Primary Care Practitioner

• Primary Care Practice Dashboard Reports
• Encounters
  • Accurate Submission of Encounter Data
• Transfer of Non-Compliant Members
• Transfer of Medical Records
• 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 may, upon sixty (60) 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.

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Primary Care Practice Dashboard Reports

Primary care practitioners 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 delivered 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” claims or encounter submission.

Information in the Primary Care Practice Dashboard Report is compiled from claims and pharmacy data. The dashboard highlights members for whom claims and pharmacy 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. 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.

Encounters

Primary care practitioners are required to report to Gateway all services they provide for Gateway members by submitting complete and accurate claims. All Gateway providers are contractually required to submit encounters for all member visits and all diagnosis codes that the member may suffer from.

Accurate Submission of Encounter Data

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. 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 Medicine, 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. 

It is very important that all diagnosis codes that are applicable to the member be submitted on every claim, especially chronic conditions.  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.

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Transfer of Non-Compliant Members

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.

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 Enrollment Department at:

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

The Enrollment Department notifies the original practitioner in writing when the transfer has been accomplished. If the member requests not to be transferred, the primary care practitioner will have the final determination regarding continuation of primary care services.

Primary care practitioners are required to provide emergency care for any Gateway member dismissed from their practice until the member transfer has been completed.

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Transfer of Medical Records

Primary care practitioners are required to transfer member medical records or copies of records to newly designated primary care practitioners within seven (7) business days from receipt of the request from the member or the member’s new primary care practitioner, without charging the member.

Primary care practitioners are required to transfer member medical record or copies of records to newly designated Managed Care Organizations within seven (7) business days from receipt of the request from the Centers for Medicare and Medicaid Services or its agent.

Appointment Standards

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

A member should be seen by a practitioner as expeditiously as the member's condition warrants, based on the severity of symptoms.  If a practitioner is unable to see the member within the appropriate timeframe, Gateway will facilitate an appointment with a participating or non-participating practitioner, if necessary.