Presence Health

  1. Accountable care organization (ACO)
  2. Clinical integration
  3. Difference between an ACO and clinical integration
  4. Blue Cross Blue Shield Medicare Advantage contract
  5. Bundled payment contracts
  6. CAQH number
  7. Capitated contracts
  8. Clinical integration contracts
  9. Data use agreement
  10. Discount from charges contract
  11. Dual eligible patients/contracts
  12. EDI
  13. Health insurance exchange
  14. ICLOPS
  15. Imagine health
  16. High value custom network
  17. Medicare Value Partners (MVP)
  18. Messenger model contract
  19. Narrow networks
  20. Non-risk contract
  21. Presence Health Partners
  22. RBRVS
  23. Risk contract
  24. Shared savings contracts

 

1. Accountable Care Organization (ACO): An ACO is a legally structured arrangement between hospitals, physicians and other providers to deliver efficient and effective care for a defined population.  The ACO takes responsibility for improving the quality of care and slowing the growth of health care costs. This responsibility may include financial risk as well.

[ Back to top ]

 

2. Clinical integration: Clinical integration is an active and ongoing PHP program to evaluate and enhance practice patterns by the network’s physician participants and to create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.

[ Back to top ]

 

3. Difference between an ACO and clinical integration?: Accountable Care Organizations are focused on larger populations over a broader spectrum of care and expected to assume financial risk for the health care coordination of the population. Successful clinical integration is an essential element of an ACO. But you do not have to be an ACO to work towards clinical integration. At this time, everyone who joins Presence Health Partners is part of clinical integration. Presence Health Partners may enter into commercial ACO contracts in the future in addition to government ACO contracts. At this time, Medicare Value Partners (MVP), a subsidiary of PHP, has an ACO-contract for Medicare patients.

[ Back to top ]

 

4. Blue Cross Blue Shield Medicare Advantage contract: Medicare Advantage (MA) plans are also part of Medicare. These health plan options, known as Part C plans, are offered by private companies and approved by Medicare. MA plans are not supplemental insurance. These plans must provide all Part A and Part B coverage and follow rules set by Medicare, including benefit design and cost-sharing.

[ Back to top ]

 

5. Bundled payment contracts: In a bundled payment methodology, a single, "bundled" payment covers services delivered by two or more providers during a single episode of care or over a specific period of time. For example, if a patient has cardiac bypass surgery, rather than making one payment to the hospital, a second payment to the surgeon and a third payment to the anesthesiologist, the payer would combine these payments for the specific episode of care (i.e., cardiac bypass surgery).

[ Back to top ]

 

6. CAQH number: CAQH stands for the Council for Affordable Quality Health Care. Participation with CAQH drastically improves the credentialing cycle time for physicians applying to participate with health plans. Most physicians currently have a CAQH number.

[ Back to top ]

 

7. Capitated contracts: Within a capitated contract, the healthcare provider is paid a set dollar amount per month to see patients regardless of how many treatments or the number of times the physician or clinic sees the patient. The agreement is that the provider will get a flat, prearranged payment in advance per month. Whether or not the patient needs services for a particular month, the provider will still get paid the same fee.

[ Back to top ]

 

8. Clinical integration contracts: Clinical Integration (CI) contracts include “risk” contracts, such as capitated arrangements and shared savings arrangements, as well as “non-risk” contracts, such as fee-for-service arrangements with quality and other incentive programs. 

[ Back to top ]

 

9. Data use agreement: The Data Use Agreement provides a legal framework for data sharing between physicians and PHP, which is essential in a Clinical Integration program in order to improve quality of care. 

[ Back to top ]

 

10. Discount from charges contractDiscount from charges contract include fee-for-service reimbursement that is calculated as a percentage discount from billed charges. 

[ Back to top ]

 

11. Dual eligible patients/contracts: In the Medicare system, Dual Eligible patients are Medicare Part A and/or B recipients who either qualify for a Medicare Savings Programs (MSP) or  qualify for Medicaid benefits. Dual Eligibles generally qualify for the Qualified Medicare Beneficiary (QMB) benefits, in which Medicare Part A premiums, Medicare Part B premiums, Medicare Deductibles, coinsurance, and copayments are covered by Medicaid, effectively providing full health care coverage.

[ Back to top ]

 

12. EDI: Electronic Data Interchange. Refers to the use of computer technology to exchange information – or data – electronically between two organizations. EDI is a set of standards that define common formats for the information so it can be exchanged. Processes, such as the submission of health care claims by physician practices to insurance companies, are conducted through the use of EDI. 

[ Back to top ]

 

13. Health insurance exchange: Refers to the mobilization of healthcare information electronically across organizations within a region, community or hospital system. HIE provides the capability to electronically move clinical information among disparate health care  information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care. HIE is also useful to public health authorities to assist in analyses of the health of the population.

[ Back to top ]

 

14. ICLOPS: ICLOPS is a health care technology company with the tools for clinical performance measurement and improving patient outcomes.  ICLOPS partners with Presence Health and is enabling us to successfully participate in the new models of Accountable Care, Medical Home, Clinical Integration, and bundled payments. ICLOPS aggregates data from disparate systems and third party sources such as payer eligibility and claims, and provides views of the registry data through a secure web portal. Providers who are enrolled in our CI program are given the ICLOPS tools to help meet the goals of Clinical integration.

[ Back to top ]

 

15. Imagine Health: A builder of custom, high-performance networks of the highest quality providers for employers with large concentrations of employees in a single geographic area. Presence Health entered into an agreement with Imagine Health to become a provider of choice for the healthcare needs for the employees of several large companies in the area. Some providers enrolled in PHP are able to access managed care contracts through the Imagine Health agreement.

[ Back to top ]

 

16. High value custom network: Presence Health Partners sometimes creates custom networks of high-performing providers for both large and small employers. High value custom networks will become more common as employers demand a high level of value and quality in the new health care marketplace.

[ Back to top ]

 

17. Medicare Value Partners (MVP): Medicare Value Partners is a group of Presence Health physicians, hospitals and providers who work together to provide high-quality, cost-effective care to Medicare beneficiaries. MVP providers have the opportunity to earn incentives share in the savings generated for the Medicare program when they meet quality and safety benchmarks that will deliver better care at a lower cost. MVP is part of the Medicare Shared Savings Program operates as a Medicare Accountable Care Organization or “ACO”.

[ Back to top ]

 

18. Messenger model contract: Messenger model contracts are non-risk, fee-for-service, PPO-type contracts. The PHO/provider organization acts as a “messenger” to physicians for these contracts, as provider organizations are not permitted to negotiate jointly for contracts with this structure. 

[ Back to top ]

 

19. Narrow networks: Narrow networks health insurers stratify physicians and other health care providers into tiered or narrow networks in an attempt to control resource use and steer patients towards less costly providers. Patients in a tiered network frequently pay higher co-pays or coinsurance.

[ Back to top ]

 

20. Non-risk contract:  Non-risk contracts are typically fee-for-service arrangements and do not include the sharing of risk.

[ Back to top ]

 

21. Presence Health Partners: Presence Health Partners is a physician-led network of health care providers who work together to provide high-quality, efficient patient care. PHP empowers providers by giving them access to innovative technology, like our patient registry, digital patient engagement solutions and the Care Coordination program for high-risk patients.

[ Back to top ]

 

22. RBRVS: In the RBRVS system, payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into three components; physician work, practice expense and professional liability insurance. Payments are calculated by multiplying the combined costs of a service by a conversion factor (a monetary amount that is determined by the Centers for Medicare and Medicaid Services). Payments are also adjusted for geographical differences in resource costs.

[ Back to top ]

 

23. Risk contract:  Risk contracts involve the sharing of risk among the providers who participate. Examples of risk contracts include capitated arrangements and shared savings arrangements.

[ Back to top ]

 

24. Shared savings contracts: Shared savings models can be roughly divided into two categories. In the first category, if the actual total costs of all care received by the patients assigned to a physician practice is lower than budgeted costs, the practice receives a percentage of the difference between the actual and budgeted costs (i.e., a "share of the savings"). However, if actual total costs exceed the budgeted costs, the practice is not on the hook for any portion of the difference. Because the practice is only at risk for additional revenue, shared savings arrangements under the first category are sometimes said to involve only "upside" risk.

[ Back to top ]