Objective 1 - Provider Reimbursement -Kong Ch 4 Provider Network

Question 1

Reasons why a health plan wants to contract with providers

Answer 1

(also referred to as contracting goals) 1. Obtain favorable pricing (less than full billed amounts) 2. Obtain payment terms that result in an underwriting gain 3. Get the provider to agree to provide services to the plan’s members 4. Meet service area access standards required by the states and Medicare 5. Obtain contractual agreement for several clauses, may of which are required by the states and Medicare. The provider agrees to: a) Submit claims directly to the plan, not the member b) Not balance bill the member for any amount above the agreed-upon payment terms c) Hold harmless the member (not bill for any amounts owed by the plan) d) Cooperate with the plan’s utilization management program e) Cooperate with the plan’s quality management program f) Give the plan the right to audit clinical and billing data for care provided to plan members g) Not discriminate (and other similar requirements)

Question 2

Reasons why a provider wants to contract with a health plan

Answer 2

(also referred to as contracting goals) 1. Obtain favorable pricing when in a strong negotiating position 2. Ensure that it will not be excluded from the network of a large payer 3. Receive direct payment from the plan, thereby avoiding the need to collect from the patient 4. Receive timely payment (usually 30 days or less) 5. Have plan members directed or steered to it 6. Not lose business (or medical staff) as a payer steers members to others who are contracted providers 7. Receive defined rights around disputing claims and payments

Question 3

Factors impacting access needs of a plan

Answer 3

1. Network expansion
2. HMO Service Area expansion
3. Recruiting for new PCPs when current PCPs are no longer accecpting new patients.
4. Improve access to areas with high membership.
5. Networks for new plan types
6. Satisfy regulatory requirements for PCP access.
7. Contracting physicians who are part of a new hospital in the network.

Question 4

Service area Considerations in contracting

Answer 4

1. HMOs must have sufficient access to providers to be licensed.
2. PPOs may not have the same limitations as HMOs
3. State and federal law and some large employers have minimum access requirements.
4. Defined by distance and number of providers
5. Different requirements for PCPs and SPECs.
6. Minimum Access Requirements Defined by
   
   1. Distance
   2. # of providers
   3. Rural vs Urban
   4. Length of time to get an appointment

Question 5

Rental Networks

Answer 5

1. BCBS Share networks nationwide to appear as 1 large network
2. Rental networks are commercial PPOs that sell access to payers and self funded groups for PCP, hospital and ancillary services
3. Services received in the rental network are paid at the contracted rate
4. Non competing health plans in different areas may rent their networks to each other
5. Rental networks logo appears on the member ID cards

Question 6

National Physician Identifier - NPI

Answer 6

1. Provision of HIPAA established in 2008
2. Uniquie 10 digit number identifies the who and what for a given physician
3. Used for all provider transactions
4. Physicians can work for groups with different NPIs

Question 7

General considerations when contracting with physicians or other professionals

Answer 7

1. Most physicians contract with a managed care plan
2. High PCP turnover raes lower patient satisfaction quality measures and preventive care measures
3. Plan access needs
   
   1. ability to accept new patients
   2. waiting time for an appointment
   3. HMO Focus - physician to member ratio
   4. PPO Focus - sufficient # of providers for major specialties

Question 8

Types of physicians and other professional providers

Answer 8

1. Primary care physicians (PCPs) and specialty care physicians (SCPs) - for traditional HMOs, the distinction between PCP and SCP is very important because the PCP acts as a gatekeeper and must authorize any visits to a specialist 2. Hospital-based physicians - specialties include radiology, anesthesiology, pathology, emergency medicine, and hospitalist. These physicians often have exclusive rights at a hospital, so they are reluctant to contract for anything less than full charges. 3. Nonphysicians or mid-level practitioners that provider primary care - the most common are physician assistants and nurse practitioners. These are a great asset in managed care because they deliver excellent primary care, tend to spend more time with patients, and are well accepted by most members 4, Mental health providers 5. Other types of professionals - podiatrists, dentists, orthodontists, optometrists, chiropractors, physical therapists, occupational therapists, nutritionists, acupuncturists, audiologists, respiratory therapists, and home health care providers

Question 9

Types of mental health providers

Answer 9

1. Psychiatrist - a physician who specializes in mental health and is able to prescribe drugs 2. Psychologist - has a doctoral degree in psychology and two years of supervised professional experience 3. Clinical social worker - a counselor with a master’s degree in social work 4. Licensed professional counselor - has a master’s degree in psychology, counseling, or a related field 5. Certified alcohol and drug abuse counselor - has specific clinical training in alcohol and drug abuse and provides individual and group counseling 6. Psychiatric nurse practitioner or nurse psychotherapist - a registered nurse practitioner with special training in psychiatric and mental health nursing 7. Marital and family therapist - a counselor with a master’s degree and special training in marital and family therapy

Question 10

Contracting considerations for different types of physician groups

Answer 10

1. Individual physicians - advantage is the direct relationship with the physician. Disadvantage is the effort to maintain the relationship is large for just one physician. 2. Medical groups - generally small (2-10), contract is with entire group,advantage is the same contracting effort yields a higher number of physicians. Disadvantage is that if the relationship is terminated then there is greater disruption in patient care. 3. Independent practice associations (IPAs) a) Advantages: a large number of providers come along with the contract, the IPA may accept more financial risk, and some IPAs perform network management credentialing, and medical management b) Disadvantages: the IPA can hold a considerable portion of the delivery system hostage to negotiations, and the plan’s ability to selection and deselect individual physicians is limited 4. Faculty practice plans (medical groups that are organized around teaching programs) a) Advantages: these programs provide highly-specialized care and they add prestige to the plan by virtue of their reputation for quality care b) Challenges include: tend to be less cost effective in their practice styles, and they are not set up for case management, so care is not well coordinated, claims and encounter data is not tracked by the physician, potential anti-selection 5. Physicians in integrated deliver systems (IDSs) - there are two types: a) Hospital systems that affiliate with private physicians b) Hospital systems that employ physicians - these often have substantial negotiating leverage 6. Patient-centered medical homes - these coordinate all care for a group of patients 7. Specialty management companies - these focus on managing very specialized services using physicians (e.g., single-specialty case management of neonatal care)

Question 11

Capabilities of a well-functioning contract management system

Answer 11

1. Identify network gaps or where provider recruiting is most needed 2. Track recruiting efforts, provide reminders, and generate recruiting reports 3. Generate new contract blanks and new contracts with information filled in 4. Store copies of different versions of any provider’s contract 5. Track and report contract changes for each provider 6. Track and manage permissions and sign-offs on contracts 7. Store images of signed documents and convert imaged documents into machine-readable formats 8. Support an entirely paperless contracting process 9. Provider early notification or reminders for upcoming actions such as re-credentialing or re-negotiations 10. Direct electronic feed of required demographic information to other internal functions 11. Direct electronic feed of market-facing systems such as internet physician searches 12. Be searchable on multiple attributes 13. Analyze the potential impact of changes in contract terms

Question 12

Reasons to outsource contracting and network maintenance

Answer 12

1. Continual pressure to reduce admin costs
2. to service specialized products such as Medicare Advantage and Medicaid
3. To obtain product knowledge or sufficient staff necessary to perform recruiting and network management

Question 13

Elements of a typical physician credentialing application

Answer 13

1. Demographics, licenses, and other identifiers (such as national provider identifier) 2. Education, training, and specialties 3. Practice details - such as services provided and office hours 4. Billing and remittance information 5. Hospital admitting privileges 6. Professional liability insurance 7. Work history and references 8. Disclosure questions - such as suspension from government programs or felony convictions 9. Images of supporting documents - such as a state license certificate

Question 14

Sources of Credentialing Verification

Answer 14

1. School confirmation of graduation from med school
2. State licensing agency to validate current medical license
3. Residency training program to verify completion of program
4. Board certification from appropriate board
5. Disciplinary action, license expiration, mailpractice insurance and member complaints and grievences should be monitored

Question 15

CAHQ Universal Provider data source

Answer 15

1. Provider self reporting
2. Information controlled and attested to by the provider
3. Verified by CVO
4. Provides ongoing network monitoring
   
   1. Disciplinary action
   2. Member complaints
   3. malpractice events
   4. license or specialty expiration
   5. Utilization Review

Question 16

National Practitioner Data Bank

Answer 16

1. Info clearing house that collects and releases all licesnure actions taken against a provider or health care entity as well as negative actions taken by peer review and private accreditation organizations related to quality of care
2. Created by HCQIA
3. Protects physicians doing peer review and credentialing from retaliatory lawsuits
4. Plan or hospital must use or face potential liabilities
   
   1. Hospitals must query every 2 years
   2. Reasons for a plan to query
      
      1. New contract with a provider
      2. considering a new medical staff applicant
      3. Peer review activities

Question 17

New Physician Orientation topics

Answer 17

1. Policy and procedues for authorizations
2. Info on QM program and peer review
3. Credentialing and recredentialing requirements
4. Reviewing necessary forms and paperwork
5. Plan member greivence procedures
6. Payment rates and schedules
7. Plan contract information
8. Network info and contracted hospitals
   
   1. formularies
   2. contracted facilities
   3. ancillary services
   4. centers of excellence

Question 18

Reasons to perform On-site Office Evaluations

Answer 18

1. NCQA requires an initial onsite eval for all PCPs, OB/GYN and high volume behavioral health providers
2. URAC requires HMOs to conduct initial onsite eval of all physicians as part of the initial credentialing
3. Primary Items evaluatied
   
   1. Ability to accept new patients
   2. Office ambiance
4. May be delagated to an IDS or IPA
5. PPO may not perform and office eval relying on min requirements
6. can be triggered by member complaints

Question 19

Reason for an onsite visits with existing providers

Answer 19

1. Poor attitudes in open panel HMOs or PPOs with individual or small group contracts
2. Large groups and IDS physicians have more contract negotiation leverage
3. Encourage physician testing of new payment methods
4. Changes in utilization patterns and UM compliance may be an early warning sign of a problem
5. Monitor member complaints

Question 20

Physician removal from a network and reasons why to remove

Answer 20

1. Sanctions for poor quality - must follow HCQIA process
   
   1. most serious
2. High cost practice style
   
   1. work on performance improvement program
   2. if no change then consider termination
3. Some states have a “due Process” for terming PCPs
   
   1. must show cause
   2. provide reason in writing
   3. allow for appeal
   4. allow for cost/util perf measure review
4. Types of disciplinary action before sanctions
   
   1. verbal warning called “ticketing”
   2. Disciplinary letter
5. Reasons not to remove a physician
   
   1. Member disruption and dissatisfaction
   2. Strategic location

Question 21

Types of health care facilities

Answer 21

1. Community-based single acute care hospitals 2. Multihospital systems (MHSs) - consolidation has led to most hospitals being part of an MHS, which gives them negotiating leverage 3. For-profit national hospital companies - because these hospitals are owned by national companies, they have much less local autonomy 4. Specialized hospitals - these provide care to only a certain type of patient (e.g., children’s hospitals and psychiatric hospitals) 5. Physician-owned single-specialty hospitals - these restrict themselves to elective procedures within a single specialty so they are not equipped to handle emergencies and severe conditions 6. Accountable care organizations - these coordinate care for designated Medicare FFS beneficiaries and participate in a shared savings program 7. Government hospitals - may be county-run, state-run, or federal 8. Subacute care (skilled or intermediate nursing facilities) - these are well suited for prolonged convalescence or recovery cases. The cost for a bed day is much less than in an acute-care hospital 9. Ambulatory surgical centers (ASCs) and procedure centers - are typically equipped to handle only routine cases 10. Hospice - a broad term referring to health care services provided at the end of life, which may be at an inpatient facility, ambulatory facility, or no facility 11. Retail health clinics - small clinics usually associated with a retail store (such as Target or Walgreens). Provide basic primary care services, such as immunizations and preventive screenings. 12. Urgent care centers - a hybrid of a low-level emergency department and a PCP practice 13. Other types of ambulatory facilities - including centers for birthing, community health, diagnostic imaging, occupational health, pain management, and women’s health

Question 22

Contracting considerations for different types of facilities

Answer 22

1. Comm Based Single Acute Care Hospital
   
   1. Dominate in rural areas
   2. can be difficult to contract with if only name in the game
   3. less technilogically advanced, lower cost
   4. may give small discounts as a trade-off on other terms
   5. can be labled an essential provider by Medicare Advantage
   6. Larger competitors lead to easier contracting
2. Multi-hospital system
   
   1. High negotiating leverage, leverage inreased if employing physicians
   2. Disadvantage to payers - Ordering higher cost services provided by the hospital system
   3. Advantage to payers
      
      1. addresses access needs
      2. professionally managed admin and EHR
      3. collaboration on new payment structures
      4. UM can be performed by the hospital system
      5. Can lead to creation of a private lable network
3. For Profit Hospital
   
   1. Consist of purchased failing hospitals
   2. Mainly owened by companies with hospitals in multiple locations
   3. Contracted at a national level
4. Specialized Hospitals
   
   1. High contracting rates due to limited competition
   2. Rehab hospitals have lower rates
5. Physician Owned Single Specialty
   
   1. can not handle patients with many and severe conditions
   2. ownership leads to high utilization
   3. expansion of these limited by the ACA
   4. Lower prices
   5. willing to accept capitation

Question 23

Negotiating and contract process

Answer 23

1. Must decide willingness to limit plan choices - Employers are becoming more willing to limit choice to save costs
2. Fewer providers in the network gives the plan better negotiating leverage
3. Most plans try to contract with most hospitals
4. Usually a proposal/conunterproposal process
5. First year is the base and future years are negotiated as a percentage change from base year costs
6. Proposals evaluated via financial models

Question 24

Facility goals when contracting with a payer

Answer 24

1. Most favorable terms as possible
2. Ensure network inclusion
3. Have plan members directed to them
4. Maintain staff - competetive advantage for recruiting
5. Direct payment from the plan
6. Timely payment
7. Defined rights regarding disputes

Question 25

Payer goals when contracting with facilities

Answer 25

1. Most favorable pricing for and highest provider participation for IN, OUT, ANC, and HBPS
2. Payment terms that lead to UW gain
3. Meet access standards
4. Ensure no member billing
5. Obtain contractual agreement on several clauses
   
   1. No balance billing
   2. Hold harmless for members
   3. Cooperation with plan QM programs
   4. Right to audit clinical and billing data
   5. non-discrimination

Question 26

Facility Credentialing Considerations

Answer 26

1. Rely on state agencies to ensure standards are met
2. Hospital accredidation performed by the joint commission
   
   1. AAAHC - Ambulatory facilities
   2. HFAP - Osteopathic facilities
   3. DNV - Hospitals
   4. AAAASF - Ambulatory facilitys
   5. CHAP - community services, hospice, home health
   6. ACHC - community services
   7. NCQA and URAC - PCMH and ACOs

Question 27

Types of ancillary services

Answer 27

1. Diagnostic a) Laboratory b) Imaging (such as x-rays and MRIs) c) Electrocardiography d) Cardiac testing 2. Therapeutic a) Cardiac rehabilitation b) Noncardiac rehabilitation c) Physical therapy d) Occupational therapy e) Speech therapy f) Other long-term therapeutic services 3. Pharmacy 4. Ambulance and medical transportation services

Question 28

Ancilary Service Contracting

Answer 28

1. Limited number of contracted providers due to elective nature of services
2. Cost and utilization managed through favorable contracting terms
3. Only contract with diagnostic service companies that require physician orders
4. If PCP owned - results in higher utilization, ways to combat
   
   1. Prohibit self referral
   2. Lower the payment rate
   3. Include in cap payment