The document discusses financial reporting requirements for organizations participating in the Michigan Primary Care Transformation Demonstration Project. It provides information on templates for reporting revenue, expenses, and membership for care coordination and practice transformation activities. It outlines reporting deadlines and requirements for documenting expenses. Guidelines are provided for reporting care management activities, retaining excess Medicaid funds, and incentivizing practices.

1. Michigan Primary Care
Transformation
Demonstration Project
September 19, 2012

2. Agenda
 Care Manager Updates
 Payer Updates
 Financial Template
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3. Why Financial Reporting
 Financial reporting ensures accountability for the
funds received
 Reporting will reconcile revenue collected and
expenses

4. Reporting Templates
 There are 4 reporting templates:
Revenue and Membership
Care Coordination
Practice Transformation
Incentive

5. Basic Components of All
Templates
 Revenue (cash collected)
 Membership ( corresponds to cash collected)
 Expense

6. Payers Included in Reporting
 Blue Cross Blue Shield of Michigan
 Blue Care Network
 Medicare
 Medicaid Managed Care

7. Reporting Deadlines
 Reports submitted on a quarterly basis for Care
Coordination and Practice Transformation
 Incentive reporting is for a 6 month period
 Data will be submitted electronically
 Details on electronic transmission will be
communicated to PO/PHO’s

8. Reporting Deadlines
 PO/PHO’s will be given 30 days after the quarter
end to submit reports
 Due dates:
• October 31, 2012
• January 31, 2013
 Data will be submitted electronically
 Details on electronic transmission will be
communicated to PO/PHO’s

9. Summary of Payer Member
Months and Revenue
 Worksheet used to summarize all payer revenues
 Care Coordination payments are made directly to
PO’s for Medicare and Medicaid Managed Care
 Care Coordination payments are made to Practices
for BCBSM and BCN
 Practice Transformation payments are made to
practices for all payers

10. Care Coordination Template
 The care coordination template identifies all
revenue and expenses

11. Care Coordination Expenses
 Care Coordination expenses are amounts spent
during the reporting period
 Expenses and FTE’s will be cross referenced to
Implementation Plan C
 Descriptions of Expenses
 Compensation, Overtime, Benefits, Training,
Education, Certification, Travel, Meeting Costs
 Other (explain)

12. Care Coordination Expense
Documentation Requirements
 The PO’s/PHO’s must complete the FTE
spreadsheet as support for Care Coordination
Expenses
 The FTE spreadsheet purpose is to reconcile
compensation and benefit expense as reported
 PO’s/PHO’s will include Implementation C plan FTE
data as a data element

13. Practice Transformation
Template
 The Practice Transformation template will present
revenue and expenses

14. Practice Transformation Reporting
Template
Revenue $5,857,357.50
PRACTICE TRANSFORMATION EXPENSES
COMPENSATION $2,000,000.00
OVERTIME $200,000.00
TRAINING $50,000.00
EDUCATION $7,500.00
CERTIFICATION $8,000.00
CARE MANAGEMENT SOFTWARE $10,000.00
COMPUTER $15,000.00
FAX $50.00
INTERFACE REGISTRY $16,000.00
MINOR EQUIPMENT $500.00
MEETING COST $125.00
PATIENT SURVEY COST $750.00
PRACTICE COACHING $50.00
POSTAGE $150.00
REFERENCE MATERIAL $650.00
RENT/SPACE $900.00
STAFF TRAINING $200.00
SUPPLIES $50.00
TELEPHONE $150.00
TRAVEL $36.00
OTHER $500.00
OTHER $1,000.00
OTHER $2,000.00
OTHER $3,000.00
Total Practice Transformation Cost $2,316,611.00
NET INCOME (LOSS) PRACTICE TRANSFORMATION $3,540,746.50

15. Practice Transformation Expenses
 Practice Transformation expenses are amounts spent
during the reporting period.
 Expenditures will be cross referenced to Practice Plan
Phase 1 item C. Expenditure deviations from the
submitted plan are permitted.
 Support for FTE’S and Expenses > $5000.00 (single
transaction) are required.
 Expenses other than Salary and Benefit cost can be
assigned on a direct cost or allocation methodology.

16. Practice Transformation Expenses
 The allocation methodology can be used for
expenses such as postage, office supplies,
telephone etc
 A column has been added to the templates for
designation D – Direct, and A‐ Allocation
 Support for FTE expenses will be the same as
required for Care Coordination
 PO/PHO’s must complete a supplemental report
for single disbursements > $5000.00

17. Excess Medicaid
Managed Care Funds
 PO/PHO’s will be allowed to roll forward no more
than 20% of Medicaid Managed Care excess of
revenue over expense for each reporting module
(Care Coordination and Practice Transformation)
 An allocation methodology will be used to
determine expense by payer using
membermonths as the basis for the allocation of
expense

18. Excess Medicaid
Managed Care Funds
 The 20% roll forward will be allowed only if
supported by documentation as to why the funds
were not expended in the year
 Amounts > 20% will be offset beginning February
2013

19. Practice Incentive Reporting
 Practice Incentive reporting is defined as all
payments received by the PO’s/PHO’s for
Medicare and Medicaid Managed Care only
 PO/PHO’s will report funds disbursed to practices
 Reporting requirements are by payer and include:
Practice name, Location, Amount, Date

20. Practice Incentive Reporting
 PO’s/PHO’s are subject to a maximum retention of
20% of the Total Incentive Dollars received
 The retention of the PO/PHO Incentive dollars
>20% requires documentation supporting the
dollars retained

21. Questions
Questions on MiPCT Financial Reporting can be
submitted to Christine Trimpe at MNO
Ctrimpe@mednetone.net

22. Overview
 Narrative Status Update
• Detail will vary by quarter
• 6 and 12 month report require practice level detail
• 3 and 9 months, brief PO‐ level overview
• Avoids duplication of SRD and Quarterly PGIP
Progress reports
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23. Narrative Status Update
 Content: based on year 1 requirements and
priorities
• Care Manager hiring progress and barriers
• Infrastructure implementation progress across
practices
• Electronic registry functionality
• Care Management documentation
• Transition notifications
• Opportunity to communicate barriers and successes
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24. Care Management Activity
Reporting
 Minimum core data:
• Number of encounters per care manager, by payer
 Will be required beginning third quarter 2012
 Necessary for reporting to participating payers
and MDCH
 Need to understand PO/practice reporting
capacity to minimize burden
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25. PDCM Payment Policy Design
 Fee‐for‐service methodology – 7 payable codes for
services performed by qualified non‐physician
practitioners
• Face‐to‐face (individual and group)
• Telephone‐based
 Payable to approved providers only
• Non‐approved providers billing for these services
are subject to recovery
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26. PDCM Codes and Fees
CODE SERVICE
G9001 Initial assessment
G9002 Individual face‐to‐face visit (per encounter)
98961 Group visit (2‐4 patients) 30 minutes
98962 Group visit (5‐8 patients) 30 minutes
98966 Telephone discussion 5‐10 minutes
98967 Telephone discussion 11‐20 minutes
98968 Telephone discussion 21+ minutes
*Net of Incentive amount
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27. Care Management Training
Guidelines
• Services provided by Moderate Care Managers
are billable once Care Managers complete
approved self‐management training
• Services provided by Complex Care Managers
are billable once care managers have completed
approved Complex Care Management training
• PDCM‐codes should not be billed by untrained
care managers
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28. Patient Eligibility
 The patient must have active BCBSM coverage
that includes the BlueHealthConnection® Program.
This includes:
• BCBSM underwritten business
• ASC (self‐funded) groups that elect to participate
• Medicare Advantage patients
Services billed for non-eligible members will be rejected with provider liability.
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29. Patient Eligibility
 Checking eligibility:
• Eligible members with PDCM coverage will be
flagged on the monthly patient list
• Providers should also check normal eligibility
channels (e.g., WebDENIS, CAREN IVR) to confirm
BCBSM overall coverage eligibility
Services billed for non-eligible members will be rejected with provider liability.
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30. Patient Eligibility
 The patient must be an active patient under the
care of a physician, PA or CNP in a PDCM‐
approved practice and referred by that clinician
for PDCM services
• No diagnosis restrictions applied
• Referral should be based on patient need
 The patient must be an active participant in the
care plan
Services billed for non-eligible members will be rejected with provider liability.
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31. Provider Requirements:
Care Management Team
 Individuals performing PDCM services must be
qualified non‐physician practitioners employed by
practices or practice‐affiliated POs approved for
PDCM payments
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32. Provider Requirements: Care
Management Team
 The team must consist of:
• A lead care manager : RN, LMSW, MSW, CNP or PA who
has completed an MiPCT‐accepted training program
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33. Provider Requirements: Care
Management Team
 Other qualified allied health professionals
 LPN, CDE, RD, Nutritionist Master’s Level,
Pharmacist, respiratory therapist, certified asthma
educator, certified health educator specialist
(bachelor’s degree or higher), licensed professional
counselor, licensed mental health counselor
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34. Provider Requirements: Care
Management Team
 Each qualified care team member must:
• Function within their defined scope of practice
• Work closely and collaboratively with the patient’s
clinical care team
• Work in concert with BCBSM care management
nurses as appropriate
Note: Only lead Care Managers may perform
the initial assessment services (G9001)
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35. Billing and Documentation:
General Guidelines
• No diagnostic restrictions
• All relevant diagnoses should be identified on the
claim
• No quantity limits (except G9001) and no location
restrictions
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36. Billing and Documentation:
General Guidelines
• Documentation demonstrating services were
necessary and delivered as reported
• Documentation identifying lead CM isn’t required,
but documentation must be maintained in medical
records identifying the provider for each patient
interaction
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