like you

8. What Base Do We Use
 Cognitive encounters for Primary Care
 Major surgery codes for general surgeons
 Specialty codes
 New measurements
 Quality
 Cost

9. Primary Care Base for Bonuses
 Typically, Primary care bonuses are based on these:
 Office/outpatient visits, CPT 99201-99215;
 Nursing facility services, CPT 99304-99318;
 Domiciliary, rest home, or custodial care services, CPT 99324-
99340; and
 Home services, CPT 99341-99350.
 In many cases, surgery and other non-diagnostic codes
are included
 BCBS list is 20 pages long

10. Cause We Like You Category

11. Medicare
 Primary Care Incentive Payment Program
 Part of the ACA
 Runs from2011 to 2015
 10% bonus on to of the fee schedule payment for select
primary care services (earlier slide)
 60% of billings must fall in the primary care services
category

12. Medicare
 HPSA General
 Shortage area
 10% bonus
 All specialties plus
chiropractors, optometrists, podiatrists, medical tele-
consults

13. Medicare
 HPSA - General Surgery
 HPSA Surgical Incentive Payment (HSIP)
 1/1/2011 – 12/31/2015
 Covers major surgical procedures in a geographic HPSA
 Additional 10% on top of the regular HPSA bonus

14. We Like You but We Need You to
Prove You Like Us Category

15. Medicare
 Transitional Care Management
 Effective 1/1/2013
 CPT Codes 99495 and 99496
 Used to report physician or qualifying non-physician
care management services following a discharge for a
hospital, SNF or CMHC stay
 30 day transition period

16. Medicare
 Transitional Care Management
 Requires
 Direct, telephone or electronic contact with the patient or care
giver within two days of discharge
 Medical decision making of moderate (CPT 99495) or high
(CPT 99496) complexity
 Face to face patient visit within 14 days (CPT 99495) or seven
days (CPT 99496) of discharge
 99495 about $150.00
 99496 about $200.00

17. BCBS
 2012 Primary Care Value-Based Payment Program
 Three Elements
 Efficiency (5% bonus)
 Quantitative (5% bonus)
 Qualitative (5% bonus)

18. BCBS
 Qualifiers
 PMD doctor for at least one year in good standing
 Must practice Geriatrics, Family Practice, Internal
Medicine, General Medicine or Pediatric Medicine
 Must utilize ETF
 Must file claims electronically
 Must have 24 hour on call coverage
 Must be Board Certified
 Must participate in all applicable BCBS of Alabama
Networks

19. Efficiency
 Overall Score of 70 is required
 Generic drug utilization performance
 >90% = 75 points
 88 – 89% = 60 points
 86 – 87% = 45 points
 Preferred drug utilization performance
 >90% = 25 points
 88 – 89% = 20 points
 86 – 87% = 15 points

20. Quantitative
 Overall score of 70 is required
 Physician Quality Indicators
 > 2.5 = 75 points
 2.25 – 2.49 = 60 points
 2.0 – 2.24 = 45 points
 Satisfaction
 3 Stars = 25 Points
 2 Stars = 20 points

21. Qualitative
 Overall score of 70 is required
 Patient Centered Medical Home (PCMH)
 NCQA Level 3 = 75 points
 NCQA Level 2 = 60 points
 NCQA Level 1 = 45 points
 NCQA Diabetes = 45 points
 Active E-Prescriber = 25 points

23. Electronic Medical Records /
Meaningful Use
 Medicare incentives
 Medicaid incentives
 Penalties
 Meaningful Use

24. Operations
 PQRS
 Should already be on board
 A basis for future programs
 Coding
 Document
 Credentialing
 Don’t be late
 Be complete

26. Other
 Medicare Value Based Modifier
 ACO and other Shared Savings
 Other

27. Medicare Value Based Modifier
 Supports the transformation of Medicare from a
passive payer to an active purchaser of higher
quality, more efficient healthcare
 Specific to Fee-For-Service (FFS) Medicare
 It’s base is PQRS
 Two primary components
 Physician Quality and Resource Use Reports (QRURs)
 A Value Based Modifier
 Mandated to start in 2015 based on 2013 data

28. Medicare Value Based Modifier
 2013 – Focused on groups with 25 or more eligible
providers filing under a single tax identification
number (TIN) who will receive QRURs
 2015 – Groups with 100 or more eleigible providers
filing under the same TIN will be subject to the
modifier based on their performance in 2013
 2017 - Expands to all physicians who participate if FFS
Medicare

29. ACO’s and Shared Savings
 Shared savings are starting on the hospital level
 Accountable Care Organizations (ACO’s) (excluded
from the Value Based Modifier Program)
 Not any real traction in Alabama, yet
 Primary care driven but control could be through a
hospital or large specialty network

30. So, why are these last two
considered a positive?
 Information is power
 It’s time to get our information together now and
 Where it’s good – let everyone know
 Where it’s not good – fix it
 PCMH?
 Meaningful Use?
 Next up – NCQA is looking at Specialty Centered
Medical Homes (SCMH)

32. Operations
 PQRS
 Should already be on board
 A basis for future programs
 Coding
 Diagnoses
 Document
 Credentialing
 Don’t be late
 Be complete