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Pennsylvania Continues Shift to Outcome and Value-based Payment Structure
On April 27, Department of Human Services (DHS) Secretary Ted Dallas announced that the state has agreed to move forward and negotiate contracts with eight managed care organizations (MCOs) to deliver physical health services to Pennsylvanians through HealthChoices, Pennsylvania’s mandatory Medicaid managed care program since 1997.
“These agreements mark the most significant change in Pennsylvania’s Medicaid program since we moved to managed care 18 years ago,” said Dallas. “Over the next three years, MCOs will be investing billions of dollars in innovative approaches that reward high-quality care that improves patient health rather than just providing services for a fee. The result will be higher levels of quality care for the 2.1 million Pennsylvanians served by Medicaid.”
HealthChoices delivers quality medical care and timely access to all appropriate services to children, individuals with disabilities, pregnant women, and low-income Pennsylvanians. For more information, visit the HealthChoices website or DHS website.
DHS has selected the following MCOs to proceed with negotiations to deliver services in Pennsylvania beginning in 2017. The agreements are awarded in five geographic regions:
Southeast Region
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Centene (Pennsylvania Health and Wellness) Health Partners Plans United Healthcare of Pennsylvania, Inc. UPMC for You, Inc. Vista–Keystone First Health Plan |
Lehigh/Capital Region | Centene (Pennsylvania Health and Wellness) Gateway Health United Healthcare of Pennsylvania, Inc. UPMC for You Vista—AmeriHealth Caritas Health Plan |
Southwest Region
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Centene (Pennsylvania Health and Wellness) Gateway Health United Healthcare of Pennsylvania, Inc. UPMC for You Vista—AmeriHealth Caritas Health Plan |
Northwest Region | Aetna Better Health of Pennsylvania United Healthcare of Pennsylvania, Inc. UPMC for You Vista—AmeriHealth Caritas Health Plan |
Northeast Region | Geisinger Health Plan United Healthcare of Pennsylvania, Inc. UPMC for You Vista—AmeriHealth Caritas Health Plan |
The Centers for Medicare and Medicaid Services (CMS) has scheduled the next hospital/quality initiative open door forum (ODF) for Tuesday, April 19, 2016 at 2:00 pm. Two of the agenda topics that will be addressed include the upcoming Improving Medicare Post-Acute Transformation (IMPACT) Act stakeholder engagement activities and the self-identified overpayment final rule.
To participate in the ODF, call 1-800-837-1935 and reference conference ID: 39978935. An encore recording of the call will be available beginning two hours after the call has ended and will expire after two business days. To listen to the encore recording, call 1-855-859-2056 and reference conference ID: 39978935.
RCPA has become aware that there have been higher than normal claims denials by both Medicare and Medicaid related to certain diagnoses. Those diagnoses are Schizophrenia and Post Traumatic Stress Disorder (PTSD) as defined by the DSM-V and ICD-10.
The DSM-V only identifies Schizophrenia Not Otherwise Specified (NOS) and PTSD NOS, versus the ICD-10 which offers eight schizophrenia diagnoses and three PTSD diagnoses. As a result, our practitioners are likely choosing Schizophrenia or PTSD NOS, since they are mostly using the DSM-V. Billing staff have options of eight or three diagnoses respectively, but will use what the practitioner has selected, the only DSM-V diagnosis available. It is highly probable that the individual being evaluated meets something other than NOS. There are very specific criteria for the NOS diagnosis which can certainly be used as the criteria is met, but when the criteria is not met, the claims are accurately denied. RCPA wants to hear from you about how this is affecting your business.
The second billing issue is related to electronic health records (EHR) that have not yet loaded the ICD-10 codes for billing. It is our understanding that there are at least two vendors doing business in Pennsylvania who have not loaded the ICD-10 billing codes into the EHR. RCPA wants to hear from members about how they are billing in the absence of the EHR, not having the ICD codes, and other universal billing concerns.
Please find more information about claims rejections here. Send comments to Sarah Eyster by Friday, April 15.
The Department of Human Services (DHS) Office of Long-Term Living (OLTL) will be submitting amendments to the Aging, Attendant Care, and Independence waivers. The public notice announcing the amendments will appear in the April 2, 2016 Pennsylvania Bulletin.
To view a side-by-side comparison of the current and revised language, and to access the amendments in their entirety (including specific HCBS Allowable Settings Transition Plans and the Community HealthChoices Transition Plans for each waiver, contained in the Main Module), visit the OLTL Waiver Amendment, Renewals, and Accompanying HCBS Transition Plans website and select the individual waiver amendment you would like to review under “Related Topics.”
OLTL is seeking public comment on the Aging, Attendant Care, and Independence waiver amendments. Those interested are invited to submit written comments to the Department of Human Services, Office of Long-Term Living, Bureau of Policy and Regulatory Management, Attention: Aging Waiver, Independence Waiver, or Attendant Care Waiver, PO Box 8025, Harrisburg, PA 17105-8025. Comments can also be sent via email, using the comment form link. On this site, select the individual waiver amendment you would like to view under “Related Topics” and the comment form will be listed in the documents.
The public comment period ends on Monday, May 2, 2016. Comments received within the 30-day comment period will be reviewed and considered for revisions to the amendments.
OLTL will offer two webinars in April for public input and discussion:
Aging, Attendant Care, and Independence Waiver Changes Webinar
Wednesday, April 13, 2:00 – 3:00 pm
Aging, Attendant Care, and Independence Waiver Changes Webinar
Tuesday, April 19, 10:00 – 11:00 am