Primary Care Practitioner

• Gateway to Physician Excellence^SM
• Reporting
• Primary Care Practice Dashboard Reports
• Encounters
  • Accurate Submission of Encounter Data
• Capitation
• Capitation Reports
• Vaccines For Children
• Processing PCP Change Requests
• Transfer of Non-Compliant Members
• Transfer of Medical Records
• Coordination of Behavioral Health and Physical Health Services
• Appointment Standards

Each member in a family has the freedom to choose any participating primary care practitioner, and a member may change to another primary care practitioner should a satisfactory patient-practitioner relationship not develop. A primary care practitioner agrees to accept a minimum number of Gateway members, as specified by their practitioner agreement, to their patient panel at each authorized office location without regard to the health status or healthcare needs of such members and without regard to their status as a new or existing patient to that practice or location. The primary care practitioner must maintain at least twenty (20) weekly appointment hours per marketed location.

The primary care practitioner after meeting their contract minimum may, upon ninety (90) days prior written notice to Gateway, state in writing that they do not wish to accept additional members. The written request excludes members already assigned to the primary care practitioner’s practice, including applications in process.

Through Gateway’s model of Prospective Care Management, we emphasize the importance of extensive member outreach, community involvement and physician practice engagement. We support the efforts of physician practices in delivering the highest quality of care to members.

Gateway Health Plan^® has designed and implemented an innovative pay for performance (P4P) program, Gateway to Physician Excellence^SM (GPE^SM). This program is aligned with the Prescription for Pennsylvania goals and the DPW’s MCO P4P Program. GPE^SM supports Gateway’s mission to deliver quality programs that positively impact the personal health of its members.

• Improve the delivery of healthcare – including quality, access, and efficiency
• Reduce racial and ethnic disparities
• Improve the member experience
• Increase physician satisfaction

• High volume primary care physician practices (minimum of 200 members)
• Including Family Practice, Internal Medicine, and Pediatrics
• These physicians touch approximately 76% of Gateway members

Performance Measures
Gateway to Physician Excellence^SM focuses on data driven measures to evaluate practice performance in the areas of Clinical Quality, Emergency Room Avoidance, and Encounter Data Submission.

• Measure ER services for members with Diabetes and Asthma, and
• Provide practices with data on “chronic” ER usage for targeted interventions.

• Supports current and future performance assessments;
• Measurement not used in calculating final score or award; intended to
• Provide feedback and encouragement for providers to submit encounters.

Scoring Methodology
Gateway uses a member-centered approach to assign the responsibility of treating patients to specific practices. If a member changes to a new assigned practice during the measurement period, then that member will be attributed to multiple practices. Physician practices are scored in relation to other practices.

All measures leverage encounter data (inpatient, outpatient, laboratory, and pharmacy). This eliminates the practice burden to self-report data through surveys or medical chart reviews.

Scorecard
Scores are measured, reported, and awarded at the practice level. Gateway will provide a scorecard to participating practices detailing:

• Practice eligible measures,
• Practice level numerator, denominator, and rate for each measure,
• Measure definitions and scoring methodology,
• Accessibility and availability factors, and
• Encounter submission rate.

Scorecards will be hand delivered to allow discussion of performance improvement opportunities.

Awards
Gateway to Physician Excellence^SM is designed to recognize and reward practice quality. The financial award is a function of four factors – final practice performance across all measures, practice member volume, practice access and availability, and the annually established Gateway to Physician Excellence^SM program budget. Annual award payments will be separate from physician base payments.

Recognition
In addition to financial awards, Gateway to Physician Excellence^SM practice participation is noted in both the provider directory and the online provider search tool.

Physician Involvement
Gateway assures that the physician community is involved by engaging GPE^SM enrolled physicians, QI/UM Committee and Physician Portfolio Workgroup members in the ongoing program development. These physicians, representing the interest of a wide range of stakeholders, have provided clinical input throughout the program design process.

Gateway strives to regularly provide Primary Care Practitioners with actionable data to help practices close potential gaps in care. The following reports are mailed or delivered on a routine basis to our Primary Care Practices:

• Primary Care Practice Dashboard Reports (quarterly)
• GPE^SM Report Cards (annually)
• Medicaid Provider Primary Care Practice Portfolio Reports (biannually)
• Capitation Reports (monthly)
• Member List (monthly)

These reports can be used to asses practice performance, plan future patient visits or perform outreach to patients in need of care. Although Gateway conducts reminder outreach to members, hearing directly from their doctor’s office helps.

Primary care physicians and their practice staff are challenged with handling and processing mountains of clinical mail from a myriad of sources. In response, we are making efforts to reduce the number of individual clinical mailings we send by consolidating that information into a compact, easily understandable Primary Care Practice Dashboard Report.

The Report is mailed quarterly (January, April, July, October) and contains data on members in your practice who are due for or missing chronic care and preventive services. Data includes member contact information, self-disclosed racial and ethnic information, preventive care (e.g., EPSDTs, mammography, etc.) and chronic care (e.g., diabetic testing, gaps in pharmacy fills for hypertension and asthma controllers, etc.) services for which we have no “Medical” or “Physician Office” claim or encounter submission.

Information in the Primary Care Practice Dashboard Report is compiled from claims data. The dashboard highlights members for whom claims data does not show the presence of a recommended test or treatment. This doesn’t necessarily mean that the test or treatment has not been done; it indicates that Gateway has not received a claim or encounter submission indicating the service was performed.

Information in the Dashboard is intended to be a practice tool that supports evidence-based care, not as a “report card.” It does not, nor is it intended to replace your professional clinical judgment as a patient’s treating physician. It is not used to determine practice reimbursement and is not connected to the Gateway to Physician Excellence^SM (GPE^SM) program. However, using this tool may promote care opportunities in your practice that, when addressed, may positively impact your performance on individual GPE^SM indicators and associated annual payments.

While we provide this information to assist you, remember that our Care Management staff is simultaneously reaching out to members through our Prospective Care Management model of care. PCM^® is designed to engage and help members follow preventive care and chronic care treatment recommendations and remain connected to their doctors.

• Schedule patients for annual physicals to review all of their needs.
• Schedule follow-up appointments before patients leave the office.
• Have a reminder system. Let patients know by mail or phone of an upcoming appointment to help minimize “no shows.”
• Arrange for patients with chronic conditions to have blood work drawn a week before their next appointment. This allows the doctor to have more information at the time of the visit and reduces the amount of required follow-up communication.
• Make use of in-office testing (e.g., HbA1c), a reimbursed service by Gateway.

Primary care practitioners are required to report to Gateway all services they provide for Gateway members by submitting complete and accurate claims regardless of expected reimbursement.

Claim/Encounter data provides the basis for many key medical management and financial activities at Gateway:

• Quality of care assessments and studies;
• Access and availability of service evaluation;
• Program identification and evaluation;
• Utilization pattern evaluation;
• Operational policy development and evaluation, and;
• Financial analysis and projection.

To effectively and efficiently manage member’s health services, encounter submissions must be comprehensive and accurately coded. All Gateway providers are contractually required to submit encounters for all member visits. Underreporting of encounters can negatively impact all stakeholders.

For primary care practitioners, encounter data is essential as many of Gateway’s quality indicators are based on this information. In capitated reimbursement systems, providers may lose the incentive to submit encounter data because reimbursement is not linked to each individual encounter. Gateway evaluates primary care practitioner encounter data in two ways. The rate of submitted encounters per member for individual primary care practitioner practices is measured and compared to a peer average based on specialty (Family Practice, Pediatric, Internal Medicine). Additionally, Gateway extracts dates of service during on-site medical record review and compares the visit dates to encounters submitted to the health plan. This rate is also compared to peer averages.

The expected rate of submission for encounters is 100%. Gateway provides support and education to practices as indicated by their encounter submission rates.

CMS uses the Hierarchical Condition Categories (HCC) model to assign a risk score to each Medicare beneficiary. Accurate and complete reporting of diagnosis codes on encounters is essential to the HCC model. Physicians must establish the diagnosis in the medical record and coders must use the ICD-9-CM coding rules to record each diagnosis. Chronic illnesses should be coded on each encounter along with the presenting illness. This will help to ensure that CMS has complete data when determining the member’s risk score.

If you would like to learn more about the CMS-HCC model and the importance of complete and accurate coding visit these web sites:

• 2003 Physicians & Medicare+Choice Risk Adjustment CD at cmstraining@aspensys.com
• Official Coding Guidelines on CDC Website www.cdc.gov/nchs/icd9.htm
• Coding Clinic for ICD-9-CM available through the American Hospital Association (AHA)

CMS, the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), and the National Center for Health Statistics (NCHS) together have developed official coding guidelines. The guidelines can be found at:
www.cdc.gov/nchs/data/icd9/icdguide.pdf

There are two volumes which consist of:
The Disease Tabular (Numeric) and is known as Volume I of ICD-9-CM. Numeric listing of codes organized by body system. This volume provides more detail than the Alphabetic Index on conditions included and excluded in the code selected. Another code in the same category may represent the diagnostic description better than the one indicated in the Disease Index.

The Disease Index (Alphabetic) and is known as Volume II of ICD-9-CM. This volume is an index of all diseases and injuries categorized in ICD-9-CM. When a code is listed after the description, it means the reader should look up that code in the Disease Tabular section to determine if that is the most specific code to describe the diagnosis. The index is organized by main terms and subterms that further describes or specifies the main term. In general, the main term is the condition, disease, symptom, or eponym (disease named after a person), not the organ or body system involved.

Primary care practitioners receive a monthly capitation payment based on the age and gender of the members who select them as their practitioner. After monitoring monthly enrollment and disenrollment from each practitioner’s member panel, Gateway issues to the practitioner, on or about the fifteenth of each month, a capitation check and report regarding the amount of payment per member.

Capitated services include all examinations, administrative and most medical procedures performed in the primary care office. (Please refer to Gateway Agreement for details) In addition to capitation, primary care practitioners are routinely reimbursed for inpatient care, attendance at delivery, and other services outside the monthly capitation payment on a fee-for-service basis.

Gateway makes every effort to avoid retroactive deductions from the capitation. These deductions are generally restricted to three months and are the result of the member changing his/her selected primary care practitioner or a delay in the Department of Public Welfare’s reporting to Gateway a member’s loss in eligibility.

Sample reports utilized by the primary care practitioner can be found in the Forms and Reference Material Section of this Manual.

Children under 19 years of age receiving MA are eligible for Vaccines For Children (VFC) Program. All primary care practitioners will be reimbursed for the administration of any vaccine covered under the VFC Program when a claim is received with the appropriate immunization code. Any procedures for immunizations not covered under the VFC Program, but covered by Gateway, will be reimbursed fee-for-service. Please reference the Primary Care Practitioner’s Agreement for fee schedules or contact your Provider Relations Representative for additional information.

When a member selects Gateway, the member’s effective date is usually the 1st or the 15th of the month. When the member is a newborn, the member may be added any time of the month. Because newborn information is reported to Gateway retroactively, newborns will show up as a retroactive addition to the primary care practitioner’s monthly panel listing. Newborns will be effective on their date of birth or the date the newborn was added to the member’s grant.

Capitation payments for newborns are as follows:

Services rendered during the newborn hospital stay are paid on a fee-for-service basis.

When a member wishes to change his or her primary care practitioner, the change is processed under the following guidelines:

• When the request is received prior to the 25th of the current month, the new effective date will be the first of the following month. For example, if a member’s request is received on October 7th, the member will be effective November 1st with the new primary care practitioner.
• When the request is received on or after the 25th of the current month, the new effective date will be the first of the subsequent month. For example, if a member’s request is received on October 28th, the member will be effective December 1st with the new primary care practitioner.
• If the member requests to change his or her primary care practitioner immediately, an exception to the above guidelines can be made if the situation warrants.

Primary care practitioners agree (a) not to discriminate in the treatment of his/her patients, or in the quality of services delivered to Gateway members on the basis of race, sex, age, religion, place of residence, health status or source of payment; and (b) to observe, protect and promote the rights of members as patients. Primary care practitioners shall not seek to transfer a member from his/her practice based on the member’s health status. However, a member whose behavior would preclude delivery of optimum medical care may be transferred from the practitioner’s panel. Gateway’s goal is to accomplish the uninterrupted transfer of care for a member who cannot maintain an effective relationship with a given practitioner.

Additionally, in order to assist Gateway practitioners in the management of members who violate office policy in regard to scheduled appointments, Gateway has instituted the following Member No-Show Policy:

Gateway will recognize the individual practitioner’s written office policy in regard to scheduled appointments. Gateway practitioners are responsible for recording no-show appointments in the member’s medical record.

When a transfer is being conducted due to member no-show, the practitioner’s notification should indicate that the practitioner wants to transfer the member to another primary care practitioner’s practice.

Should an incidence of inappropriate behavior or member non-compliance with no-show policies occur, and transfer of the member is desired, the practitioner must send a letter requesting that the member be removed from his/her panel including the member’s name and Gateway ID Number, and, when applicable, state their no-show policy, and the member(s) who has (have) violated the policy to the Provider Relations Department at:

Gateway Health Plan^®
Attention: Provider Relations
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219-2740.

All written requests are forwarded to the Enrollment Department within 48 hours of receipt of the practitioner’s request. The Enrollment Department notifies the original practitioner in writing when the transfer has been completed. If the member requests not to be transferred, the primary care practitioner will have the final determination regarding continuation of primary care services.

When the request is received prior to the 25th of the month, the new effective date will be the first of the following month. When the request is received on or after the 25th of the current month, the new effective date will be the first of the subsequent month. An exception to the above guidelines can be made if the situation warrants an immediate transfer. Primary care practitioners are required to provide emergency care for any Gateway member dismissed from their practice until the member transfer has been completed.

Primary care practitioners are required to transfer member medical records or copies of records to newly designated primary care practitioners within fifteen (15) business days from receipt of the request from the Department of Public Welfare, its agent, the member or the member’s new primary care practitioner, without charging the member.

No mental health or drug and alcohol services are covered by Gateway except for emergency room services, home healthcare, pharmacy services, and emergency transportation services. Gateway is responsible for all emergency and non-emergency transportation in an ambulance to an emergency room and to a behavioral health facility. All prescribed medications are dispensed through the Gateway pharmacy network. This includes drugs prescribed by both physical health and behavioral health practitioners. The only exception is that the Behavioral Health Managed Care Organization (BH-MCO) is responsible for the payment of Methadone and LAAM when used in the treatment of a substance abuse disorder, and when prescribed and dispensed by BH-MCO service practitioners.

Emergency services provided in general hospital emergency rooms are the responsibility of Gateway regardless of the diagnosis or services provided. The only exception is for emergency room evaluations for voluntary or involuntary commitments pursuant to the 1976 Mental Health Procedures Act (50 P.S. Section 7101, et seq), which are the responsibility of the BH-MCO.

Both primary care practitioners and behavioral health clinicians have the obligation to coordinate care of mutual patients in accordance with state and federal confidentiality laws and regulations. This includes but is not limited to: obtaining appropriate releases to share clinical information; making referrals for social, vocational, education or human services when a need is identified through assessment; notifying each other of prescribed medications; and being available for consultation when necessary.

Referrals are not necessary for members to receive the services of a behavioral health practitioner.

If a member requires home healthcare ordered by a BH-MCO practitioner that meets the conditions of 55 Pa. Code, Chapter 1249 (relating to Home Healthcare Services), Section 1249.52 (relating to payment conditions for various services), the services would be covered by Gateway.

Please refer to the Quick Reference Section of this Manual for a listing of Behavioral Health Managed Care Organizations or behavioral health agencies and their corresponding telephone number, county serviced, and services provided.

Primary care practitioners agree to meet Gateway’s appointment standards, as follows: