IPA Presentation March 30, 2022 Introduction

Transcript:IPA Presentation March 30, 2022 Introduction:
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: 818-817-1623 Fax: 818-817-5000 Changes, Challenges, and Crisis COVID-19 (Delta, Omicron, Subvariant BA.2) Inflation Ukraine War (Increases in Fuel & Gas Prices) Caloptima vs. Kaiser Permanente Robust IT department All-inclusive services system Restricted panel of specialists and primary care physicians Cherry-pick Members 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 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 AGENDA Introduction Family Choice Initiatives PCP Care Coordination Referral and Follow-up for Specialty Visits 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 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. 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. Overview: Family Choice Initiatives Neutral/cost-based budgeting: One strategy for controlling specialty/ancillary costs is to set