Quality Partners Provider Partnership Participation

Christiana Care Quality Partners has created physician partnerships throughout Delaware. As of June 27, more than 1,400 physicians, mainly across New Castle County, participate in Quality Partners. All of these clinicians are available as in-network providers to Christiana Care’s employees and their dependents, beginning July 1.
These partnerships represent approximately 95 percent of the local primary and specialty care physicians. Almost all specialty areas have eclipsed the 90 percent threshold, including such areas as cardiology, obstetrics and gynecology and orthopaedics. Christiana Care Health System and its employees have indicated a high level of satisfaction with the network.

The one specialty area with less significant physician participation is dermatology. Here is a list of the in-network dermatologists accepting new patients.

For a list of participating physicians, visit www.thehealthplan.com/cchs. You can also call the Quality Partners Provider Relations office at 302-623-7959. Participating providers may not be listed in the Provider Directory due to a timing issue of getting their names listed after they have received approval from the Quality Partners Credentialing Committee.

Christiana Care Quality Partners Board and Committee Structure

Quality Partners is a wholly-owned subsidiary of Christiana Care Health Services. This limited liability company operates with a separate Board of Managers and several committees that guide the work of the board. Physicians throughout the community staff the committees with a majority – 75 percent of the 63 – coming from the private physician community. This diagram displays this structure and identifies the clinician members that make up each committee.

Claims Payment and Adjudication Update

• Sign up for Electronic Funds Transfer (EFT) – Get your reimbursement faster and easier via EFT by clicking below, completing the form, and faxing it back to (570) 214-1553. Click here to fill out the EFT enrollment form.
• Sign up for NaviNet – If you already use NaviNet, click here to set up access with Geisinger. If you are new to NaviNet, click here to sign up. If you have been unable to find Geisinger and/or sign up for NaviNet thus far, please try again. If you continue to experience problems, please call us at 302-623-7959 for further assistance.
• Modifiers – Geisinger Health Options and Quality Partners recognize all modifiers listed in the latest edition of the AMA CPT-4 Coding Manual. Many of these are listed in the full Quality Partners Provider Manual. One modifier to take note of is modifier -25.  Many of you are aware that this modifier is used when a significant, separately identifiable E&M service is provided by the same physician on the same day of a procedure of other service. Upon Geisinger’s recommendation, Quality Partners may require clinical documentation to support the use of this modifier. However, there are also several instances when this requirement is not necessary and claims will not suspect and are NOT subject to the clinical documentation expectation. Contact your Provider Relations Representative if you want to discuss this further.
• Weekend and Evening Office Hours – In support of the Triple Aim of better care, better health, and improved value, Quality Partners recognizes that patient access is an important for success. The Quality Partners Reimbursement Committee and Board of Managers have approved the use of CPT codes 99050 and 99051. 
  • Code 99050 can be used when services are provided in the office at times other than regularly scheduled office hours or days when the office is normally closed (holidays, Saturday or Sunday) in addition to basic service.
  • Code 99051 can be used when services are provided in the office during regularly scheduled evening, weekend or holiday office hours, in addition to basic service.
  • Quality Partners appreciates any efforts made on behalf of practices to alter their office hours to more closely match the community need for such services. These codes and the associated Program Rate ($25) is one example of Quality Partners’ willingness to adopt innovative programs with the hope of advancing care and service locally.
• Quality Partners Identification Card – Christiana Care employees and dependents that live in Delaware started receiving new identification cards the week of June 23. Contact your Provider Relations representative if you have any questions.

Population Health Management

Population health management has become a core competency for a medical community to attain a higher success in advancing the Triple Aim of better care, better health and improved value. Quality Partners and Christiana Care Health System are partnering with Geisinger Health Options to establish a framework to support this initiative. This program will initially begin with the July 1 go-live for Christiana Care employees and dependents. 

“To be effective, a population health program requires input from primary care physicians,” said Alan Greenglass, M.D., Medical Director and Chief Executive Officer, Quality Partners. “That’s how Christiana Care knows where to focus efforts and resources to improve the health of our employees and dependents.”

The theory behind population health is that it’s more efficient and effective to focus on care for a defined population. The first step is to identify those who need more care – those with chronic or complex conditions such as diabetes, heart failure or hypertension.

That’s where case managers come into play. Through our partnership with Geisinger Health Plan, Christiana Care offers trained case managers to help these patients. These nurses, employed by Geisinger Health Plan, help coordinate the patient’s care through all parts of the health care system. They work closely with the patient, the patient’s family and all the patient’s health care providers to ensure the patient gets the appropriate care. This extra assistance, in close collaboration with the member’s other care providers, keeps patients healthier and improves their quality of life.  

For those who are relatively healthy, we can identify preventive tools, such as screenings and education, to help them live the best life possible.

By focusing on population health, we are better able to support our physician community and to help our employees and their dependents get the help they need.

We believe that this success begins with the member/physician relationship. Christiana Care has emphasized this theme with its employees in Focus articles and town hall meeting. During the benefits open enrollment process, employees identified their primary care physician. 

Tel-A-Nurse Program

Christiana Care employees and dependents now have access to a Tel-A-Nurse program through Geisinger Health Options. This telephone accessed system is available 24 hours a day, seven days a week. Members can speak to a nurse or go online for non-emergency medical advice. This resource does not replace the member’s physician and should not serve as a substitute to any answering services in place through the physician’s office. Read the Tel-A-Nurse brochure for more information.

Medical Management

The efficient and effective use of medical services is essential for members of any plan to achieve the clinical outcomes desired and is also a core element to the ultimate determination of value in the health care system. For Quality Partners, the Clinical Operations Committee has the primary responsibility for recommending to the Board of Managers the preferred approach associated with the topic of medical management.

From Quality Partners perspective, medical management broadly means the oversight of incurred or planned clinical services. This involves services such as:

• Inpatient stays
• Outpatient procedures
• Medical and cardiac Imaging
• Medical pharmaceuticals (not routine pharmacy, but rather infused medications)
• Rehabilitation services

The Clinical Operations Committee has spent significant time determining how best to assure our medical community, plan members and payors that appropriate and effective tests and treatment regimens are occurring in a safe and timely manner. The recommended approach is different for the aforementioned areas.  Some services, such as inpatient stays and certain outpatient procedures, require a notification of intended services so that a review and authorization for service can be applied.

Other areas, such as medical pharmaceuticals and imaging services, do not require preauthorization for services to occur.

While high-end imaging for Quality Partner patients will not require pre-authorization, Quality Partners will promote a physician-implemented initiative to ensure appropriate use of imaging.  As part of this initiative, you may occasionally receive a phone call from one of the Quality Partners Radiology providers to discuss exam appropriateness or to consider an alternate, possibly more appropriate exam. The ordering physician will have the final decision on what imaging exam is utilized. We expect that over time, collaborative physician-implemented best practices and utilization norms evolve around high-end imaging within Quality Partners.

As to physical and occupational therapy, Quality Partners is instituting a preauthorization process under the guidance of the Clinical Operations Committee after the initial 12 visits take place. The therapy provider’s office and Geisinger Health Options perform the authorization process. Other than providing the physician order for this ongoing care, the patient’s physician is not involved in the authorization process.

The Quality Partners Medical Management strategy and approach are subject to change based on a continual review of the clinical outcomes and results. 

Pay-for-Value Programs

Much of the current or initial Quality Partner physician payment principles are structured around CPT codes and based on the volume of members seen. It is a system commonly used in the past and reflective of what many providers experience currently and/or in the recent past with other payors. In addition to this process, Quality Partners has incorporated an enhanced payment system for certain specialty areas – including all of primary care – that is dependent on the effective achievement of established metrics based in quality of care and overall value to the patient, member and/or payor.

Quality Partners anticipates all specialty areas will develop pay-for-value criteria over the first 12 months of the program. All programs will be discussed and ultimately recommended, as a group, through each unique specialty representation (e.g., all participating cardiology or orthopaedics practices) in tandem with their hospital departmental or service-line leadership. Recommendations go to the Quality Improvement and Reimbursement Committees for formal approval. Once approved, the target is to incorporate these programs into each specialty’s reimbursement programming in July 2015.

The goal for this or any other financial plan is to move Quality Partners and the medical community ever-closer to the highest possible achievement of the Triple Aim of better care, better health and improved value.

Quality Partners is excited that your group is a participating provider in the network. As we “go-live” on July 1, do not hesitate to contact us with questions or concerns you may have. Refer to the “Who To Call” link as a reference for all of the contacts you need at both Quality Partners and Geisinger Health Options.

Together, we can enhance patient outcomes and add value to the care we provide.

Click here for more information or call 302-623-7950.