IPA Presentation March 30, 2022 Introduction
Description: IPA Presentation March 30, 2022 Introduction Family Choice is committed to following: Keeping providers well-informed Excellence care coordination to members Concierge services to both providers members Phone 1: 800-611-0111 Phone 2:
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slide1. IPA Presentation
March 30, 2022<br>
slide2. Introduction Family Choice is committed to following:
Keeping providers well-informed
Excellence care coordination to members
Concierge services to both providers & members
Phone 1: 800-611-0111
Phone 2: 818-817-1623
Fax: 818-817-5000<br>
slide3. Changes, Challenges, and Crisis COVID-19 (Delta, Omicron, Subvariant BA.2)
Inflation
Ukraine War (Increases in Fuel & Gas Prices)<br>
slide4. Caloptima vs. Kaiser Permanente Robust IT department
All-inclusive services system
Restricted panel of specialists and primary care physicians
Cherry-pick Members<br>
slide5. Calopitma recent press release Easy Access (Same Day Authorization of Specialized Services)
Same Day Processing Claims (Expansion of PCP and SPC Panel)
Street Medicine
Cal-Aim<br>
slide6. Family choice updates Family Choice Application for Restricted Knox Keene (RKK)
Network Adequacy (Contract with other OC Hospitals & Expansion of Providers Panel)
Additional CAP for Providers who serve members with mental health illnesses and homelessness. (Submit Encounter Data)
Merit-Based Incentive Distribution<br>
slide7. AGENDA Introduction
Family Choice Initiatives
PCP Care Coordination
Referral and Follow-up for Specialty Visits<br>
slide8. Overview: Family Choice Initiatives Family Choice has undertaken several initiatives in response to the CalOptima rates cuts:
Reducing PCP cap
Ensuring VSP is paying for routine eye exams, especially diabetic screening
Scrutinizing use of ancillary services—PT repeatedly and routinely asks your office to request thousands of dollars of services
Eliminating routine approval of high acuity codes—99204, 99205, 99215, 99245 and 99255—these will require your office to submit notes
Specialty/ancillary self-referral will require medical justification that demonstrates care cannot be delivered by the member’s PCP
Increasing HEDIS payments and patient satisfaction
Improving RAF scores through improved documentation<br>
slide9. Overview: Family Choice Initiatives Eliminating routine approval of high acuity codes—99204, 99205, 99215, 99245 and 99255—these will require PCP office to submit notes
99204: a comprehensive examination; medical decision making of moderate complexity. Counseling and/ or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.<br>
slide10. Overview: Family Choice Initiatives Fraud, Waste and Abuse:
Fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get money. Waste is when someone overuses health services carelessly. And abuse happens when best medical practices aren't followed, leading to expenses and treatments that aren't needed.<br>
slide11. Overview: Family Choice Initiatives Neutral/cost-based budgeting:
One strategy for controlling specialty/ancillary costs is to set a target for the specialty and adjust the fee schedule as utilization varies
Fee schedule x utilization = total cost
Another strategy is to narrow the network and capitate the specialty
One of these strategies needs to be adopted if high volume/high cost specialties—Ophthalmology, Cardiology and PT—continue to grow at unsustainable rates<br>
slide12. PCP Care coordination PCP care coordination is the backbone of managed care and the strength of FCMG’s continued success
Reduces readmissions
Avoids duplication of services
Eliminates unnecessary ED utilization
Enhances HEDIS scores
Ensures care is comprehensive and effective
Improves patient satisfaction
PCP engagement tracked through submission of encounter data<br>
slide13. PCP Care coordination To ensure care coordination is taking place, FCHN allows 2 specialty visits per authorization and 12 ancillary Units (97110--3 hours of PT)
Additional requests for services should involve a PCP visit
Specialists need to submit notes back to the PCP with directions for follow up or additional services required<br>
slide14. Referral and follow up for specialty visits Direct referral to network specialists was always intended to cover two visits
Expectation that PCPs will re-engage at that point with specialty guidance
PCPs routinely being asked to authorization 4-6 specialty visits
PCPs are expected to more closely monitor their members<br>
slide15. Evaluation form Please fill out the evaluation form and return it to Family Choice within 30 days to receive the meeting stipend.<br>
slide16. Q&A SESSION<br>
March 30, 2022<br>
slide2. Introduction Family Choice is committed to following:
Keeping providers well-informed
Excellence care coordination to members
Concierge services to both providers & members
Phone 1: 800-611-0111
Phone 2: 818-817-1623
Fax: 818-817-5000<br>
slide3. Changes, Challenges, and Crisis COVID-19 (Delta, Omicron, Subvariant BA.2)
Inflation
Ukraine War (Increases in Fuel & Gas Prices)<br>
slide4. Caloptima vs. Kaiser Permanente Robust IT department
All-inclusive services system
Restricted panel of specialists and primary care physicians
Cherry-pick Members<br>
slide5. Calopitma recent press release Easy Access (Same Day Authorization of Specialized Services)
Same Day Processing Claims (Expansion of PCP and SPC Panel)
Street Medicine
Cal-Aim<br>
slide6. Family choice updates Family Choice Application for Restricted Knox Keene (RKK)
Network Adequacy (Contract with other OC Hospitals & Expansion of Providers Panel)
Additional CAP for Providers who serve members with mental health illnesses and homelessness. (Submit Encounter Data)
Merit-Based Incentive Distribution<br>
slide7. AGENDA Introduction
Family Choice Initiatives
PCP Care Coordination
Referral and Follow-up for Specialty Visits<br>
slide8. Overview: Family Choice Initiatives Family Choice has undertaken several initiatives in response to the CalOptima rates cuts:
Reducing PCP cap
Ensuring VSP is paying for routine eye exams, especially diabetic screening
Scrutinizing use of ancillary services—PT repeatedly and routinely asks your office to request thousands of dollars of services
Eliminating routine approval of high acuity codes—99204, 99205, 99215, 99245 and 99255—these will require your office to submit notes
Specialty/ancillary self-referral will require medical justification that demonstrates care cannot be delivered by the member’s PCP
Increasing HEDIS payments and patient satisfaction
Improving RAF scores through improved documentation<br>
slide9. Overview: Family Choice Initiatives Eliminating routine approval of high acuity codes—99204, 99205, 99215, 99245 and 99255—these will require PCP office to submit notes
99204: a comprehensive examination; medical decision making of moderate complexity. Counseling and/ or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.<br>
slide10. Overview: Family Choice Initiatives Fraud, Waste and Abuse:
Fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get money. Waste is when someone overuses health services carelessly. And abuse happens when best medical practices aren't followed, leading to expenses and treatments that aren't needed.<br>
slide11. Overview: Family Choice Initiatives Neutral/cost-based budgeting:
One strategy for controlling specialty/ancillary costs is to set a target for the specialty and adjust the fee schedule as utilization varies
Fee schedule x utilization = total cost
Another strategy is to narrow the network and capitate the specialty
One of these strategies needs to be adopted if high volume/high cost specialties—Ophthalmology, Cardiology and PT—continue to grow at unsustainable rates<br>
slide12. PCP Care coordination PCP care coordination is the backbone of managed care and the strength of FCMG’s continued success
Reduces readmissions
Avoids duplication of services
Eliminates unnecessary ED utilization
Enhances HEDIS scores
Ensures care is comprehensive and effective
Improves patient satisfaction
PCP engagement tracked through submission of encounter data<br>
slide13. PCP Care coordination To ensure care coordination is taking place, FCHN allows 2 specialty visits per authorization and 12 ancillary Units (97110--3 hours of PT)
Additional requests for services should involve a PCP visit
Specialists need to submit notes back to the PCP with directions for follow up or additional services required<br>
slide14. Referral and follow up for specialty visits Direct referral to network specialists was always intended to cover two visits
Expectation that PCPs will re-engage at that point with specialty guidance
PCPs routinely being asked to authorization 4-6 specialty visits
PCPs are expected to more closely monitor their members<br>
slide15. Evaluation form Please fill out the evaluation form and return it to Family Choice within 30 days to receive the meeting stipend.<br>
slide16. Q&A SESSION<br>