At QualChoice, our goal is to make health insurance simple. To do that, we’re helping PCPs make healthcare better. We’re working with healthcare providers, other insurance firms and state and federal groups to help PCPs move from volume-based care to value-based care.

With value-based care, provider payments are partially based on the quality and efficiency of the care. Providers are rewarded for working together, for providing the right care and for achieving positive outcomes. QualChoice participates in these value-based care programs:

Comprehensive Primary Care Plus (CPC+)

Comprehensive Primary Care Plus (CPC+) is a five-year, multi-payer model that builds on the original CPC initiative (CPC Classic) to improve primary care. Participating primary care practices receive additional payment outside of the fee-for-service, including population-based care management fees for better coordination of patient care and the opportunity for performance-based incentives.

Review the CPC+ Participating Provider Training deck for an overview of the program.

  • What is the difference between CPC & CPC+? CPC+ replaced the CPC Classic program. CPC+ offers providers two separate participation tracks. The track dictates the care delivery capabilities practices will develop and the payment structure they will receive.
  • What are the benefits of CPC+? CPC Classic achieved gross savings and was nearly cost neutral, with positive quality results in its first year. These findings came earlier than expected in a model involving significant changes in the delivery of primary care. CPC+ looks to build on these results by offering two tracks with different payment options to better accommodate the diverse needs of primary care practices.
  • What are the different participation tracks and what is the difference between them? There are two different participation tracks. Both will receive care coordination fees during the year and performance payments if they meet quality and utilization metrics after the completion of the first year.
    • Track One Will Be Paid: Fee-For-Service (FFS) from payers as usual throughout the five years.
    • Track Two Will Be Paid: Reduced Fee-For-Service (FFS) and comprehensive primary care payments, beginning January 1, 2018. After 3 years, further reductions may apply to the payments in a phased approach.

Patient-Centered Medical Homes (PCMH)

The Patient-Centered Medical Homes program is also a multi-payer model to improve primary care. Participating primary care practices are compensated in the same way as in the CPC+ program.

Review the PCMH Participating Provider Training deck for an overview of the program.

Frequently Asked Questions

General Information

  • What is the purpose of these programs?  The CPC+ and PCMH programs were designed to test improved payment and service delivery models, to achieve better care for patients, smarter spending and healthier communities. Payment redesign offers greater cash flow and flexibility for primary care practices to deliver high-quality, whole-person, patient-centered care while lowering the use of unnecessary services that drive total costs of care.
  • How are primary care practices encouraged and rewarded for their accountability for patient experience, clinical quality and utilization?  We pay a performance-based incentive retrospectively if they meet annual performance thresholds.

Participating Practices

  • Which payers are participating? 
    • CPC+ participants in Arkansas are QualChoice, Medicare, Medicaid, Arkansas Health and Wellness Solutions, HealthScope, Arkansas Superior Select and Arkansas Blue Cross Blue Shield.
    • PCMH participants are QualChoice, Medicaid, Arkansas Health and Wellness Solutions and Arkansas Blue Cross Blue Shield.

All payers are participating with the common goal of improving primary care to the patient.

    • How were practices selected for these programs? 
    • CPC+ Practices were selected through a competitive application process based on their:
      • Use of health information technology
      • Ability to demonstrate recognition of advanced primary care delivery by accreditation bodies
      • Service to patients covered by participating payers
      • Participation in practice transformation and improvement activities
      • Diversity of geography, practice size and ownership structure
    • PCMH Practices were selected through an application process with Arkansas Medicaid. If selected as a PCMH practice with Medicaid, practices are eligible to participate in the QualChoice PCMH program.
  • Are practices required to participate in CPC+ for the full five years? Practices that participate are expected to do so for the full five years. However, participation is voluntary and practices may withdraw without penalty.
  • What must a practice do to withdraw from the programs? 
    • CPC+ practices must notify CMS at least 90 calendar days before the planned day of withdrawal. They may also notify QualChoice directly of their intent to withdraw.
    • PCMH practices are required to notify QualChoice at least 90 calendar days before the planned day of withdrawal.

Member Rosters

  • How do I know which members are CPC+ or PCMH members? QualChoice will post a list of your members monthly on the CPC+ or PCMH landing page in the My Account provider portal.
  • How can I make changes to my CPC+ member roster? QualChoice has two distinct sets of membership within CPC+:
    • Individual Metallic Health Plans — these members are required to actively select their PCP. If the member has selected a PCP in your clinic, then they are assigned to you. The member will remain on your attribution report until they inform us that they have selected a new PCP.
    • All other QualChoice non-self funded members are attributed to a PCP based on past claims history. They will be reattributed if their claims history indicates they have changed PCPs.

Performance – Quality and Utilization Metrics

  • What are the performance thresholds?  The performance thresholds are broken into two distinct components, on which QualChoice will pay performance-based incentives retrospectively:
    • Performance on clinical quality/patient experience is based on specific quality performance measures and Consumer Assessment of Healthcare Providers and Systems (CAHPS) metrics.
    • Performance on utilization is based on claims-based measures commonly used to determine total cost of care and measurable at the practice level [e.g., inpatient admissions and emergency department visits that are available in the Healthcare Effectiveness Data and Information Set (HEDIS)].
  • Where are the metrics listed?  Quality and utilization metrics can be found in your QualChoice CPC+ or PCMH provider contract. These metrics are also summarized in the CPC+ and PCMH training decks.
  • What are the targets for each measure?  There are no fixed targets. The mean (mathematical average) has to be calculated for every performance metric, based on the data we receive. The goal is to perform above average (better than peers).
  • How are the quality metric thresholds calculated?  Each quality metric will have an arithmetic mean of performance across all participating practices. The goal is to have “above average” performance (better than the arithmetic mean—whether better means higher or lower) compared to other practices. The quality threshold (to be eligible for performance incentives) is above-average performance relative to other practices on all combined quality metrics. This means a practice may or may not perform above average on every single quality metric but may still achieve overall, combined above-average performance.
  • How does a practice earn a performance payment?  Performance incentive payments to practices are based on quality and utilization metric reports. Eligibility for performance payment requires above-average performance relative to other participating practices on all combined quality metrics. This means that a practice may or may not perform above average on every single quality metric, but may still achieve overall combined above-average performance for quality and, therefore, will be eligible for performance payment. The performance on utilization metrics will then be considered and subject to the same methodology.

Care Plans

  • What percent of members require submission of a care plan date?  QualChoice requires care plan dates to be submitted on the top 10% of high-risk members.
  • How do we determine which patients need care plans?  The practice (not QualChoice) must identify their top 10% of highest risk/tier patients. Every practice may not have tier 4 or tier 5 patients. The highest risk members will require care coordination as well.
  • What care plan information is required?  At this time, we do not require specific information or format for care plans. We require only the dates when care plans were created or updated.
  • How do I submit care plan dates?  Sign in to My Account at QualChoice.com. In the CPC+ or PCMH section, follow the links to search members and submit care plan dates.
  • When are care plans submitted?  Care plan dates must be submitted once every six months for each of the top 10% high-risk patients in your practice.

Payments

  • How are primary care practices paid?
    • Care Management Fee (CMF):  This is a non-visit based, retrospective payment Per Member Per Month (PMPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for a practice’s specific population. Practices will use this enhanced, non-visit-based compensation to augment staffing and training in support of population health management and care coordination.
    • Performance-Based Incentive Payment:  QualChoice will pay retrospectively and annually an incentive payment based on how well the practice performs on clinical quality measures and on utilization measures that drive total cost of care. The incentive payment will be based on both quality and utilization reports. Reporting data will be collected from claims and Category II CPT Codes (non-billable codes). Each practice should have minimum of 50 attributed members captured on a quarterly attribution report to qualify for performance incentive payment.
    • CPC+ Payment Tracks:

Participants in both tracks will receive care coordination fees and performance payments in the first year.

      • Track One practices will continue to receive their regular fee-for-service payments for covered evaluation and management services throughout the five years.
      • Track Two practices receive a hybrid of fee-for-service and Comprehensive Primary Care Payment (CPCP). The hybrid value-based reimbursement pays for covered evaluation and management services, but allows flexibility for the care to be delivered outside of a traditional office visit. Over the next 3 years, fee-for-service payments will be reduced and value-based payments increased, in a phased approach.
  • Why do different payers pay different fees?  Each payer determines their own financial support to practices, separately from that of normal fee-for-service.
  • When is the care management fee PMPM paid and how much is the payment?  Care management fees are paid quarterly. The payment is issued in the month following the end of a quarter. Your care management fees are outlined in your QualChoice CPC+ or PCMH provider contract.
  • How will a provider recognize the care coordination payments on their Remittance Advice?  Care coordination payments will be made through normal claims payment. Clinics will see a claim payment for assigned members under CPT code CPCPO for CPC+ or CPT code PCMH1 for PCMH. For example, the provider RA will show a claim for an assigned member for a date of service in April, May or June for CPT code CPCPO or PCMH1 with the assigned PMPM amount as the allowed amount.
  • What is the timeline for performance incentive payments?  An annual performance incentive payment will be made to eligible practices during the quarter following the performance year.
  • How will the amount of the incentive bonus be determined?  The amount of the payment will depend on the degree of variance from the average. In other words, the higher the practice performance above the average of practices, the higher the payment amount.

Performance Reports

  • How do providers submit reports? Sign in to My Account at QualChoice.com to upload your reports.
  • What is the timeline for attribution and performance reports?  CPC + member rosters are published the first of each month. PCMH member rosters are published at the end of each month. Performance reports are published quarterly. PCMH reports will begin in fall 2018 when there is sufficient data for publication.

Training and Additional Information

Online Program Information and Services

  • Where do I submit care plans and find reports?  Go to QualChoice.com and sign in to the My Account provider portal. On your Provider Home page, look for the CPC+ or PCMH section at right.
  • How do I sign up to be a portal user? Download and complete the Provider Portal Administrator and User Access Forms.