We know how important it is to have the Priority Health members you see assigned to your practice. That’s why we’re making changes based on your feedback to improve our member assignment.
This spring, we’ll review our HMO and POS members’ assigned Primary Care Provider (PCP) compared to the PCP they’re seeing based on claims data. We’ll change a member’s PCP if our claims show they’ve seen a different primary provider than the one assigned and that PCP does not belong to the same health system.Download a PDF of this post
Frequently Asked Questions
Why did Priority Health make this change? How does it improve my practice’s experience and what problems does it attempt to solve?
We’re making this change to improve the accuracy of the members assigned to your practice. This means the data in your reports will be improved, as well as our evaluations and payments to you through our PCP Incentive Program (PIP). Improved reports will help you better target patients for chronic disease management and quality work while reducing your administrative effort.
How will the member assignment update work?
We’re completing a claims review of our HMO and POS members to address data integrity issues surround PCP assignment. Using a similar process to our patient attribution described in PIP, we’ll review claims data for inconsistencies in PCP assignments. For PCP reassignment to happen, the PCP in the claims must be from a different health system than the member’s currently assigned provider.
Where can I find more information on Priority Health’s attribution process?
We have detailed information on our attribution process on page seven in the PIP manual. Our manual is always posted at priorityhealth.com/provider/center/incentives/pip (login required).
How often will Priority Health review claims to reassign patients?
We’ll complete one review during calendar year 2020. Look for future communications on how we’re moving forward.
Help me understand impacts of this process on patient’s self-selection of a PCP.
Our new member assignment process is meant to be cooperative to our member’s self-selection of their PCP. We’ll continue to support a member’s choice of provider; however, the process will better help us identify the PCP of members who fail to choose.
Will patients receiving primary care services through an advanced practice provider (APP) be reassigned to that APP through the member assignment process?
If a member receives primary care through an APP who is not designated to carry a patient panel, the reassignment will default to the member’s selected PCP or the PCP most often seen in the
past. However, if the APP is designated to carry a patient panel and is attached to a different health system, the member will be reassigned to that APP.
What if the patient changes their PCP mid-year?
Let’s review this by using the following example:
Member John Smith previously had Dr. Health as their primary care provider through March 2020. In April 2020, John Smith decides to change his PCP to Dr. Wellness and establishes care.
In the above example, John Smith will be attributed to Dr. Wellness because he will have claims under his newly chosen provider. To maintain high member satisfaction, we also included a rule in
our process ensure that PCP changes made within the last 6 months will remain in place.
What is the impact of this new assignment change process on PIP credit for gap closure?
This change will not change any rules within our PIP program. The provider the patient is assigned to at the end of the program year will get credit for all gap closures. Please refer to the PIP manual
for more details. Our manual is always posted at priorityhealth.com/provider/center/incentives/pip (login required).
When will updates to PCP assignments due to the new process be reflected in Filemart Reports?
Each Filemart report includes data up to the last day of the previous month. For example, May’s reports are scheduled to publish to Filemart on May 15 and will include data through April 30. Using
this timeframe, the individual product claims review that is effective May 1 will be reflected in your May Filemart reports. Look to future communication on the timing for our other product lines.
COVID-19 has resulted in the increase use of evaluation & management (E&M) codes for telehealth visits. How will Priority Health consider these visits?
We recognize there is a higher risk of telehealth services including E&M codes during the COVID-19 pandemic; however, we do not believe it will have a significant impact on membership assignment. Currently, many health systems using E&M codes during telehealth are doing so to reach out to our members for primary care services. This is often being accomplished by their PCP or another provider within the same organization. We will not be moving patients between providers working within the same health system. This should eliminate assignment changes due to the increase use of telehealth during the COVID-19 pandemic.