Independent Practice Association
Kentucky Primary Care Association
Summary of IPA Contracts
Updated for IPA Members March 1, 2016
The Kentucky Primary Care Association (KPCA) operates a messenger-model Independent Practice Association (IPA), which negotiates on behalf of clinic members with Medicaid Managed Care Organizations (MCOs), Medicare Advantage plans, and other commercial payors.
IPA participating clinics can “opt in” (participate) or “opt out” (not participate) of any contract. Contracts KPCA negotiates include a range of incentives for quality, Patient Centered Medical Home (PCMH) recognition, control of medical services spending, as well as delegated credentialing to expedite enrollment with most health plans.
KPCA contracts with Precision Healthcare Delivery (Precision) to manage clinic provider rosters, delegated credentialing, claims resolution issues that cannot be resolved at the Provider Services/Claims Resolution/Provider Representative level with the Managed Care Organization (MCO) or other payers. The IPA also receives claims data from the MCOs and develops reports with actionable data provided to clinics on a secure FTP (File Transfer Protocol) web site. The IPA supports a team of Quality Improvement Specialists who work directly with clinics to help them review HEDIS and incentive quality measures to help you achieve the targeted measures for incentive payments. The IPA provides assistance on achievement of initial recognition and ongoing maintenance of PCMH through the Kentucky REC and through individualized consultation from a KPCA National Committee for Quality Assurance (NCQA) reviewer/expert for clinics. Some MCOs provide additional incentives for PCMH recognition and it is a model that helps transform practices to accommodate the value-based reimbursement system that is wide-spread among insurers and MCOs.
The KPCA IPA and Precision provide weekly communications and updates, more frequent information as needed and a monthly webinar on the 3rd Wednesday of each month. All of these communications are essential information meant to help you succeed. It is highly recommended that you participate in the webinar and the many educational offerings through KPCA.
KEYS TO SUCCESS FOR YOUR CLINIC
- Always check eligibility, preferably on the MCO or Insurance Carriers Web Site. This allows the clinic to access the most recent information as we all know patients often move between plans and/or eligibility.
- Always check the PCP the patient is assigned to for care. If the patient is not assigned to your clinic, ask them to change so you can receive credit for the work you do. If you do not move these patients to your panel you may miss PMPM payments and targeted incentives.
- Check your NPI, Taxonomy Codes (both the facility and every billable provider), Provider Type with Provider Enrollment DMS.
- Submit all information requested by KPCA in a timely fashion. Credentialing of your providers and facilities is essential for the clinic to be paid timely.
- Watch your coding! The MCOs and all commercial carriers are required to follow NCCI requirements (National Correct Coding Initiative).
- Check and update your patient’s problem list routinely. This is ultimately useful in setting risk scores. Not paying attention to this could adversely affect your ability to reach targeted MLR for incentive payments.
- Know your Clearing House, what it does, if it is submitting up to seven diagnostic codes (used in determining Risk Scores) and notification on front-end edits that may mean your claims are not being submitted, among other things. Most have reporting that is useful in working AR for a clinic.
- As a first step in claims resolution contact the individual MCO if you have issues. Always get a reference number and the name of the person from Customer Support, or document the contact with the MCO’s Provider Representative. If the issue is not resolved timely contact the KPCA’s contracted IPA management group, Precision, and the issues will be addressed by them for resolution directly, in bi-weekly Issues Log Discussions, or in a face-to-face meeting held every other month.
- Submit and review your provider roster routinely and let Precision know about any changes or additions of providers or facilities. If they are not loaded or the providers are not credentialed, you will not get paid. It generally takes up to six weeks from the date of submission of a complete provider credentialing packet to review and approve the provider. Facilities may also need to be surveyed, depending on the requirements of the payor.
- Keep your provider credentialing information updated (review the CAQH, Council for Affordable Quality Healthcare, routinely as required, as an example), and submit your credentialing information timely and in a complete fashion.
- Use the data available to you provided by KPCA/Precision.
- Work with the KPCA/Precision QI Specialists to reach quality targets.
- Read the material that is sent to you and participate in the webinars and other trainings offered by KCPA.