2016 Quality Bonus Program for Pcps

PROVIDER INCENTIVE PROGRAM

2016 Quality Bonus Program for PCPs

PCP’s contracted with Brand New Day are entitled to receive an incentive of $150 per member (once a year) for thoroughly completing a Brand New Day Annual Physical Exam form. This bonus is paid directly to the Physician (PCPs) in addition to any reimbursement given to them by the IPA or Medical Group.

PROCESS

The Primary Care Physician completes the attached Annual Physical Exam Form making sure to thoroughly address all body systems and documenting ALL Chronic Conditions. If the Provider is using a template from their Electronic Medical Record (EMR), Provider must attach a copy to the Annual Physical Exam form ensuring they have addressed all areas included on the Brand New Day Physical Exam form.

Qualifying Quality Bonus requirements:

o Address every section of the APE Form / o Attach any applicable Progress note
o Order All applicable Labs, Test & Exams / o Complete W-9 form (blank one attached)

SUBMISSION

Annual Physical Exams must be submitted directly to Brand New Day in order to qualify for the bonus. Please send the Quality Bonus Claim to Brand New Day as follows:

By mail to:
Risk Adjustment Department
Attention: Mechelle Reed
Brand New Day
Quality Bonus Program (or QBP)
5455 Garden Grove Blvd., 5th Floor
Westminster, CA 92683
Or by FAX:
QBP
Attention: Mechelle Reed
Fax # 714-933-4812

Please contact provider relations for any follow up questions or concerns regarding the Quality Bonus at:

Brand New Day Health Plan would like to thank you for participating in the Quality Bonus Program.

ANNUAL PHYSICAL EXAMINATION
PATIENT NAME: / PATIENT ID #: / DATE: / /_ /
DOB:
PCP NAME: / GENDER:

Medical Assistant to complete

Check the Appropriate “BMI” Code:

¨ BMI 19 (Z68.10); ¨ BMI 20.0-20.9 (Z68.20); ¨BMI 21.0-21.9 (Z68.21); ¨BMI 22.0-22.9 (Z68.22);

¨ BMI 23.0-23.9 (Z68.23); ¨BMI 24.0-24.9 (Z68.24); ¨BMI 25.0-25.9 (Z68.25); ¨BMI 26.0-26.9 (Z68.26); ¨BMI 27.0-27.9 (Z68.27);

¨ BMI 28.0-28.9 (Z68.28); ¨BMI 29.0-29.9 (Z68.29); ¨BMI 29.0-29.9 (Z68.29); ¨BMI 30.0-30.9 (Z68.30); ¨BMI 31.0-31.9 (Z68.31); ¨BMI 32.0-32.9 (Z68.32)

¨ BMI 33.0-33.9 (Z68.33); ¨BMI 34.0-34.9 (Z68.34); ¨BMI 35.0-35.9 (Z68.35); ¨BMI 36.0-36.9 (Z68.36); ¨BMI 37.0-37.9 (Z68.37); ¨BMI 38.0-38.9 (Z68.38)

¨ BMI 39.0-39.9 (Z68.39); ¨BMI 40.0-40.9 (Z68.41); ¨BMI 45.0-45.9 (Z68.42); ¨BMI 50.0-50.9 (Z68.43); ¨BMI 60.0-69.0 (Z68.44); ¨BMI 70 or greater (Z68.45)

Check the Appropriate “Blood Pressure” Procedures (SBP =Systolic BP; DBP =Diastolic BP):

¨ SBP 130 (3074F); ¨ SBP 130-139 (3075F); ¨ SBP 140 or over (3077F); ¨ DBP 80 (3078F); ¨ DBP 80-89 (3079F); ¨ DBP 90 or over (3080F)

Medical Assistant to complete questions 1-9 Physician to score

DEPRESSION SCREEN (PHQ9)
Over the last 14 days, how often have you been bothered by any of the following problems? / 0 / 1 to 6 / 7 to 11 / 12 +
1 / Little interest or pleasure in doing things / 0 / 1 / 2 / 3
2 / Feeling down, depressed or hopeless / 0 / 1 / 2 / 3
3 / Trouble falling asleep, staying asleep, or sleeping too much / 0 / 1 / 2 / 3
4 / Feeling tired or having little energy / 0 / 1 / 2 / 3
5 / Poor appetite or overeating / 0 / 1 / 2 / 3
6 / Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down / 0 / 1 / 2 / 3
7 / Trouble concentrating on such things as reading the newspaper or watching TV / 0 / 1 / 2 / 3
8 / Moving or speaking so slowly that other people could have noticed or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. / 0 / 1 / 2 / 3
9 / Thinking that you would be better off dead or that you want to hurt yourself in some way / 0 / 1 / 2 / 3
Diagnosis Guide / Total Score: Depression Severity:
1 – 4 Minimal depression
5 – 9 Mild depression
10 – 14 Moderate depression
15 – 19 Moderately severe depression - Refer to Case Management
20 – 27 Severe depression - Refer to Case Management / Total Score
Total circled numbers
Unable to complete the depression assessment due to:
¨ Unresponsive ¨ Uncooperative ¨ Severe Dementia ¨ Patient Refused ¨ Other (explain below)
On Treatment for Depression? Yes ¨ No ¨
Additional Notes/Comments:

Medical Assistant to complete

CURRENT MEDICATIONS (Prescription and Over-The-Counter medicine): Include Over-the-Counter and Herbal Medications Attach a page if more space is needed
# / Drug / Dose / Route / Frequency
1
2
3
4
5
6
ANNUAL PHYSICAL EXAMINATION
PATIENT NAME: / PATIENT ID #: / DATE: / /_ /
DOB:

Check both the “Medication List” and “Medication Review” Codes: ¨ Medication List ( 1159F ); ¨ Medication Review ( 1160F )

Medical Assistant to complete

Medical Assistant to complete

PAIN ASSESSMENT
Do you have pain? / ¨  No / ¨  Yes / If yes, Location:
Intensity (circle one) / Scale: 0 1 2 3 4 5 6 7 8 9 10
None Moderate Severe
How long?
What do you take to help?
Comments:
Check at least one appropriate “Pain Screening” Code:

¨ Plan of care to address pain documented ( 0521F ); ¨ Pain severity quantified, Pain Present ( 1125F ); ¨ Pain severity quantified, NO Pain present ( 1126F )

Physician to complete

FALL RISK ASSESSMENT
(Assess the below given Functions) / Yes / If Yes, Specify / No / Comments
High Risk for Fall
Cognitive Impairment
Plan:
Housing assessment needed? / ¨ Yes ¨ No / If yes, order review from Brand New Day (refer to Case Management).

Physician to complete

HISTORY
ALCOHOL / TOBACCO DRUGS RISK SCREEN / Have you ever smoked cigarettes, a pipe or cigars or chewed tobacco? ¨ Yes ¨ No
If Yes, how much and for how long? Do you ever drink alcohol? ¨ Yes ¨ No
If Yes, how much?
Have you ever used any street drugs or taken prescription medications that were not prescribed for you? ¨ Yes ¨ No If Yes, what drugs/meds? For how long?
PERSONAL HISTORY / Marital Status: ¨ Married ¨ Single ¨ Divorced Advance Directive ¨ Yes ¨ No
PAST SURGICAL HISTORY
ANNUAL PHYSICAL EXAMINATION
PATIENT NAME: / PATIENT ID #: / DATE: / /_ /
DOB:

Physician to complete

If system deferred, check here / PHYSICAL EXAM
(Please complete thoroughly each section unless exam component was deferred)
Normal / Abnormal / Describe Finding
¨ / GENERAL
¨ / HEAD
¨ / EYES
¨ / ENT
¨ / NECK
¨ / RESP
¨ / CV
¨ / CHEST / BREAST
¨ / GI
¨ / GU
¨ / LYMPH
¨ / MS
¨ / SKIN
¨ / PSYCH
¨ / NEURO
OTHER LAB RESULTS
(state specific findings add diagnosis to assessment/plan)
OTHER XRAY RESULTS
(state specific findings add diagnosis to assessment/plan)
ANNUAL PHYSICAL EXAMINATION
PATIENT NAME: / PATIENT ID #: / DATE: / /_ /
DOB:
PREVENTIVE CARE
SCREENING CHECKLIST
SCHEDULED / YES / COMPLET NO / ED
N/A / ORDERED
Flu Vaccine in current season
Patients 65 yrs. and older: Pneumococcal vaccine
Patients 50 yrs. and ¨ Flex Sig in last 5 years older: ¨ Colonoscopy in last 10 years
¨ Fecal occult blood in current year
Patients 65 yrs. and older: Glaucoma test by ophthalmologist or optometrist
Male Only
Lipid disorder screening
Abdominal aortic aneurysm screening after 55 years old
Female Only
Women 50-74 yrs. and older: Mammogram in current or prior year
Women with bone fracture in last 6 months: Bone density test OR on medication to treat or prevent osteoporosis.
Patient with Cardiovascular Disease
Patients with cardiovascular conditions in current or prior year.
---Lab test for LDL-C in current year
---Most current LDL-C value in current year in <100mg/dL
Patient with Diabetes
Lab test for HbA1c in current year
---Most current HbA1c value is <8.0%
Retinal eye exam in current year
Lab test for LDL-C in current year
---Most current LDLC value is 100 mg/dL
Most current blood pressure is <150/80
Microalbumin test in current year OR patient on ACE or ARB
Patient with Rheumatoid Arthritis
Patients with diagnosis of RA should be on DMARD
Patient with COPD
Spirometry test to confirm diagnosis within 1 year of diagnosis
Patient on Certain Medications
Patient ACE inhibitor or ARB OR diuretics OR Digoxin for 6 months or more in current year have these labs:
Potassium AND BUN OR Creatinine
Patients on Anticonvulsants for 6 months or more should have a lab blood level of that medication.
Patient with Hypertension
Most current blood pressure in current year is <140/90
60 years +, Non Diabetic <150/90
Other Needed Services
ANNUAL PHYSICAL EXAMINATION
PATIENT NAME: / PATIENT ID #: / DATE: / /_ /
DOB:
IMPRESSION / PLAN
DIAGNOSIS DESCRIPTION / STATUS OF DIAGNOSIS / PLAN OF CARE / CURRENT RX
¨ Stable ¨ Declining ¨ End Stage
¨ Stable ¨ Declining ¨ End Stage
¨ Stable ¨ Declining ¨ End Stage
¨ Stable ¨ Declining ¨ End Stage
¨ Stable ¨ Declining ¨ End Stage
¨ Stable ¨ Declining ¨ End Stage
¨ Stable ¨ Declining ¨ End Stage
¨ Stable ¨ Declining ¨ End Stage
¨ Stable ¨ Declining ¨ End Stage
DIABETIC DIAGNOSIS / STATUS OF DIAGNOSIS / PLAN OF CARE / CURRENT RX
¨ Diabetes / ¨ Stable ¨ Declining ¨ End Stage
¨ Diabetic Nephropathy / ¨ Stable ¨ Declining ¨ End Stage
¨ Diabetic Neuropathy / ¨ Stable ¨ Declining ¨ End Stage
¨ Diabetic Peripheral Angiopathy / ¨ Stable ¨ Declining ¨ End Stage
¨ Diabetic Retinopathy / ¨ Stable ¨ Declining ¨ End Stage
¨ CKD due to Diabetes / ¨ Stable ¨ Declining ¨ End Stage
¨ Diabetic PVD / ¨ Stable ¨ Declining ¨ End Stage
¨ ESRD due to Diabetes / ¨ Stable ¨ Declining ¨ End Stage
DIAGNOSIS DESCRIPTION / STATUS OF DIAGNOSIS / PLAN OF CARE / CURRENT RX
¨ CHF / ¨ Stable ¨ Declining ¨ End Stage / ¨ Echo – EF:_
¨ ACE Inhilator:
¨ COPD / ¨ Stable ¨ Declining ¨ End Stage / ¨ Spirometry Resoults: FEV:
PATIENT EDUCATION:
¨ Advance Directives ¨ Asthma ¨ Breast Self Exam ¨ Cholesterol ¨ Diabetes
¨ Diet ¨ Exercise ¨ Family Planning ¨ Hypertension ¨ Immunizations
¨ Medications ¨ Obesity ¨ Medication Adherence ¨ STD’s ¨ Substance Abuse
¨ Testicular Self Exam ¨ Tobacco Cessation ¨ Tuberculosis ¨ Fall Prevention ¨ Other
Check at least one appropriate “Advance Care Plan” code:

¨ Advanced Care Plan or other legal document present in medical record (1157F); ¨ Advanced Care Plan discussion documented in medical record (1158F)

Print Provider Name: Print Group Name:

Provider Signature: (check one) ¨ MD ¨ DO ¨ NP ¨ PA

BMI; Blood Pressure (SBP and DBP); Medication List and Medication Review; Functional Status Assessment; Pain Screening;Advance Care Plan

The HEDIS and Five-Star Quality Rating System, or Star Ratings, documentation guidelines are provided to assist you in your ongoing participation in the Optum Healthcare Quality Patient Assessment Form (HQPAF) program. Medical records returned with the HQPAF can be used to support our clients’ HEDIS and Star Ratings data collection efforts. This tool may help ensure you have included all the necessary documentation.

For more information on HEDIS and the Star Ratings, please ask your Optum Healthcare Advocate for a copy of our Quick reference guide: Codes for the Five-Star Quality Rating System and HEDIS (Healthcare Effectiveness Data and Information Set) measures.

A referral will not meet HEDIS compliance for an open care opportunity. Documentation in the medical record must include date/results as defined by specific measure criteria.

Quality measure / HEDIS and Star Ratings requirements / Documentation guidelines
Care for Older Adult (COA) Advance Care Planning (Special Needs Plan measure) / Recommended during the calendar year for adults 66 years and older. / Progress notes documenting the discussion (including date) is sufficient to demonstrate the required interaction with the patient. The documentation of discussion must be in the measurement year.
Body mass index
(BMI) / Screening is recommended for all patients age 18-74. / Medical record must indicate weight and BMI value, dated during the measurement year or year prior to measurement year.
Breast Cancer Screening / Screening is recommended for female patients age 50-74, who have not had a mammogram in the 27 months prior to 12/31 of the current year. / Medical record stating date mammogram was completed or diagnostic report or documentation of exclusion reason (two unilateral mastectomies or bilateral mastectomy).
Colorectal Cancer Screening / Screening is recommended for patients age 50- 75, who have not had any of the following:
  FOBT in the current calendar year
  Flexible sigmoidoscopy during current or 4 prior calendar years
  Colonoscopy during current or 9 prior calendar years / Medical record stating screening was completed on a specified date with/without result or radiology/lab report or documentation of exclusion reason (colorectal cancer or total colectomy).
Care for Older Adult (COA) Comprehensive Pain Assessment (Special Needs Plan measure) / Recommended that adults 66 years and older have at least one pain assessment during the calendar year. / Medical record with documentation of comprehensive pain assessment or result of assessment using standardized pain assessment tool.
Diabetes: Eye exam / Exam is recommended for patients with diabetes, age 18-75, who have not had a dilated eye exam by an optometrist or an ophthalmologist in the current calendar year. / Medical record stating screening was completed during calendar year by an acceptable provider with results or the consultation report or progress note documentation of date of referral. Documentation of a negative retinal or dilated exam (negative for retinopathy) in the prior year by an eye care professional meets the requirement for this screening.
Diabetes:
HbA1c Screening / Test is recommended for patients with diabetes, age 18-75, who in the current calendar year:
  Have an HbA1c result over 8% or
  Have not had an HbA1c test
  Star Ratings measure defines HbA1c levels
>9.0% as poorly controlled. / Medical record stating screening was completed during calendar year with result or lab report.
Diabetes: Hypertension / Screening is recommended for patients with diabetes, age 18-75, and controlled to <140/90. / Medical record stating that blood pressure was completed during calendar year with result.
Diabetes: Nephropathy Screening / Screening is recommended for patients with diabetes, age 18-75, who have not had a diabetic nephropathy screening in the current calendar year. Patients seeing a nephrologist are excluded. /   Medical record stating micro albumin was completed during calendar year with the result or lab report
  Medical record stating that the patient is on an ACE/ARB medication or has been referred to a nephrologist
 
Quality measure / HEDIS and Star Ratings requirements / Documentation guidelines
Care for Older Adult (COA) Functional Status Assessment (Special Needs Plan measure) / Recommended that adults 66 years and older have at least one functional status assessment during the calendar year. / Notations for a complete functional status assessment must include one of the following: 1. Assessment of instrumental activities of daily living (IADL) such as shopping for groceries, driving, using public transportation, using the telephone, meal preparation, housework, home repair, laundry, taking medications or handling finances, etc. OR 2. Assessment of activities of daily living (ADL) such as bathing, dressing, eating, transferring (i.e., getting in and out of chairs), using the toilet and walking OR 3. Results using a standardized functional status assessment tool OR 4. Assessment of three of the following four components A) Cognitive status B) Ambulation status C) Sensory ability ( must include hearing, vision, and speech) D) Other functional independence (e.g., exercise, ability to perform job) 5. A functional status assessment limited to an acute or single condition, event, or body system (e.g., lower back, leg) NOT meet criteria for a comprehensive functional status assessment.
Hypertension: Controlling Blood Pressure / Patients with diagnosis of high blood pressure who receive treatment and are able to maintain a healthy pressure during the calendar year:
  <140/90 for patients 18–59 years of age or patients 60–85 years of age with a diagnosis of diabetes
  <150/90 for patients 60–85 years of age without a diagnosis of diabetes / Medical record stating hypertension diagnosis and that blood pressure was completed on a specified date with result.
Documentation must be from provider managing condition.
Exclusions are: patients with ESRD (dialysis) or kidney transplant; a diagnosis of pregnancy during year; or nonacute inpatient admission during year.
Medication Review (Special Needs Plan measure) / Recommended that adult 66 years and older have an annual review all medications (prescriptions, OTC, herbal/supplemental therapies). / Medication list and evidence of medication review by prescribing practitioner or clinical pharmacist, including date when performed or notation that member is not taking any medication and date when noted.

*Requires that vision, speech and hearing all be assessed.