Fillable Printable Value Based Payment Public Comment

Value Based Payment Public Comment

AHCCCS Value Based Purchasing (VBP) Activity

AHCCCS is providingthe following value based purchasing (VBP) decisions:

For the contracting year October 1, 2017 through September 30, 2018 [Contract Year Ending (CYE)

2018], select AHCCCS-registered Arizona providerswhich meet Agency established value based

performance metrics requirements will receive a VBP Differential Adjusted Payment. The AHCCCS

Administration is implementingthese VBP Differential Adjusted rates to assure that payments are

consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so

that care and services are available at least to the extent that such care and services are available to the

general population in the geographic area. AHCCCS will implementvalue based purchasing differential

adjusted rates for the followingproviders:

•Hospitals Subject to APR-DRG Reimbursement

•Other Hospitals and Inpatient Facilities

•Nursing Facilities

•IntegratedClinics

•Physicians, Physician Assistants, and Registered Nurse Practitioners

VBP Differential Adjusted Payments are currently in place for select hospitals, Nursing Facilities and

Integrated Clinics for dates of service beginning October 1, 2016. These adjusted paymentsexpire after

September 30, 2017, dates of service. The VBP Differential Adjusted Payments in this Notice for CYE

2018 will beeffectivewith dates of service beginning October 1, 2017(with some exceptions noted

below), and all noted providers (based on distinct Provider Types)will have the opportunity to be

considered for meeting thecriteriadescribed further below.

CYE 2018VBP Differential Adjusted Rates:

The VBP Differential Adjusted Payment Schedule represents a positive adjustment to the AHCCCS Fee-

For-Service rates.The purpose of the VBP Differential Adjusted Payment is to distinguish providers

which have committed to supporting designated actions that improve patients’ care experience,

improve members’ health, and reduce cost of care growth. These fee schedules will be limited to dates

of service in CYE 2018.

AHCCCS MCOs (including Regional Behavioral Health Authorities - RBHAs) will be required to pass-

through VBP Differential Adjusted Paymentincreases totheir contracted ratesto match the

corresponding AHCCCS Fee-For-Service rate increase percentages.

Hospitals Subject to APR-DRG Reimbursement(Provider Type 02) - Participation in the Network, the

state’s health information exchange (HIE),qualifies the hospital for a 0.5% VBP Differential Adjusted

Payment increasefor both inpatient and outpatient services:

•“Participation in the Network” means: By May 15, 2017, the hospital must have executed an

agreement witha qualifying health information exchange organization and electronically submit

laboratory, radiology, transcription, and medication information, plus admission, discharge, and

transfer information (including data from the hospital emergency department) to a qualifying

health information exchange organization

If AHCCCS continues this increase beyond CYE 2018, it is anticipated that hospitals qualifying for the VBP

Differential Adjusted Payment may qualify for an additional increase for inpatient andoutpatient

services effective October 1, 2018, if the hospital holds the following certification by April 30, 2018:

•Pediatric Prepared Emergency Care certification

Other Hospitalsand Inpatient Facilities(Psychiatric Hospitals, Provider Type 71; Subacute Facilities(1-

16 Beds), Provider Type B5; RehabilitationHospitals, Provider Type C4; Long Term Acute Care Hospitals,

Provider Type C4) - Participation in the Network, the state’s health information exchange (HIE),qualifies

the hospital for a 0.5% VBP Differential Adjusted Payment increase for both inpatient and outpatient

services, effective with dates of admission from January 1, 2018 through September 30, 2018:

•“Participation in the Network” means: By October 1, 2017,the hospital must have executed an

agreement with and electronically submitted admission, discharge, and transfer information, as

well as data from the facility’semergency departmentif appropriate, to a qualifying health

information exchange organization. Facilities must have an executed agreement and initiate

activity with the state’s HIE by May 15, 2017 to meet this October 1, 2017 deadline.

Additionally, the Network will conduct a readiness assessment of all interestedfacilities and will

determine, based on the results of the assessment, whether or not the facility is approved to

proceed with connectivity and meeting the program deadlines.

Nursing Facilities(Provider Type 22) - Vaccination rates for pneumococcal and influenza vaccines at or

above the statewideaverage based on Medicare Compare data qualifies the Nursing Facilityforup to a

2% VBPDifferential Adjusted Payment increase:

•Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

based on the facility’s performance results on Medicare Nursing Home Compare for this Quality

Measure: Facility results will be compared to the accompanying Arizona Average results for the

measure, for the most recently published rate as of April 30, 2017. Nursing Facilities that meet

or exceed the Medicare Nursing Home Compare Arizona Average for the pneumococcal vaccine

measure qualify for a 1% VBP Differential Adjusted Payment increase

AND/OR

•Percent of long-stay residents assessed and given, appropriately, the influenzavaccine based

on the facility’s performance results on Medicare Nursing Home Compare for this Quality

Measure: Facility results will be compared to the accompanying Arizona Average results for the

measure, for the most recently published rate as of April 30, 2017. Nursing Facilities that meet

or exceed the Medicare Nursing Home Compare Arizona Average for the Influenza vaccine

measure qualify for a 1% VBP Differential Adjusted Payment increase

Nursing Facilities will be eligible for a 1% increase for meeting each variable, thus having the potential to

earn up to a 2% VBP Differential Adjusted Payment increase if both criteria are met.

Integrated Clinics(Provider Type IC) –AHCCCS registration as an Integrated Clinic, with claims for

behavioral health services accounting for at least 40% of total claims, qualifies the IC for a 10% VBP

Differential Adjusted Payment increase for select codes:

•An Integrated Clinic is a provider licensed by the Arizona Department of Health Services as an

Outpatient Treatment Center which provides both behavioral health services and physical

health services.

•Utilizing claims and encounter data for dates of service from October 1, 2015 through

September 30, 2016,AHCCCS will compute claims for behavioral health services as a

percentage of total claims as of May 15, 2017to determine which providers meet the 40%

minimum threshold

oOnly approved and adjudicated AHCCCS claims and encounters will be utilized in the

computations

oAHCCCS will not consider any other data when determining which providers qualify for

the VBP Differential Adjusted Payment increase

•The VBP Differential Adjusted Rates will be paid for select physical health services and will

provide an increase of 10% over the AHCCCS Fee-For-Service rates for those dates of service in

CYE 2018 that coincide with the provider’s registration as an IC

Physical health services which qualify for the increase include Evaluation and Management

(E&M) codes, vaccineadministration codes, and a global obstetric code. See the attachment for

the specific list of codes which are proposed to increase for purposes of VBP

If AHCCCS continues this increase beyond CYE 2018, it is anticipated that, in order to qualify fora VBP

Differential Adjusted Payment increase, the ICprovider will be required to have an executed agreement

with the Network, the state’s HIE,and submit data to the Network.

Physicians, Physician Assistants, and Registered Nurse Practitioners (Provider Types 08, 31, 18, 19) –

Physicians, physician assistants, and registered nurse practitionerswho have written at least 100

prescriptions for AHCCCS members, and who have written at least 50% of their total AHCCCS

prescriptions as Electronic Prescriptions (E-Prescriptions) will qualify for a 1% VBP Differential

Adjusted Payment increase for all servicesbilled on the CMS Form 1500.

E-Prescription statistics will be identified by the AHCCCS provider ID for the prescribing provider, and

computed by AHCCCS based on the following factors:

•Only approved and adjudicated AHCCCS claims and encounters for July 1, 2016 through

December 31, 2016 dispense dates will be utilized in the computations

•AHCCCS will not consider any other data when determining which providers qualify for the VBP

Differential Adjusted Payment increase

•E-Prescriptions include those prescriptions generated through a computer-to-computer

electronic data interchange protocol, following a national industry standard and identified by

Origin Code 3

•Refills of original prescriptions whereby the original prescriptions meet the definition of E-

Prescriptions shall not be counted as E-Prescriptions

The VBP Differential Adjusted Payment will apply to claims for covered AHCCCS services where the

rendering provider ID on the claim is the same as theprescribing provider ID that was identified and

found to meet the VBP criteria described above.

If AHCCCS continues this increase beyond CYE 2018, physicians, physician assistants, and registered

nurse practitioners who meet the E-Prescription criteria will see a VBP Differential Adjusted Payment

increasefor all services effective October 1, 2018. It is anticipated that physicians, physician assistants,

and registered nurse practitioners whodo notmeet the E-Prescription criteria will see a VBP Differential

Adjusted Payment decreasefor all services effective October 1, 2018.

The following is the anticipated timeline regarding VBP Differential Adjusted Payments:

Activity

Date

Post Notice of Proposed Rulemaking (NPRM)

Week of April10,2017

Tribal Consultation

April 20, 2017

NPRM Public Comments Due

May2017

Submit State Plan Amendment to CMS

May 2017

Implement VBP Differential Adjusted Payments

•October 1, 2017 – September 30, 2018

Dates of Servicefor specific Provider Types

included in this Public Notice

•January 1, 2018 – September 30, 2018

Dates of Admission for specific Provider

Types included in this Public Notice

Note: Dates are subject to change

AHCCCS anticipates that the criteria for VBP Differential Adjusted Payments could change for CYE 2019

and may differ for inpatient and outpatient services. AHCCCS also expects to expand VBP Differential

Adjusted Payments to other provider types for CYE 2019. VBP Differential Adjusted Payments noted

above may change based on budgetary guidelines.

Integrated Clinic (IC) Physical Health Services Codes for AHCCCS VBP Differential Adjusted Rates -

Proposed

CPT

DESCRIPTION

59400

ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINA L DELIVERY (WITH OR WITH

90471

IMMUNIZATION ADMINI S TRATION (INCLUDES PER CUTANEOUS, INTRADERMAL, SUBCUTANEOUS,

90472

IMMUNIZATION ADMINI S TRATION (INCLUDES PER CUTANEOUS, INTRADERMAL, SUBCUTANEOUS,

90473

IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; ONE VACCINE (SINGLE OR

90474

IMMUNIZATION ADMINI S TRATION BY INTRANASAL OR ORAL ROUTE; EACH ADDITIONAL

99201

New patient office or other outpatient visit, typically10 min ut es

99202

New patient office or other outpatient visit, typically 20 minutes

99203

New patient office or other outpatient visit, typically 30 minutes

99204

New patient office or other outpatient visit, typically 45 minutes

99205

New patient office or other outpatient visit, typically 60 minutes

99211

OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLI

99212

Established patient office or other outpatient visit, typically 10 minutes

99213

Established pat i ent offi ce or other outpatient visit, typically 15 minutes

99214

Established patient office or other outpatient, visit typically 25 minutes

99215

Established patient office or other outpatient, visit typically 40 minutes

99243

Patient office consultation, typically 40 minutes

99244

Patient office consultation, typically 60 minutes

99245

Patient office consultation, typically 80 minutes

99381

INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT OF AN INDIVI

99382

INITIAL COMPREHENSIVE PREVENTIVE MEDICI NE E V ALUATION AND MANAGEMENT OF AN INDIVI

99383

INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT OF AN INDIVI

99384

INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT OF AN INDIVI

99385

INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVA LUATION AND MANAGEMENT OF AN INDIVI

99391

Established patient periodic preventive medicine examination infant younger than

99392

Established patient periodic preventive medicine examination, age 1 through 4 ye

99393

Established patient periodic preventive medicine examination, age 5 through 11 y

99394

Established patient periodic preventive medicine examination, age 12 through 17

99395

Established patient periodic preventive medicine examination age 18-39 years

99403

PREVENTIVE MEDICINE COUNSELING AND/OR RISK FACTOR REDUCTION INTERVENTION(S)

*Descriptionsare truncated due to field length limitations in the AHCCCS mainframe