Provider Digest | Issue 11

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New Provider Manual Effective January 1, 2023

You can find our updated Provider Manual and a list of new and retired policies on our website.

Changes to the January 2023 Provider Manual include the addition of:

  • Policy 300-4180-Training and Payment for Adverse Childhood Experiences Screening (Section 3. The Role of a Primary Care Provider).
  • Policy 300-4035-Community Health Workers Requirements (Section 6. Alliance Covered Benefits and Services).
  • Electronic Visit Verification Overview, information about the process including requirements and exclusions (Section 10. Claims).
  • Policy 300-4175-Enhanced Care Management Encounter Data, and Policy 300-4185-Community Supports Encounter Data (Section 11. Care Management Services).

If you have any questions about the updates, please call Alliance Provider Services at 831-430-5504.

Best practices for maximizing CBI incentives and performance

Based on an initial analysis of Q2 Care-Based Incentive (CBI) data, many providers fall below the 50th percentile on one or more Quality of Care measures. If performance doesn’t improve in select measures, providers are at risk of receiving a CBI payment adjustment (which could be a smaller payment or no CBI payment for the 2022 calendar year).

In Q2, the measures with the highest number of providers below the 50th percentile included:

  1. BMI Assessment: Children and Adolescents.
  2. Diabetic HbA1c Poor Control >9.0%.
  3. Cervical Cancer Screening (Pap and HPV screenings and hysterectomies).

Note: While Breast Cancer Screening and Depression Screening are Quality of Care measures, they are not included in the payment adjustment calculation.

Additionally, many providers fell below the 50th percentile for pediatric measures.

To improve measure performance, our Quality Improvement team recommends:

  • Routine review of monthly quality reports to measure gaps in care.
  • Diligent utilization of the Data Submission Tool (DST).
  • Where applicable, a focus on scheduling patients for preventive services before the end of the year.

Entering data with the DST

The measures that most often dip below the 50th percentile are likely due to data gaps, which can be remedied using the Data Submission Tool (DST).

The DST is available in the Alliance’s Provider Portal under “Data Submissions.”

Please make sure you are using the DST to submit data from EHR and paper records. Data submitted through the DST can help your clinic improve compliance for CBI and Healthcare Effectiveness Data and Information Set (HEDIS) measures.

Scheduling children for preventive services

There is still time to schedule pediatric and other preventive service appointments before the close of the year. To ensure your clinic does not fall below the 50th percentile for pediatric measures, it is important that children linked to your practice are coming in for needed services in alignment with the Bright Futures periodicity schedule.

If you have questions about pulling non-compliant member lists, please contact your Provider Relations Representative at 800-700-3874, ext. 5504.

Radiology rates update

The Alliance is notifying providers that the Department of Health Care Services (DHCS) adjusted certain Medi-Cal reimbursement rates for radiology (effective Jan. 1, 2022).

Pursuant to Senate Bill 853 (Chapter 717, Statutes of 2010), DHCS has adjusted Medi-Cal reimbursement rates for radiology services so they do not exceed 80 percent of the corresponding Medicare rate. The updated radiology reimbursement rates are available on the Medi-Cal Rates page.

The Alliance has implemented the above referenced rate adjustments for claims with dates of service on or after Oct. 1, 2022. Claims adjustments will be made incrementally.

No action is required on your part. Additional information regarding these adjustments can be found on the Medi-Cal website.

For more information, please review article 5 of the August 2022 Medi-Cal Update bulletin.

Thank you for your partnership!

Stay up to date on ECM/CS trainings

To access the latest trainings on Enhanced Care Management and Community Supports (ECM/CS), visit our Webinars and Trainings page and filter the dropdown menu to “ECM-Community Supports.” You can also access answers to common ECM/CS questions on our provider ECM/CS page.

New training available: Smart Referrals (Monterey County)

This training is for Monterey County Alliance providers who give or receive referrals for Enhanced Care Management and Community Supports (ECM/CS).

Earlier this month, we hosted a training on Smart Referrals in partnership with United Way Monterey County. The training gives an overview of the Smart Referral Software and the Smart Referral Network, including:

  • How the network functions and the benefits it offers to members.
  • A list of participating organizations.
  • Smart Referral Network expectations for making referrals, responding to referrals and submitting referral data to the Alliance.

You can watch the training on our website. If you have any questions about Enhanced Care Management or Community Supports, please visit the ECM page of our website or contact the Alliance ECM team at [email protected].