2015 Quality Incentive Program

Like you, quality performance is important to California Health & Wellness. Every day we strive to ensure our members are receiving high quality care, when they need it and where they need it. Your partnership helps us achieve our goal, which is why we are launching our new Quality Incentive Program (QIP). The focus of this program is to provide our provider partners three potential incentive bonus opportunities based on HEDIS performance improvement starting in July 2015.

  1. Patient Level Compliance Bonus: All California Health & Wellness primary care providers (PCP) are eligible to be rewarded for converting their noncompliant HEDIS patient listings to compliant before the end of the time period outlined below.

    • Bonus Payout: By October 31, 2015 for services in July, August, September
    • Bonus Payout: By March 31, 2016 for services in October, November, December

      We will pay you an incentive bonus for each of your California Health & Wellness patients who we identify as needing to be complaint for a certain HEDIS measure. The payment differs based on whether the measure is deemed as critical or important. For the five critical measures, we will pay $75 per patient converted from noncompliant to compliant. For the six important measures we will pay $25 per patient converted from noncompliant to compliant.

      It’s important to keep in mind that compliance is based on NCQA HEDIS measure specifications and must be received as a medical claim with the correct coding or by submission of the medical record with the correct documentation that meets measure compliance guidelines (see FAQ below).
  2. Provider Quality Performance Ratings: For those high volume providers who serve as a PCP (based on Tax Identification Number) for more than 1,000 members as of June 30, 2015, they will also be eligible for additional payments based on their cumulative HEDIS performance at the end of the year. This will be based on a 4 Star Rating Scale. This star rating will become part of our ongoing quality improvement program. This potential bonus increases for each .5 increment up to 4 (i.e. 2, 2.5, 3, 3.5, 4)

    • Bonus Payout: By March 31, 2016
  3. Notice of Pregnancy (NOP) Bonus: Improving Prenatal Care is a critical goal for California Health & Wellness and early identification of patients increases the likelihood of a successful and healthy pregnancy. Providers are asked to complete an NOP form for every patient with a new diagnosis of pregnancy. For every new NOP submitted for patients in their first trimester, you will receive a bonus of $75 for each one if you are the first provider to submit it. This is an Ongoing Bonus Payout starting in October 2015.

Our Quality Incentive Program is just the first step to building a high quality program. In addition, we have improved our HEDIS status report to provide you a clear snap shot of your California Health & Wellness patients and their state of compliance for each measure. You will receive this report monthly with a year-to-date status. It is a tool to support you in delivering the highest quality care and it provides details you need to reach your bonus payout potential.

We have scheduled a series of webinars and teleconference calls to introduce you to this Quality Incentive Program. Dates, times, call information, and webinar links can be found on our webinars page. Our Provider Relations and HEDIS teams will also be available to provide personalized in-service training and to address any questions and/or concerns you may have about the program.

2015 Quality Incentive Program Presentation (PDF)
HEDIS Measure Specifications

Provider Incentive FAQs

  • Monthly reports are generated to help identify new or existing patients that have not had a preventive service (e.g. childhood immunization, cervical cancer screening, diabetic eye exam) based on our records.
  • Check your patient records and ensure service has not been rendered, if it has please send in the clinical documentation so we can ensure compliance and process for your HEDIS Provider Incentive and Star Rating.
  • If service has yet to be rendered, please contact your patient and schedule the preventive service. Once complete please send clinical documentation which indicates compliance so we can review and process for your HEDIS Provider Incentive and Star Rating
  • Patient will remain on your list each month, and status will be non-compliant
  • You may find that you don’t have a patient name in your database; however, this doesn’t mean they aren’t assigned to you as their Primary Care Provider (PCP). If a member has not selected a PCP, one will be auto-assigned for them. This monthly report is a great tool to help you identify your new patient population and ensure your timeliness of preventive screenings.

There are 5 “critical” measures and 6 “important” measures that we are focusing on:

Critical Measures:

  • Childhood Immunizations
  • Well Child Visits
  • Controlling High Blood Pressure
  • Diabetic HbA1c Test
  • Cervical Cancer Screening

Important Measures:

  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
  • Adolescent Immunizations
  • Diabetic Care: Eye Exam
  • Diabetic Care: Medical Attention for Nephropathy
  • Children and Adolescents Access to Primary Care
  • Annual Monitoring for Patients on Persistent Medications

There are two ways to submit data to qualify for the provider incentive:

  • Fax clinical documentation specific to the measure to our QI department for review at 1-877-278-9978
  • Submit claims and encounters
  • 1st Bonus Payout: October (services in July, August, September)
  • 2nd Bonus Payout: March (services in October, November, December)

If you have any questions about our 2015 Quality Incentive program, please contact Tiffany Perez at 1-916-246-3637 or tiperez@cahealthwellness.com.