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Care Management: Benefiting the Patient and Provider

August 16th, 2019

Care teams continue to work collectively to outreach and engage appropriate members for care management services to improve quality of care, cost, and care coordination services. BCBSM has recognized the value of care management services for their Provider Delivered Care Management (PDCM) members and offers Value-Based Reimbursement (VBR) opportunities for practices to identify and engage members who will benefit from patient centered care. Additional VBR opportunities are associated with quality metrics including A1C control, blood pressure control, ED utilization, and readmission rate. For measurement year 2019, the PDCM Population Management VBR is 5%. Practices must engage 3% of their eligible PDCM population to achieve this uplift. Engagement is defined as an eligible member with 2 billable encounters, one of which must be a PDCM code. Medication reconciliation (1111f) and transition of care codes (99495, 99496) will be considered for the second code. Practices are also eligible for PDCM Outcomes VBR if they are PCMH designated and delivering PDCM services to at least 1% of their population with two touches on different days. Each of the four metrics mentioned have an eligible VBR of 1.5% (6% total eligible VBR tied to Outcomes VBR). Performance benchmarks for each metric are based on the Milliman Loosely Managed Benchmark for utilization and NCQA percentiles for A1C control (75th percentile) and high blood pressure (50th percentile). Our care managers and the quality improvement team continue to support and guide practices toward meeting these goals. Successful achievement of benchmarks and engagement targets to obtain VBR must be a concentrated effort of the entire care team, including practice staff. For the first time, BCBS has opened specific telephonic PDCM codes for non-licensed staff members, including Medical Assistants (MA) and Community Health Workers (CHW) to provide care coordination (99487, 99489) and brief telephonic support (98966) to eligible members. MA’s and CHW’s must complete required training components, one of which is Care Coordination Training offered by Practice Transformation Institute. This one-day workshop focuses on self-management support, opportunities to enhance care coordination activities, and builds upon PCMH in transforming care delivery. For additional information, or to register, please visit https://www.transformcoach.org/care-manager-training/. In addition to ensuring staff receives appropriate training to deliver and bill PDCM services, physicians should be conducting regular team conferences (G9007) and providing care team oversight (G9008). The coordinated care oversight code is a physician delivered service commonly used when the physician discusses engagement in care management with the patient, coordinating care with the team or interacting with another healthcare provider seeking guidance or background information to coordinate and inform about the care process. Both physician delivered services are PDCM codes considered as one of the two touches that constitutes patient engagement.

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