Just Announced: The 2023 Provider Incentive Program

HCP is pleased to offer the 2023 Provider Incentive Program. The purpose of this incentive is to reward providers for delivering high-quality healthcare, properly documenting care in their patients’ medical records, and submitting the associated claim and encounter data.

Medicare Advantage Incentive

Part 1: Complete Annual Wellness Visits (AWVs)

The purpose of this incentive is to reward providers for delivering high quality preventative healthcare with proper documentation. An Annual Wellness Visit is the perfect time to review medical history, risk factors for disease, medications, current health status, and develop a plan to keep your patient healthy.

Documentation Submission Criteria:

• Requires completed HCP AWV form with corresponding G-Code billed for same date of service within calendar year 2023.
• Acceptable codes include:
  • G0402 – IPPE (Welcome to Medicare)
  • G0438 – Initial AWV
  • G0439 – Subsequent (yearly) AWV
• Your chart notes must include patient name and DOB, along with provider signature with credentials and date of service.

Part 2: Minimum of 3 Visits per Patient

Medicare-aged patients who see their PCP at a regular, pre-determined cadence (i.e. quarterly) experience improved disease management and higher rates of preventative screenings. These patients are less likely to go to the ED or get admitted with ambulatory-sensitive or newly emergent symptoms.

Patient must be seen by PCP 3 or more times within the calendar year.

Documentation Submission Criteria:

• One visit must be a Complete Physical Exam
  • 99381-99387 – New Patient Annual Physical Exam
  • 99391-99397 – Established Patient Annual Physical Exam
• Measured via patient claims during calendar year

Part 3: Patient Post-Discharge Visits

Patients who receive PCP follow-up and medication reconciliation within 7 days of hospital discharge are significantly less likely to be readmitted.

Documentation Submission Criteria:

• 99495 (includes medication reconciliation) within 7 days of patient discharge
• 99496 (includes medication reconciliation) within 7 days of patient discharge
• 99483 for patients with cognitive impairment resulting in a written care plan (includes medication reconciliation) within 7 days of patient discharge
• Office visit code + 1111F (medication reconciliation) within 7 days

Part 4: STAR Measures Closed

• Breast Cancer Screening
• Care for Older Adults – Pain Assessment
• Care for Older Adults – Medication Review
• Colorectal Cancer Screening
• Controlling High Blood Pressure
• Diabetes Care – Blood Sugar Controlled (A1c<9)
• Diabetes Care – Retinal Eye Exam
• Medication Adherence for Cholesterol (Statins)
• Medication Adherence for Diabetes Medications
• Medication Adherence for Hypertension
• Medication Reconciliation Post-Discharge
• Statin Therapy for Patients with Cardiovascular Disease
• Statin Use in Persons with Diabetes

Eligible Submission:

Measures are paid as patients achieve compliance in accordance with current HEDIS® specifications.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

Primary Care Physician Gain Sharing

Gain share positions the PCP as a partner in value without downside financial exposure. The goal is to reward providers for their contributions to improving care and reducing preventable medical costs.

Criteria:

• HCP exceeds Medicare Advantage MLR target in aggregate
• PCP exceeds Medicare Advantage MLR target
• PCP achieves Stars score of 4 or better
• PCP has avg. of 30+ HCP Medicare Advantage patients

Payment Methodology:

Weighted PMPM calculation per PCP based on cumulative PCP MLR versus target

* i.e. The lower a qualifying PCP’s MLR, the greater payment amount PMPM

*Gain share payment requires complete claims runout

Commercial Incentive

Patient Post-Discharge Visits

Commercial patients who receive PCP follow-up and medication reconciliation within 7 days of hospital discharge are significantly less likely to be readmitted.

Documentation Submission Criteria:

• 99495 (includes medication reconciliation) within 7 days of patient discharge
• 99496 (includes medication reconciliation) within 7 days of patient discharge
• 99483 for patients with cognitive impairment resulting in a written care plan (includes medication reconciliation) within 7 days of patient discharge
• Office visit code + 1111F (medication reconciliation) within 7 days

Medicaid Incentive

Primary Care Physician Gain Sharing

Gain share positions the PCP as a partner in value without downside financial exposure. The goal is to reward providers for their contributions to improving care and reducing preventable medical costs.

Criteria:

• HCP exceeds Medicaid MLR target in aggregate
• PCP exceeds Medicaid MLR target
• > 75% Completion of Medicaid Wellness Visits
• > 50 Medicaid Members Enrolled with HCP

Payment Methodology:

Weighted PMPM calculation per PCP based on cumulative PCP MLR versus target

* i.e. The lower a qualifying PCP’s MLR, the greater payment amount PMPM

* Gain share payment requires complete claims runout and comprehensive reconciliation to ensure accurate calculation