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Pay-for-Performance Program (P4P)

Revised: 10-25-2013

Cardiovascular Disease & Diabetes

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Billing
  • Definitions
  • Legal References
  • Overview

    In 2008, MHCP implemented a P4P program for MHCP fee-for-service (FFS) providers. The program awards $250 up to two times every 12 months when physicians or advance practice registered nurses (APRNs) render optimal chronic disease care to their qualifying MHCP recipients with cardiovascular disease or diabetes or both. MHCP will use a combination of four clinical results for cardiovascular disease and five treatment measures for diabetes to determine if the provider is eligible for a results payment.

    Clinical results for optimal care are:

  • • HbA1c: < 8 (optimal diabetes requirement only)
  • • Lipids: LdL–C: < 100 performed annually
  • • Blood pressure: < 140/90
  • • Aspirin: the client is over 40 and taking aspirin daily
  • • Tobacco: documented absence of any tobacco use

  • Each successful P4P request is paid individually. It will appear on the Remittance Advice and include the recipient and payment information.

    P4P rewards requests will be denied if the NPI/UMPI does not exactly match the location where the provider rendered the associated clinical evaluation and management procedures and laboratory services. Providers must select the correct clinic location when submitting claims with a consolidated NPI/UMPI or MHCP will deny the claim.

    Providers must resubmit the reward request with the correct NPI/UMPI to receive the reward payment if the initial request is denied. Refer to the Billing section for directions on submitting a request.

    If a documented contraindication for aspirin exists, the recipient may not be disqualified. In those instances, MHCP has a limited P4P exception process to evaluate claims that would not normally meet the target for a results payment.

    Eligible Providers

    The following enrolled provider types are eligible to receive payment for this service:

  • Clinic
  • Clinical Nurse Specialist
  • Community Health Clinic
  • Critical Access Hospital
  • Federally Qualified Health Center (FQHC)
  • Hospital
  • Indian Health Service (IHS)
  • Nurse Practitioner
  • Physician
  • Public Health Clinic
  • Rural Health Clinic (RHC)
  • Tribal Health Facility

  • Eligible Recipients

    MHCP FFS recipients of Medical Assistance (MA) and MinnesotaCare are eligible for this service if they meet the following criteria:

  • • Are between ages 18-75
  • • Have a diagnosis in one or both of the following categories:
  • • Diabetes (ICD diagnosis codes: 250 – 250.93, 357.2, 362.0-362.07, 366.41)
  • • Cardiovascular disease (ICD diagnosis codes: 410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 411.0, 411.1, 413.0, 413.1, 413.9, 414.0, 414.8, 414.9)
  • Ineligible Recipients

    Recipients not eligible for the cardiovascular disease or diabetes P4P program are those:

  • • Eligible for or receiving Medicare
  • • Diagnosed with gestational diabetes
  • • Electing hospice at any time during the measurement period
  • • Deceased prior to the end of the measurement period

  • Indian Health Services (IHS) providers may not collect a P4P results payment for recipients enrolled in the MHCP Programs MA, EH, RM, and Minnesota Care FF and LL.

    Billing

    Providers must document the required clinical results in the patient medical record. Results must be associated with the six-month period immediately preceding the submitted transaction in MN–ITS Interactive.

    To receive the P4P results payment, the claiming provider must have:

  • • Seen the recipient at least two times for the specific diabetes or cardiovascular disease or both diagnoses
  • • Obtained corresponding lab test results
  • • Received payment from MHCP for the necessary physician visits and lab tests

  • Providers rendering optimal care to recipients with both qualifying diagnostic categories in a 180-day period may receive two results payments per qualifying recipient.

    Providers must:

  • • Complete the appropriate P4P transaction in MN–ITS Direct Data Entry (DDE)
  • • Verify the NPI/UMPI is the exact clinic location where the patient received the required health care services. If the number is not the exact clinic location the rewards request will deny.
    Resubmit the reward request with the correct NPI/UMPI of the exact clinic location where the patient received the required health care services.
  • • Document all results in the recipient’s medical record for periodic audits

  • For questions about denial reasons or the NPI/UMPI, contact the Provider Call Center at 651-431-2700 or 1-800-336-5411.

    FQHC & RHC

    Claims to support P4P must include appropriate revenue and HCPCS/CPT codes.

    For FQHCs/RHCs to be eligible to earn P4P results payments, a physician or an APRN must provide the services.

    Exception Process

    Recipients with a medical contraindication for aspirin (allergy or taking a medication that should not be used with aspirin) must submit documentation for approval before a results payment can be awarded. If you indicated the recipient qualifies for this exception, after submitting the P4P results print the response page, attach the required documentation, and mail or fax (secure fax is preferred) to MHCP for review at:

    PMQI Division
    P O Box 64986
    St Paul, MN 55164-0986
    Fax: (651) 431-7577

    Definitions

    Optimal Diabetes Care: Compliant with all five of the clinical results for optimal care listed.
    Optimal Cardiovascular Care:
    Compliant with four of the clinical results for optimal care listed.

    Legal References

    MS 256.01, subd. 2b Performance payments

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