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PCMH Frequently Asked Questions and Overview

Overview

  1. What is the purpose of a PCMH?
    A Patient Centered Medical Home (PCMH) is a care team that manages the overall health and coordinates the care of a patient. The PCMH program is designed to assist primary care practices in transitioning to PCMHs through guidance and support, while rewarding them for high-quality, coordinated and efficient care.

  2. Will other Arkansas Blue Cross and Blue Shield plans participate?
    Health Advantage fully-insured plans, Arkansas Blue Cross and Blue Shield fully-insured plans and some self-insured plans began participation in 2015.

Enrollment

  1. Who is eligible to enroll as a PCMH?
    Primary Care Physicians that are credentialed with Arkansas Blue Cross and Blue Shield who practice in the following areas: Family Medicine, General Practice, Geriatrics, Internal Medicine, and Pediatrics.

  2. How does a practice enroll?
    The enrollment period for 2017 has closed. Practices interested in participating during the 2018 program year may enroll between October 1, 2017 and December 1, 2017 through AHIN.

  3. Will providers that do not enroll in PCMH be penalized?
    No. The PCMH program is voluntary and will not affect your network participation.

Requirements

  1. What does a PCMH practice have to do to receive per member per month (PMPM) payments?
    The practice must be enrolled in the PCMH program, perform all required activities by their respective due date, and meet the majority of quality metrics to receive practice support.

  2. What happens if a PCMH practice does not meet the requirements for practice support?
    A PCMH practice that fails to complete all practice support activities or meet the majority of metrics by their respective deadlines must address their shortfalls or risk program suspension or termination. See the Arkansas Blue Cross and Blue Shield PCMH Provider Manual for more information regarding remediation.

Practice Support

  1. How are PMPM payments calculated?
    Practices enrolled in the 2017 PCMH program will earn a $5 care management fee PMPM for patients on a fully-insured plan. For those practices that hold NCQA PCMH recognition, PMPM payments for fully insured membership will be based on the level of recognition at the time of enrollment. If NCQA PCMH recognition expires prior to December 31, 2017 the PMPM payments will revert back to the base level the month following the expiration unless an updated recognition certificate has been submitted to primarycare@arkbluecross.com.

    Self-insured groups that participate in the PCMH program will determine their own PMPM payments.

    2017 PMPM payments will not be risk-adjusted.

  2. If I become recognized by NCQA as a PCMH during the program year when does the increased reimbursement begin?
    The increased reimbursement will not change until the beginning of the next program year.

  3. How often will payments be processed?
    Care coordination payments are processed monthly.

  4. If the number of attributed patients to my clinic changes, will my payment amount change?
    Yes. The total payment may change monthly based on the number of attributed patients.

High Priority Beneficiary List

  1. Will I have to choose my top 10% of high priority patients for Arkansas Blue Cross and Blue Shield as well as Medicaid?
    Practices enrolled in both Medicaid and the Arkansas Blue Cross PCMH program will need to select the top 10% high priority patients for both payers. Your list of Arkansas Blue Cross Plan patients will load onto the PCMH Portal beginning late March and you will choose your top 10% of high-risk patients from that list. Practices will need to identify the Arkansas Blue Cross Plan high-risk patients by April 30, 2017.

  2. I am trying to print a report of just our high priority patients but the only thing I have been able to do is print the entire list. Is there a way to split up the report?
    The spreadsheet can be exported into an Excel spreadsheet and filtered however the provider sees fit.

  3. After choosing and submitting my top 10% high priority patients, what if my number of attributed patient’s changes? Do I need to choose more to make up the percentage?
    No. Those patients chosen on the high priority list by the due date (April 30, 2017) will remain for the program year. You will not need to adjust due to caseload changes.

Metrics tracked

  1. Will I have to meet all of the metric targets for my Arkansas Blue Cross Plan patients in 2017?
    To receive practice support, participating clinics must meet activities and quality metrics. Please see the Arkansas Blue Cross PCMH provider manual for more information.

Reports

  1. Will Arkansas Blue Cross and Blue Shield provide clinic reports?
    Yes. Quarterly reports will be available through the AHIN portal. Monthly data will be available through the Care Management portal.