The overall
goal of the incentive plan is:
- to
reward providers for the outstanding care you provide
for our members who, due to the nature of the program,
can be more time consuming, less compliant, and overall
more challenging than the general population, and
- to
encourage a seamless system of care by improving the quality
assurance activities that providers are required to participate
in anyway
Unlike
other incentive plans that have a performance based pay
plan, the focus is on Quality Assurance activities which
indirectly benefits the member in that we can better measure
the care they are receiving.
This
model does not force providers to compromise the care they
give our members as it is a quality versus clinical outcomes
based measurement.
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Unlike
other incentive plans that have a performance based pay
plan, the focus of Gold Choice is on Quality Assurance activities
which indirectly benefits the member in that we can better
measure the care they are receiving.
This
model does not force providers to compromise the care they
give our members as it is a quality versus clinical outcomes
based measurement.
The overall
goal of an incentive plan is:
- to
reward providers for the outstanding care you provide
for our members who, due to the nature of the program,
can be more time consuming, less compliant, and overall
more challenging than the general population, and
- to
encourage a seamless system of care by improving the quality
assurance activities that providers are required to participate
in anyway
Financial
rewards and potential earnings are based on panel size (number
of providers at each site) and number of members assigned
to each site. The 2008 budget is funded through the administrative
fee charged to providers. Because we have been notified
by the New York State Department of Health Bureau of Managed
Care financing that the current Medicaid capitation rates
for Gold Choice will be extended through June 30, 2009,
and we have not been able to give providers a cap increase
for 7 years, we wish to offer rewards to providers who serve
our membership.
Providers
will be paid at the site level (to agent with whom the agreement
is with) for quality assurance activities and targets as
described in this guide. No specific payment will be made
that is an inducement to reduce or limit medically necessary
services furnished to Gold Choice member. This incentive
arrangement means any payment under which a contractor may
receive additional funds over and above the capitation rates
they are paid.
All
providers are eligible to participate and eligibility for
incentive rewards is tied to specific membership based on
PCP assignment, number of providers at a given site, and
standards of care as outlined in the Gold Choice QAP.
Providers
are reimbursed quarterly separate from monthly capitation
payment. A report of which indicators were measured and
how the amount was tallied will be included. Criteria based
assessment is ongoing i.e. points are recorded as they are
received in an Access Database. The dollar amount each provider
receives is based on number of patients served and compliance
with guidelines and criteria.
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MEMBER
CARE MANAGEMENT
Integrated
Care Coordination Management
Because
Gold Choice is a partially captitated program we do not
receive information regarding any ancillary services. In
order to better assess if appropriate coordination of services
is being given to members with the goal of clinical linkages;
to monitor and encourage service delivery we will offer
incentives for providers who give us care coordination information.
This information will be used for the Chronic Disease Case
Management program, Mammography Case Management program,
and to monitor if specified standards of care are being
adhered to.
Once the information is received the information will be
put in the member’s electronic and paper file so that
if the member is in or will become a case management file
the information is available for the case manager.
Providers
will receive .25 point value for each care coordination
form is received via fax or mail, for one of our members.
Providers can use the Gold Choice triplicate form provided
or the information can be given on the providers script
pad as long as the referring provider ID information is
included.
Reimbursement
is based on how many members are assigned to the provider
site and how many notifications are received per member.
Clinical
Measure Scores
In order
to determine if guidelines for C/THP, Lead screening, HIV
screening, STD screening are being adhered to (if not a
referred service) an analysis of primary care encounter
data will be performed. A list of the specific diagnostic
codes will be provided to all providers prior to measurement.
Providers
will be given .25 points for each ICD-9-CM diagnostic code(s)
for selected clinical measure that is found by analysis
of primary care encounter data. Reimbursement is based on
how many members with specific indicators are assigned to
the provider site.
Physician
Self-Assessment (PSA)
Physician
self-assessments (PSA) are an effective and inexpensive
alternative to assess guideline adherence for standards
of care as outlined in the Gold Choice QAP. It also serves
as a useful tool to improve physician knowledge of best
practices as documented in current guidelines.
Providers
will receive points for completing the assessment and returning
it within required time-frames. PSA’s are validated
annually by auditing charts for 10% of the members for whom
the information was requested and comparing data provided.
Annual
Clinical Study (Chronic Kidney Disease for 2008) - 2 points
for every PSA returned within the required timeframe
Annual Appointment Availability PSA - 1 point for every
PSA
returned within the required timeframe
Child/Teen Health Plus Guidelines PSA-1 point for every
PSA
returned within the required timeframe
Diabetes
Telephonic Case management Request
In order
to better coordinate care for Diabetic members identified
and placed in Gold Choice case management it is necessary
to have open communication with the assigned PCP. Gold Choice
has a mechanism in place that identifies members with Diabetes
and works to coordinate with the PCP as well as other ancillary
providers in order to reach certain goals regarding the
member’s illness.
Providers will be given 1 point for each PSA related to
Diabetes Telephonic Case Management returned.
SMI
(Seriously Mentally Ill) Case Management Request
In order to better coordinate primary health and ancillary
services care for SMI members who are identified by the
Office of Mental Health and are enrolled with the Single
Point of Entry Program, is it necessary to have open communication
with the assigned PCP.
Providers will be given 1 point for every PSA related to
SMI Telephonic Case Management returned.
Roster
Fax Back
Due to the transient nature of this population it is necessary
to make every effort to keep current information on members.
Providers earn .25 point for each Gold Choice member whose
information (address and/or phone number) is updated using
information provided on the monthly provider roster. Roster
can be faxed or mailed back monthly. Potential points earned
is dependent on number of members assigned to PCP who have
an address of phone number change.
Hospitalization
Data Exchange
In order
to ensure proper coordination of care provider will be encouraged
to notify Gold Choice when one of its members has an ER
or inpatient hospital event. We identify members who utilize
the emergency room on a quarterly basis as a function of
QA. This is done in order to determine if primary care and
counseling linkages are necessary so the member can obtain
preventative care on a regular basis instead of using the
ER or to ensure proper follow up is coordinated.
Providers
will be given 1 point for each notification of ER or inpatient
hospital stay for each Gold Choice member. Providers can
use the Gold Choice form or their own and it can be faxed
or mailed. Potential points earned is dependent on number
of members assigned to PCP who have an ER or inpatient visit
reported to them.
Chart
Request
In order
to measure standards and performance goals for participating
providers they are rated on the Medical Record Review Standards
as outlined in the QAP.
Gold
Choice will reward the provider site 5 points for every
requested chart received within the requested timeframe.
Because chart reviews are a Quality Assurance requirement
5 points will be deducted each time a RN Case Manager must
travel to your site for review.
PROVIDER
RELATIONS
Educational
In-Services
Initially, the in-service is performed to provide an overview
of the medical record standards of care, clinical studies,
clinical guidelines for STD/HIV/Lead poisoning/CTHP, credentialing,
contracts, and the case management protocols. Addition in-services
are scheduled to keep site abreast of any changes and train
new staff.
Provider sites will be awarded 5 points for each educational
in-service that is scheduled with a provider office. Potential
points is 15 per year (3 in-services per office per year
maximum).
Contract
related Correspondences
To assure documentation is received in a timely manner so
there is no interruption in care for members incentives
will be offered.
Provider will be awarded 2 points for each contract or addendum
returned after the first request. Two points will be deducted
for each document not received each month until document
is received. If not received within three months Gold Choice
may elect to terminate the agreement.
Credentialing
In order to ensure, in accordance with Article 44 of the
Public Health Law, that all persons providing care and services
for GOLD CHOICE membership satisfy all applicable licensing,
certification or qualification requirements under New York
State law, providers are required to complete a written
application process. This includes documentation to support
the primary verification sources, and that documentation
is received in a timely manner.
Provider sites will be awarded 5 points for a complete new
provider application including all signatures and documents.
Maximum points awarded is 25 per site per year. Incomplete
applications will be returned as “unprocessed”
Recredentialing
To assure documentation is received in a timely manner so
there is no interruption in care for members.
Providers will receive 1 point per requested document with
the required timeframe (via fax or mail). Because recredentialing
requests are a Quality Assurance requirement 1 point will
be deducted after the third request and for each month until
the document is received. If the document is not received
within 3months the provider’s panel will be closed.
Electronically Submitted Encounter Data
To assure data is received in a timely manner for reporting
purposes incentives will be offered
Provider will be awarded 5 points per quarter for encounter
data via email, disk or travel drive. As this a quality
assurance requirement if no encounter data received by two
weeks after the of the quarter and there is no attestation
that there were no Gold Choice encounters, 3 points will
be deducted each quarter. If no data is received after three
consecutive quarters capitation payments will be withheld.
