PRIMARY CARE PHYSICIAN – PROVIDER-DELIVERED CARE MANAGEMENT

ABOUT:

Engrained in the Blue Cross Blue Shield of Michigan (BCBSM) Patient Centered Medical Home (PCMH) program, Provider Delivered Care Management (PDCM) is a model where care management is provided within the primary care physicians’ practice by trained care managers. Multi-year studies demonstrated positive outcomes with care manager engagements within the practices. For example, those patients who engaged with care managers had reductions in costs, risk score, and readmissions.

The Physician Alliance aims to provide the necessary support to practices to ensure success in mainstreaming the integration of care managers into primary care practices, billing of the 13 PDCM codes, and building additional program criteria to increase revenue growth and improving the quality of care and patient satisfaction.

Blue Cross Blue Shield of Michigan (BCBSM) expanded its Provider Delivered Care Management (PDCM) participation to all Patient Centered Medical Home (PCMH) designated practices. PDCM is the mechanism used by BCBSM to reimburse for care management and care coordination activities for BCBSM members through the billing of care management codes.

  • PDCM care management billing was available since July 1, 2015 and is the payment methodology that will be used to support the CPC+ and SIM initiatives.
  • For practices to receive an additional 5% PDCM-PCP valued based reimburse (VBR):
    • The Physician Alliance (TPA) must attest each fall/winter on the practices’ behalf that the practices have met the eligibility requirements listed below:
      • The practice must have at least one physician that supports care management, and understands the PDCM program (A physician champion must be named).
      • The practice must have either:
        • A lead care manager who has successfully completed the BCBSM approved care manager training by June 30th of the first year of attestation. The care manager must receive the designated care management and self-management training in addition to obtaining an additional 12 hours of care management training annually.
        • A lead care manager must be either a registered nurse, licensed social worker, physician assistant and/or a nurse practitioner.

OR

  • A qualified healthcare professional who has successfully completed online PDCM training and 8 hours of additional clinical educational webinars annually.
    • The qualified healthcare professional must be either a clinical pharmacist, LPN, certified diabetes educator, registered dietician, masters of science-trained nutritionist, respiratory therapist, certified asthma educator, certified health educator specialist (bachelor’s degree or higher in health education, licensed professional counselor or licensed mental health counselor.
    • The qualified healthcare professional does NOT need to be supervised by an on-site by a lead care manager to bill care management codes however they must have access to a lead care manager.
    • QHP is not considered a lead care manager and therefore will not be able to bill for code G9001.
  • The practice must have a practice panel manager or PO clinical lead that will actively work to close gaps in care across the practice’s population (panel manager or PO clinical lead name must be provided to TPA as part of the attestation process). A panel manager is a clinical team member trained in panel management - the primary contact person for running gaps in care in the practice.
  • The practices must submit claims for a specific percentage per year for BCBSM commercial PDCM-eligible patients (January 1st –December 31st).
    • In 2018:  At least two paid claims are processed for 3% of the eligible BCBSM Michigan members (exclude members added under BDTC-hosted patients in 2017)

Although BDTC-hosted patients will not be counted in the denominator for 2018 attestation, if hosted patients do receive care management services and there is a paid claim, they will be counted in the numerator to meet the required touchpoint for the PDCM 5% VBR.

  • In 2019:  At least two paid claims are processed for 3% of all eligible BCBSM Michigan members (both Michigan and BDTC-hosted patients).
  • Practices should strive to engage all high complexity patients flagged in the monthly eligible lists as Blue Cross may soon require practices to engage a specific percentage of high complexity patients to qualify for the PDCM 5% VBR.
  • Codes included in the analysis are: HCPCS codes G9001, G9002, G9007, G9008, S0257 and CPT codes: 98961, 98962, 98966, 98967, 98968, 99487, 99489 and 99496.
  •  The 5% PDCM-PCP VBR will be assessed annually and will continue, start, or stop based on performance and reaching the required touch rate for the year.
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BENEFITS OF PARTICIPATION IN PDCM:

  • More money – earn an additional 5 % PDCM-PCP VBR
  • Increased revenue through reimbursement for care management services
  • Improve quality and increase the capture of pay for performance dollars
  • Reduce cost with care being provided in the lower cost settings
  • Add a trained care manager to expand the practice’s care team
  • Prepare your practice to manage risk
  • There is the potential to earn an additional 5% VBR if the practice qualifies as an Advanced Practice beginning in 2019. Details to be available at a later date.

Learn more about Provider Delivered Care Management, the benefits to your primary care practice and more : View the presentation

Additional resources:
Care management/PDCM billing and coding webinar presentation
BCBSM PDCM data dictionary information
How to open and reply to an encrypted email tip sheet

*Training information can be located here.

 

For more information on the Provider Delivered Care Management program, contact Fran Burley MSN RN CPHQ at (586) 498-3588 or email This email address is being protected from spambots. You need JavaScript enabled to view it..

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