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Provider Pay-for-Performance (P4P) Program

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"Pay-for-performance" is an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care. These arrangements provide financial incentives to physicians and dentists to carry out such improvements and achieve optimal outcomes for patients.

AmeriHealth Caritas Pennsylvania offers several P4P program opportunities to our network providers. These programs offer providers the opportunity to receive incentive payments for the completion of visits, screenings, or other services related to specific HEDIS® measures. 

All aspects of the P4P programs are reviewed annually by AmeriHealth Caritas Pennsylvania (the Plan) and submitted annually to the Pennsylvania Department of Human Services (DHS) for review and approval.

The Primary Care Practitioner (PCP) Quality Enhancement Program (QEP) 

The PCP QEP is a reimbursement system developed by the Plan that provides financial incentives over and above our base compensation for participating PCP practices. The QEP is intended to be a fair and open system that provides incentives for high-quality and cost-effective care, member service and convenience, and submission of accurate and complete health data.

Incentive payments are not based on individual provider performance, but rather the performance of a practice as a whole, unless you are a solo practitioner. Certain QEP components can only be measured effectively for offices whose panels averaged 50 or more members for a defined average enrollment period. For offices with fewer than 50 members, there is insufficient data to generate appropriate and consistent measures of performance. These practices are not eligible for participation in the QEP.

Quality performance is the most important determinant of the additional compensation. This component of the QEP is based on quality performance measures consistent with HEDIS technical specifications and predicated on the Plan’s Preventive Health Guidelines and other established clinical guidelines.

The incentive payment calculation is based on how well a PCP office scores on each measure relative to established targets.

View the most current PCP QEP Manual (PDF).

The Maternity Quality Enhancement Program (MQEP)

The MQEP is a reimbursement system developed by the Plan for participating obstetricians, midwives, and family practice practitioners who provide obstetric care. 

The MQEP provides financial incentives over and above the provider group’s base compensation for prenatal and postpartum care service. Incentive payments are not based on individual provider performance, but rather the performance of the overall practice in providing comprehensive prenatal and postpartum care services in accordance with quality metrics outlined in the MQEP.

Quality performance is the determinant of the additional compensation. The incentive payment is based on the completion of the quality measures for women who have delivered and received the required care. These measures are based on services rendered during the reporting period and require accurate and complete encounter and clinical reporting.

The quality performance measures were selected based on national and state areas of focus and predicated on the Plan’s Preventive Health Guidelines and other established clinical guidelines.

View the most current MQEP Manual (PDF).

Dental Check Rewards for Quality Care® Program

Dental Check integrates the goals and values of providing high-quality and cost-effective preventive dental care for Plan members ages 0 to 20, while incenting our dental providers with supplemental payments for partnering with us to improve clinical outcomes.

Goals

  • To provide our dental providers with a unique opportunity to improve clinical outcomes and compensate them for their efforts.
  • To address health care disparities to ensure our members with cultural and linguistic needs have access to the best possible dental care and services.

Dental Check program details

To reduce risks related to poor dental hygiene and associated risks for dental caries for our members ages 0 to 20, the program aims to:

  • Provide members ages 0 to 20 with oral hygiene instructions (OHI) on the date of prophylaxis.
  • Provide members ages 0 to 20 with a caries risk assessment (CAT) and corresponding documentation on the date of prophylaxis.
  • Submit claims with CAT results using the appropriate risk stratification CDT procedure codes.
  • Provide an additional prophylaxis and/or fluoride treatment* visit for members identified as high-risk in the CAT.

*Current benefit guidelines and age limitations apply.

A key component of the Dental Check program is to provide quality dental care to a culturally diverse membership. To be successful in meeting this goal, the full engagement of our provider network is crucial. We encourage you to take the free Cultural Competency Oral Health Provider continuing education (CE) training. Participants can earn up to 6 CE credits.

See complete information about the Dental Check program.

Circle of CareSM dental program for PCPs

We created the Circle of Care value-based program for PCPs to address the implications of oral health care on systemic health. The program aims to facilitate increased access to, and utilization of, dental care for members in specific physical health cohorts, namely, those with diabetes and asthma. The goal of the program is to facilitate more dental care for members in these cohorts to further improve health and overall well-being for them.

Circle of Care is implemented using a three-pronged approach. Members within the cohorts will be identified through diagnosis, and dental claims utilization is overlaid to determine who among them has received dental care within the past calendar year. The three-pronged approach encompasses:

  1. A broad-based education and awareness outreach effort, aimed at PCPs’ and primary dental care providers’ (PDPs’) members and internal stakeholders, to inform them about the importance of dental and oral health care for those who are diagnosed with diabetes and asthma, and that the management of oral and dental disease has been proven in many cases to facilitate improved outcomes and better control of the those conditions.
  2. The distribution of focused outreach educational materials to the members identified in these cohorts.
  3. An incentive opportunity for PCPs treating these members to engage in more focused referral to dentists.

For members in these cohorts, an incentive payment will be made to the provider when a dental claim is noted and paired with a PCP claim within 60 days prior to the date of the initial dental appointment. Once an eligible member receives an initial exam that corresponds with a specific dental (D) code, a 60-day look-back will be initiated.

If a PCP claim is identified within this 60-day time frame, an incentive payment of $25 per qualifying member will be paid out to the PCP. The goal is for the physician and staff to have oral-health-focused conversations relating to the physical health conditions, and refer the members to dentists within the network participating in Circle of Care.

Complete information about Circle of Care.

Circle of Care dental program for OB/GYNs

We have created the Circle of Care value-based program for participating OB/GYN providers to address the implications of oral health care on systemic health. The program aims to facilitate increased access to, and utilization of, dental care for pregnant members. The goal of the program is to facilitate more dental care for pregnant members to further improve health and overall well-being for them.

Circle of Care for OB/GYNs was implemented using a three-pronged approach. Pregnant members will be identified through diagnosis, and dental claims utilization is overlaid to determine who among them has received dental care within the past calendar year. 

  1. Circle of Care is a broad-based education and awareness outreach effort, aimed at OB/GYN members and providers, to inform them about the importance of dental and oral health care during pregnancy, and that the management of oral and dental disease has been proven in many cases to facilitate improved pregnancy outcomes. 
  2. Circle of Care distributes focused outreach materials to the identified members. 
  3. Circle of Care is an incentive opportunity for OB/GYNs treating our members to engage in more focused referral to dentists.

For pregnant members, an incentive payment will be made to the providers when a dental claim is noted and paired with an OB/GYN claim within 60 days prior to the date of the initial dental appointment. Once an eligible member receives an initial exam that corresponds with a specific dental (D) code, a 60-day look-back will be initiated.

If an OB/GYN claim is identified within this 60-day time frame, an incentive payment of $25 per qualifying member will be paid out to the OB/GYN. The goal is for the physician and staff to have oral-health-focused conversations relating to the physical health conditions, and refer the members to dentists within the network participating in Circle of Care.

Complete information about Circle of Care for OB/GYNs.

Pediatric Preventive program for dental providers

To support our continuing efforts to increase the number of children receiving preventive oral health services, we have implemented the Pediatric Preventive dental P4P opportunity.

The goal of this program is to have earlier intervention into the disease prevention process and to increase inclusion of patients who previously had not been active in receiving quality oral health services.

Populations included in this program are:

  • Children ages 6 months to 20 years who have been continuously enrolled with the plan for 90 days within the measurement year.

Children eligible for inclusion are further divided into two cohorts:

  1. New patients — children who have not received a preventive dental service in the previous calendar year, but received a preventive dental service in the measurement year.
  2. Returning patients — children who received a preventive dental service in the previous calendar year and received a preventive dental service in the measurement year.

Episode of care included in this program

The episode of care must include one of the following oral examination procedures:

  • D0120 Established patient – periodic oral evaluation.
  • D0145 Oral evaluation for a patient under 3 years of age and counseling with primary caregiver.
  • D0150 New or established patient – comprehensive oral evaluation.

And the episode must also include one of the following prophylaxis procedures:

  • D1110 Dental prophylaxis – adult.
  • D1120 Dental prophylaxis – child.

And the episode must also include one of the following fluoride application procedure types*:

  • D1206 Topical application of fluoride varnish.
  • D1208 Topical application of fluoride – excluding varnish.
*Excludes members ages 17 to 20 as fluoride application is not covered.

In most cases, the three components of the episode of care will be completed on the same date of service. If this is not possible, the provider will have 30 days to complete the episode of care.

Please contact your dental Account Executive (PDF) for more information about the Pediatric Preventive dental P4P opportunity. 

See complete information about the Pediatric Preventive dental P4P program (PDF).