Category: Reimbursement

Introducing the Care MAP Tool: A Comprehensive Guide

Introducing the Care MAP Tool, designed to support healthcare providers in managing complex care needs. This user-friendly, Excel-based tool offers a structured framework for effective care coordination, resource allocation, and patient management. With modules for an overview and practical scenarios, plus a comprehensive resource library and FAQ section, the Care MAP Tool enhances care strategies and improves patient outcomes. Download it today and elevate your care management practices.

Effective care management is crucial in today’s complex healthcare landscape. To support healthcare professionals and organizations, we are excited to introduce the Care MAP Tool, a valuable resource designed to aid in complex care management. This blog will provide an overview of the Care MAP Tool, walk you through an example scenario, and offer access to a resource library and frequently asked questions (FAQ) section.

Module 1: Care MAP Overview

The Care MAP (Management and Planning) Tool is designed to support healthcare providers in managing and planning care for patients with complex health needs. This tool provides a structured framework to help clinics navigate the intricacies of care coordination, resource allocation, and patient management. Here’s what you can expect from the Care MAP Tool:

  • Framework for Complex Care Management: The tool offers a comprehensive structure to address the multifaceted needs of patients requiring intensive care management.
  • User-Friendly Interface: The Excel-based tool is intuitive and easy to navigate, ensuring that healthcare providers can quickly integrate it into their workflows.
  • Scalable and Adaptable: Whether you’re a small clinic or a large healthcare organization, the Care MAP Tool can be scaled and adapted to fit your unique needs.

Module 2: Example Scenario

To illustrate the practical application of the Care MAP Tool, let’s walk through an example scenario:

Scenario: Managing a Patient with Multiple Chronic Conditions

  1. Patient Overview:
    • Name: Jane Doe
    • Age: 65
    • Conditions: Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease (COPD)
  2. Initial Assessment:
    • Medical History Review: Gather comprehensive information about Jane’s medical history, including past treatments, hospitalizations, and medications.
    • Social Determinants of Health: Assess factors such as living conditions, access to transportation, and social support.
  3. Care Coordination:
    • Interdisciplinary Team: Form a care team that includes primary care physicians, specialists, nurses, social workers, and community health workers.
    • Care Plan Development: Create a personalized care plan that addresses Jane’s medical and social needs, with clear goals and timelines.
  4. Monitoring and Evaluation:
    • Regular Check-ins: Schedule regular appointments and follow-ups to monitor Jane’s progress.
    • Adjustments: Modify the care plan as needed based on Jane’s response to treatment and changes in her condition.

Resource Library

The Resource Library is a curated collection of materials to further support your use of the Care MAP Tool. Here, you’ll find:

  • Guides and Manuals: Detailed instructions on how to use the Care MAP Tool effectively.
  • Case Studies: Real-world examples of the tool in action, showcasing its impact on patient outcomes.
  • Training Videos: Step-by-step video tutorials to help you and your team get up to speed quickly.

FAQ

To ensure you have all the information you need, we’ve compiled a list of frequently asked questions:

Q1: Who can use the Care MAP Tool?
A1: The tool is designed for healthcare providers, including clinicians, care coordinators, and administrative staff.

Q2: Is there a cost associated with the Care MAP Tool?
A2: No, the Care MAP Tool is available for free download.

Q3: How do I get support if I encounter issues with the tool?
A3: Support is available through our online helpdesk. You can also refer to the Resource Library for troubleshooting guides.

Care MAP Tool Download

By using the Care MAP Tool, you acknowledge that you have read and agree to the disclaimer below. If you share the tool, ensure that all individuals given access to it have reviewed and agreed to the disclaimer language before using it for any purpose.

Disclaimer: The Care MAP Tool is intended as a general framework to support considerations around complex care management in a clinic setting. It is not meant for final staffing, clinical, administrative, operational, and/or financial decision-making. Information obtained from this tool is not and should not be taken as legal or financial advice and is not a substitute for consulting a qualified professional. Community Initiatives does not accept responsibility for any loss that may arise from reliance on this tool.

Source Link:

Download Materials:

Care-MAP-Tool-Example-Scenario-3Download
Care-MAP-Tool-Blank-1Download

Feel free to reach out with any questions or feedback about the Care MAP Tool. Happy planning!

Health Insurance Providers’ Actions Concerning Mental Health

  • AllWays Health Partners has teamed up with Lyra Health to offer a new solution to expand the availability of mental health support and counseling. Through Lyra, members will be able to seek clinically proven mental health support, find high-quality providers tailored to their individual needs, and book appointments quickly with a therapist or coach by video or in-person securely and confidentially. Lyra will be rolled out in phases beginning June 2022.
  • AmeriHealth Caritas posted 5 questions that patients can use to find culturally competent mental health professionals. The questions include:
    • Does the provider ask about your problems in the context of your social network, such as family or friends, others in your community?
    • Does the provider ask you what you think the causes of your problems are?
    • Does the provider ask about the most important aspects of your background or identity and whether they make a difference to your problem (i.e. discrimination)?
    • Does the provider ask about barriers that have prevented you from getting the help you need, including any stigmas or social determinants of health?
    • If there are differences in your backgrounds, does the provider ask about your concerns around these differences and what your expectations are?
  • A 3-year grant provided by the Anthem Blue Cross and Blue Shield Foundation to the Chris Atwood Foundation will allow more individuals to seamlessly progress from treatment for substance use disorder, incarceration, or other high-risk transition points into a safe and supportive recovery housing environment. For the past 9 years, the Foundation has worked to save lives from overdose and support recovery from substance use disorder. The $150,000 Anthem grant will support the organization’s Revive to Thrive program and allow them to offer housing and peer support to 300 more individuals.
  • The Anthem Foundation has committed $13 million in grants to promote equity in mental health, particularly for people with substance use disorders. Each program will focus on one of the following goals: prevention and early intervention of risk factors that lead to substance use disorders, improved access and quality of treatment to reduce morbidity and mortality of substance use disorders, and community support to promote lifelong recovery. These grants are part of up to $30 million the Foundation plans to invest over the next 3 years to make significant progress toward reducing substance use disorders and their health impacts.
  • Anthem Blue Cross and Blue Shield, through its Student Advantage health plans, has entered into an exclusive partnership with Christie Campus Health to help colleges and universities address escalating rates of anxiety and depression reported on campuses throughout the country. The 2 companies will provide a student-centered mental health platform that helps counseling centers meet the high demand for services. Christie Campus Health currently helps over 40 colleges and universities bring timely and accessible mental health and wellbeing support to more than 430,000 students. Christie Campus Health’s CONNECT@College product will allow Anthem Student Advantage to offer a comprehensive solution that focuses on both the physical and emotional wellbeing of today’s college student.
  • Anthem has launched a number of specific physical and mental health/substance use disorder (MH/SUD) health integrated care management and outreach programs utilizing predictive modeling related to comorbid conditions that include licensed clinicians and peer/wellness and recovery coaches. These programs include Cardiac Pain, Sleep Apnea, Predictive High Utilizing Alcohol and Opioid Users, and Suicide Prevention. Additionally, to meet the needs of members with complex conditions, Anthem created the High Outreach to Promote Engagement (HOPE) program. These populations have the highest rates of multiple chronic conditions and higher than average emergency room visits and inpatient admissions for both MH/SUD and physical health. Case managers in this program take a broad view of a patient’s whole health and assist consumers in a variety of ways, including providing transportation or coordinating doctor appointments. Anticipating and supporting member’s needs before and after they need medical care significantly improve member outcomes and lower healthcare costs. By anticipating and supporting members’ needs, Anthem has decreased major incidents such as ER visits and inpatient hospitalizations by 50%.
  • To respond to growing needs throughout its 72,000-square-mile footprint, Avera Health Plans opened a new four-story wing as part of its Avera Behavioral Health Hospital in Sioux Falls.The Helmsley Behavioral Health Center adds 60,000 more square feet of space for treating psychiatric needs among children, youth, and adults. This wing adds several new services including 24/7 Behavioral Health Urgent Care, observation care, youth addiction care services, and partial hospitalization for youth.The wing also will house Avera’s senior behavioral health unit, which is currently located on the Avera Prince of Peace campus. This will provide an opportunity to add to the continuity of mental health services while enhancing and expanding this program. In total, Avera Behavioral Health Hospital will have 146 inpatient behavioral health beds plus 8 addiction residential beds for adolescents – all private rooms.
  • Beacon Health Options has partnered with the Kennedy-Satcher Center for Mental Health Equity (KSCMHE) to address behavioral health equity ahead of the 988 suicide prevention lifeline launch in July. The partnership centers on 2 main components: a research and policy initiative that imagines equitable crisis response for the future of behavioral health service delivery, and a leadership summit to explore how to embed equity into crisis response. Some recommendations for embedding behavioral health equity into state and local 988 systems include:• Prioritizing visibility of groups that are historically excluded or inadequately reached by psychiatric emergency systems
    • Deploying law enforcement in psychiatric emergency response only as needed
    • Leveraging mobile crisis units staffed by culturally competent staffBeacon Health Options is a wholly-owned subsidiary of Anthem.
  • Blue Shield of California posted a back-to-school mental health Q&A with Dr. Nicole Stelter, Blue Shield’s Director of Behavioral Health. Dr. Stelter discussed the growing mental health crisis adolescents are facing, as well as steps students, parents, and teachers can take to support youth mental health.
  • Blue Shield of California is investing in 4 organizations that are working to support youth mental health in California. In total, Blue Shield of California is providing more than $1.1 million to the 4 organizations. Mental illness is the number one reason children in the state are hospitalized, and half of all lifetime cases of mental illness begin by the age of 14. The support is part of Blue Shield of California’s BlueSky Initiative, which provides resources and support for youth, families, educators, and caregivers to promote emotional well-being for youth. Over the last year, BlueSky and its programs almost doubled the number of educators it trained to spot warning signs of mental health concerns in youth, conducted more than 4,000 counseling sessions, and supported cultivating a pipeline of diverse youth to work in the mental health field. The new financial support will continue enhancing these mental health supports with a focus on reducing health disparities.
  • A recent Blue Shield of California post shared important points for seniors about behavioral health, mental health stigma, the pandemic’s effect on this health issue, and how treatment and self-care can help. Getting treatment sooner rather than later is important, and seniors should start by making an appointment to see a primary care doctor or a mental health care professional to discuss whether treatment might help, said Jennifer Christian Herman, vice president, Mindbody Medicine at Blue Shield of California.
  • Funding from Blue Shield of California’s BlueSky youth mental health initiative has let the National Alliance on Mental Health (NAMI) California expand its On Campus High School clubs throughout the state, increasing membership from 1,051 in 2020 to 1,271 participants in 80 clubs across 16 counties in 2022. The clubs provide peer-led support for students with mental health conditions, students whose family members have a condition, or students who are interested in the field or in advocacy – all focused on the goal of reducing mental health stigma among youth.
  • The Health Care Service Corporation is providing access to an online self-service platform to help fill a gap for some untreated members who have been reluctant to seek care or had difficulty finding it. The platform, provided by an independent company called Learn to Live, offers around-the-clock mental health assessments and online cognitive behavioral therapy (CBT) for mild to moderate depression, substance use, social anxiety, insomnia, and stress, worry, and anxiety. It is available at no added cost to 11 million members, starting at 13 years of age, in most group health plans across its communities in Illinois, Montana, New Mexico, Oklahoma, and Texas.
  • Blue Cross and Blue Shield of Montana awarded 4 nonprofits with a $70,000 Big Blue Sky Initiative major grant through the Healthy Kids, Healthy Families® program. All 4 grant recipients will use the funds to help improve pediatric behavioral health. In addition to the 4 grants, Blue Cross and Blue Shield of Montana also made a $15,000 grant to NAMI Montana to bolster the organization’s mission to support, educate, and advocate for Montanans with mental illnesses and their families.
  • Blue Cross and Blue Shield of Montana (BCBSMT) is providing access to an online self-service platform to help fill a gap for some untreated members who have been reluctant to seek care or had difficulty finding it. The platform, provided by an independent company called Learn to Live, offers around-the-clock mental health assessments and online cognitive behavioral therapy (CBT) for mild to moderate depression, substance use, social anxiety, insomnia, and stress, worry and anxiety. It will be available at no added cost to members at least 13 years old in most of group health plans.
  • Blue Cross and Blue Shield of Montana is becoming more strategic in coordinating access to life-saving behavioral health services for members throughout the state — particularly in its most isolated areas. BCBSMT launched Big Blue Sky Initiative in 2018 to help fight opioid abuse, rising suicide rates, and methamphetamine and heroin epidemics. The company also helped fund a new psychiatry residency to bring more mental health professionals to Montana, as well as other programs. To improve access, leaders are working with providers and policymakers to develop care models that will keep members closer to home and reduce obstacles to care, including expanded telehealth services. The effort is part of a larger initiative to create more medical and behavioral health access and better care management for BCBSMT members no matter where they live.
  • New Mexico Kids Matter received a $25,000 grant from Blue Cross and Blue Shield of New Mexico’s Healthy Kids, Healthy Families® initiative. The grant will support New Mexico Kids Matter’s Successful Transitions and Adulthood Readiness (STAR) Program, which works to prepare teen foster youth for their transition out of foster care and into healthy and safe adulthood and independent living situations. Studies have shown youth who spent their teenage years in foster care and/or aged out of the foster care system suffered significant challenges as adults in the areas of mental health, education, employment, and finances. Without intervention, these youth have a higher likelihood of violence, homelessness, incarceration, and poverty in their adult lives.
  • Jardin de los Niños has received a $25,000 grant from Blue Cross and Blue Shield of New Mexico’s Healthy Kids, Healthy Families® initiative. The grant supports Jardin de los Niños’ Flourishing Families Infant Mental Health and Wellness Program, which provides direct therapy services to homeless and near-homeless children and their families to address trauma. The grant also supports an anti-hunger component that provides healthy and nutritious meals to address food insecurity.
  • Blue Cross and Blue Shield of North Carolina is expanding its network of behavioral health providers through a collaboration with Headway, a mental health care company that works with insurers to deliver high-value mental health care. Together the 2 companies will make it easier for Blue Cross NC members to quickly access – as soon as 48 hours – in-network therapists and psychiatrists who meet their specific needs. The focus of the collaboration is on improving access to care for underserved communities, including rural and socially vulnerable counties, children and adolescents, and individuals across diverse racial and ethnic backgrounds.
  • Blue Cross and Blue Shield of North Carolina is investing more than $2 million to support 11 organizations across North Carolina to improve access to behavioral health care services in rural and marginalized communities and in HPSAs (Health Professional Shortage Areas). This funding initiative is part of Blue Cross NC’s statewide commitment aimed at addressing and eliminating racial, health, and geographical disparities in North Carolina and supports the company’s goal to improve access to behavioral health care in rural and underserved communities by 25% in 5 years.
  • Blue Cross and Blue Shield of North Carolina has announced a new collaboration with Mindoula to help address the complex health needs of members with serious mental illness and/or substance use disorder. The program leverages expertise from the tech-enabled behavioral health management company to expand access to behavioral health services and will launch on January 1, 2023. Blue Cross NC will work with Mindoula to directly address the mental health crisis and health care shortage in North Carolina by providing tech-enabled support that expands outpatient behavioral health care to members in the greater Triangle area, as well as eligible members outside of North Carolina.
  • Blue Cross and Blue Shield of Oklahoma has made a grant to the National Alliance on Mental Illness of Oklahoma to support mental health efforts focused on young children. The grant will support the “Meet Little Monster” coloring and mental health activity book created for young children to express and explore their feelings as well as to help foster dialogue between children and the safe adults in their lives. The book is available in English and Spanish for families, organizations, teachers, and young people across Oklahoma at no cost.
  • The CalOptima Board of Directors has authorized a grant agreement of up to $1 million to support the Be Well Orange Campus, a mental health and substance use treatment facility in Orange. The grant will enhance intake and admissions coordination services for CalOptima Medi-Cal members who need behavioral health services. The two-year grant will ensure CalOptima members have timely access to services, assessment and placement into care through an improved intake and coordination process at the Be Well Orange Campus. The cost of coordination includes staffing, training and development, administrative services, and a phone system upgrade.
  • The Cambia Health Foundation has invested more than $300,000 in non-profit organizations that are part of the National Suicide Prevention Lifeline system. The goal of the investments is to support, expand, diversify, and train the behavioral health workforce.
  • CareFirst BlueCross BlueShield is collaborating with Headway, a tech-enabled company that expands access to in-network mental health care by removing barriers faced by providers, payers, and the people they serve, to support CareFirst’s mental healthcare system. The collaboration will help eliminate obstacles to providing and accessing behavioral health while delivering quality, easy-to-access mental health care for all members. Headway’s secure online platform is available to CareFirst’s network of mental health providers at no cost and will enable efficient scheduling, billing and more. This allows providers to focus on quality care delivery, rather than administrative tasks.
  • CareOregon has provided Lutheran Community Services Northwest with a $79,867 grant to help make more culturally specific mental health resources available to newly arriving and already resettled Ukrainian refugees in the region. The funds from the grant will be used to hire 1 additional full-time peer support specialist and 1 Ukrainian speaking clinician that will support the increasing demand for care. The grant will also help fund additional support for the broader Ukrainian community. The peer support specialist will provide timely support to Ukrainian refugees to help address mental health and trauma and connect clients to the appropriate services and resources. Services include individualized psychological first aid such as mental health counseling, emotional support groups, workshops to aid in resettlement and referrals for any additional needs like wellness exams, immunizations, housing, employment and more.
  • CareOregon announced that it has awarded $210,000 in community giving grants to nine local nonprofit organizations that provide social support and improve access to medical care for seniors, communities of color and other underrepresented communities across the Portland metropolitan region. Among the grants awarded, CareOregon is investing $50,000 in Lines for Life’s Cultural Engagement Initiative, which prioritizes the mental health needs of communities of color. The funding will support Lines for Life’s effort to reach 1,500 community members who identify as Black, Indigenous, and from other communities of color with mental health support through direct outreach by community health workers and hosting community-wide events that aim to reduce stigma.
  • CareOregon and the Alliance for Culturally Specific Behavioral Health Providers have codesigned a payment model to improve health outcomes for Oregon’s communities of color. Numerous national studies have shown that these communities are disproportionately impacted by lack of access to mental health support. Over the past 2 years, the collaboration has hit several milestones, most recently resulting in expanded payments for culturally specific providers that leverages both traditional payment models by increasing rates and Health Related Service dollars to compensate providers for time invested in outreach and engagement activities. These changes will result in an increase of up to 20% in payment to culturally specific providers.
  • CareSource is collaborating with Clarigent Health to bring artificial intelligence to behavioral health providers in Ohio. Clairity, Clarigent Health’s software tool, analyzes speech with artificial intelligence trained to identify patients at risk of suicide. Behavioral health providers in the Ohio Children’s Alliance (OCA) and Ohio Behavioral Health Provider Network (OBHPN) can now be reimbursed through CareSource when using Clairity. Between the 2 networks, more than 265,000 families and youth will have access to the technology.
  • The CareSource Foundation has awarded Overdose Lifeline, Inc. a more than $178,000 grant to improve the prevention of and response to opioid overdoses in Indiana schools. These funds will provide school partners with the emergency, life-saving medication naloxone, develop a custom training course for school staff and connect schools to evidence-based prevention programs.
  • CareSource has announced a new option with the Montgomery County Board of Developmental Disabilities (MCBDDS) and I Am Boundless to provide respite care for parents and other caregivers of people with intellectual and developmental disabilities (I/DD) and behavioral health challenges. This new collaboration will provide respite services to those families with I/DD youth. Services such as after-school and day programming, and therapeutic supports will be embedded in each respite opportunity.
  • Centene has launched an all-employee training on Mental Health and Substance Use Disorder Parity to educate employees on parity law and outline Centene’s policies that ensure delivery of benefits that do not discriminate against individuals with mental health conditions or substance use disorders. Centene also maintains youth and adolescent programs focused on mental health, including the Choose Tomorrow™ Suicide Prevention Program, which uses evidence-based practices to screen for suicide risk, develop member-driven safety planning, provide connection to community resources, and monitor members’ treatment progress to prevent suicide.
  • Centene is a driving partner in solving the problem of social isolation in schools through No One Eats Alone® Day, created by the nonprofit Beyond Differences and sponsored by The Centene Charitable Foundation. Mental well-being is especially important now as youth continue to experience stressors from the COVID-19 pandemic. Centene health plans across the country helped raise awareness by hosting virtual and in-person events in February and March to encourage inclusion and teach children how to combat isolation. They worked with 108 schools across 10 states, engaging at least 48,500 students in educational and fun activities.
  • Centene recently released a white paper entitled, “Advocating for the Mental Health of Medicare Recipients.” The white paper notes the important role Medicare plays in the more than 63 million Americans who received Medicare benefits in 2021 and the unique challenges the Medicare population faces.The white paper also highlight’s Centene’s role in keeping people enrolled in Medicare healthy, stating: “While recent policy changes have improved access to mental health services for Medicare beneficiaries, there is still work to be done to ensure they can easily receive the care they need to live healthier, higher-quality lives. As an industry leader and one of the largest Managed Care Organizations in the country serving many of our nation’s most vulnerable citizens, Centene is committed to ensuring the mental wellbeing of Medicare beneficiaries through access to high-quality care, innovative programs, and a wide range of health solutions.”
  • The Cigna Foundation has made more than $3 million in grants to local nonprofits to help address childhood hunger and mental health concerns as schools return to session. Programs spanning communities in 16 states will receive critical financial support enabling them to positively impact thousands of children across the country. All grants are made available through Cigna Foundation’s Healthier Kids For Our Future® program, a 5-year, $25 million global initiative focused on improving the health and well-being of children. Since its inception in 2019, the program has awarded more than $18 million in grants.
  • Cigna Chairman and CEO David M. Cordani unveiled new findings about the growing mental health crisis among teenagers and the impact it is having on parents, both at home and work. Cigna and Evernorth, its health services business, commissioned the study from Economist Impact to examine the mental health effects of the COVID-19 pandemic on teenagers and their parents. The study was conducted in April 2022 and key findings include:
    • Approximately 80% of working parents reported some form of impact on the mental health of their teenage children as a result of the pandemic, including new or increased levels of anxiety, depression, behavioral issues, and problems with social interactions.
    • Nearly one in five working parents reported a negative impact on their work performance and productivity because of concerns about their child’s mental health.
  • Aetna, a CVS health company, and Psych Hub have launched an Adolescent Treatment Training Series to meet the urgent needs of youth and young adults. This joint effort arms the 283,000 behavioral health and employee assistance program providers in Aetna’s commercial network, Aetna’s internal clinicians, and CVS Health’s licensed counselors at MinuteClinics in select HealthHUB locations with access to a no-cost, evidence-based curriculum in the form of courses and resources to identify and treat adolescents and young adults along a full continuum of care, from prevention through intervention, for those at risk of suicide.
  • CVS Health is providing support to the National Association of Free and Charitable Clinics, the American Foundation for Suicide Prevention, and Mental Health America, in recognition of Mental Health Awareness Month. The support is focused on equitable, quality access to mental health care services and resources, particularly among the Black, Indigenous, and People of Color (BIPOC) community. A recent CVS Health/Morning Consult survey of Americans age 18+ also found that mental health concerns are continuing to rise among individuals of all backgrounds, especially Black, age 65+, young adult, and LGBTQIA+ respondents. The survey also found more Americans agree that the pandemic has made them more comfortable seeking support for mental health and using technology to address it.
  • Elevance Health is working to address the behavioral and mental health care needs of all members, at every age. Through the Sydney Health app, for example, a spectrum of care delivery options is available: digital, virtual, and in-person. Sydney Health can connect eligible members to a virtual text visit or a video visit with a behavioral or mental health provider such as a therapist or counselor. The app allows users to get important information about benefits and claims, track progress toward health goals, access a member ID card, and more. Elevance Health is also dedicated to advancing health equity through a “health equity by design” approach. This approach is personalized and intentional, ensuring that people can receive individualized care.
  • The Florida Blue Foundation is making a $3.8 million investment to enhance mental health for Florida’s children, families, and seniors. Twelve nonprofit organizations across the state share in the investment, which will support community-based programs that directly improve access to and quality of mental well-being services, particularly for the underserved and uninsured, including racial and ethnic minorities, and low-income populations. The investment will provide mental health counseling and education in schools for under/uninsured students and provide a safe environment for mental and emotional healing for members of the LGBTQ+ community, transgender individuals, victims of hate crimes, and LGBTQ+ seniors, in addition to supporting other mental health programs.
  • Highmark is encouraging members to focus on mental health in 2022 and is reminding them of resources that are available to better manage stress, anxiety, and depression. One new option for members is Meru Health, a 12-week evidence-based program to treat depression, anxiety, and burnout that mixes a clinical human touch with technology, self-care, and data via a discreet smartphone app. The 12-week treatment program includes consultation with a dedicated licensed therapist, evidence-based video lessons, guided mindfulness practices, habit-changing activities, and anonymous peer support groups, all done on a mobile device. Members will also have access to on-going support following the completion of the 12-week program.
  • Horizon Blue Cross Blue Shield of New Jersey members have access to Equip as an in-network option. Equip offers Family-Based Treatment for eating disorders through a 5-person virtual care team including a therapist, dietitian, medical provider, peer mentor, and family mentor. Equip is designed to replace the residential level of care and support families throughout their journey to really be the last treatment they will need.
  • Horizon Blue Cross and Blue Shield of New Jersey is offering eligible members access to MindRight Health, a mental health coaching service that leverages texting to provide coaching and emotional support to young adults ages 13 to 25. Once users sign up on their phones (no face-to-face meeting or phone call required), they can receive guidance from a team of coaches supervised by licensed mental health clinicians.
  • Independence Blue Cross released a video featuring Independence and community experts discussing how the COVID-19 pandemic has changed the ways in which people think about mental health and access behavioral health services. The video discussed changes in the workplace, the increased use of telemedicine, persistent disparities in health care, and how Independence can support young people who have suffered losses during this time.
  • Independent Health highlighted the mental and physical health benefits of yoga at the 2nd annual Yogathon for Suicide Awareness & Prevention, presented in conjunction with Power Yoga Buffalo. The Yogathon helped raise awareness of suicide prevention as well as funds to benefit mental health programs at Mental Health Advocates of WNY.
  • Independent Health has been awarded the 2022 platinum Bell Seal for Workplace Mental Health by Mental Health America (MHA). The Bell Seal is a workplace mental health certification that recognizes employers who strive to create mentally healthy workplaces for their employees. Independent Health is the only organization in Western New York to be certified by MHA. Independent Health’s status as a platinum-level Bell Seal-certified organization demonstrates the company’s ongoing commitment to employee mental health and well-being, which in turn is instilled in the company’s wellness and mental health programming for its employer groups and members.
  • Kaiser Permanente has awarded a 2-year, $125,000 grant to the Boulder Valley School District to bolster ongoing efforts to increase mental health among teachers, staff, students, and their families following the recent Marshall Fire. The grant will help the district expand an existing Kaiser Permanente initiative called Resilience in School Environments, or RISE. The program provides emotional support and trauma-informed training to staff members, who then help other staff members and students. The grant will extend support for staff members, students, and families who are experiencing traumatic stress following the Marshall Fire.
  • A mental health initiative developed by Kaiser Permanente and esports organization Cloud9 has been found to be an effective way of supporting the mental health of young adult esports players and fans, according to a new study from the NEJM Catalyst. Presence of Mind launched in May 2020 with the goal of reaching teens and young adults with positive mental health messages in places where they spend a lot of their time: online gaming and esports platforms. The initiative includes 2 seasons of live Twitch Stream series featuring prominent players; mental health experts and influencers; creator-led YouTube video content from some of esports’ favorite players sharing insights, positivity, and personal mental health messages; and a series of free, online interactive training sessions to help address critical mental health issues. As of May 2022, the training sessions have been accessed by more than 51,000 teens and young adult gamers who have learned how to better manage their mental health and support their friends when they need it most.
  • A telehealth program at Kaiser Permanente Northern California (KPNC) is expanding support for people with serious, persistent mental illness by adding psychiatric clinical pharmacists to their care teams. The care teams deliver a package of comprehensive care for a highly vulnerable patient population, who are more likely to have chronic conditions such as diabetes and hypertension and a lifespan shortened by 10 to 25 years. The program takes advantage of a growing workforce of clinical pharmacists with 2 years of postgraduate training in psychiatry. Working closely as a team with the patient’s psychiatrist and other clinicians, clinical pharmacists act as care navigators, establishing an ongoing partnership with patients through regular video and telephone appointments.
  • Kaiser Permanente adult members in Colorado now have access to a 90-day subscription to Ginger, an on-demand mental health care solutions provider. Ginger provides confidential emotional support through on-demand coaching via text-based chats and skills-building content. Eligible members can use their smartphone to connect with a highly trained emotional support coach 24/7 — at no cost and with no referral or appointment needed. The private, one-on-one texting sessions provide support in coping with common challenges such as managing stress or getting better sleep.
  • Kaiser Permanente in Hawaii has awarded a $500,000 grant to Mental Health America of Hawaii to support its youth resilience and wellness training and education program. The program will provide 1,300 youth and youth-serving adults with evidence-informed suicide prevention and bullying prevention training over 6 months and will enable Mental Health America of Hawaii to increase training to individuals in rural areas of Oahu, Hawaii Island, and Kauai.
  • Magellan Healthcare will hold a series of virtual events in support of Suicide Prevention Awareness Month and Recovery Month in September. Magellan will host events Sept. 14 and 22 focused on suicide prevention, and recovery from mental health and substance use conditions.
  • Magellan Health, Inc. has opened a complimentary 24-hour crisis line for individuals impacted by gun violence in Chicago and surrounding communities. Magellan confidential consultation services are offered at no charge to the communities to assist individuals as they work to cope with the feelings of fear, sadness, anger, or hopelessness related to these kinds of incidents. Crisis line callers may also seek information and guidance to other available resources, such as community-based support.
  • Magellan Health subsidiary Magellan Federal has launched a program that provides United States military families with personalized, digital mental health and well-being support by combining NeuroFlow’s technology with evidence-based resources and clinical support provided by Magellan Healthcare. The 18-month long first phase will be launched on three installations through the Military & Family Life Counseling (MFLC) program. NeuroFlow will supplement Magellan’s MFLC counseling services to provide service members and their spouses with personalized, self-directed mental health resources, tools, and support, all from a smartphone. Member usage of NeuroFlow will also produce de-identified, population-level data to highlight mental health trends at each installation without compromising an individual service member’s privacy.
  • Magellan Health has opened a complimentary 24-hour crisis line for individuals impacted by the elementary school shooting that occurred in Uvalde, Texas. The line is available to all Superior HealthPlan members and the local community. The toll-free number to access free, confidential consultation services is 1-800-327-7451. Magellan confidential consultation services are offered at no charge to the community to assist individuals as they work to cope with the feelings of fear, sadness, anger, or hopelessness related to these kinds of incidents.
  • Magellan Healthcare has launched a Digital Emotional Wellbeing program that helps members improve overall health and wellbeing, manage stress, and build resilience in a confidential manner. Participating Magellan members with emotional concerns who use the NeuroFlow app or website receive recommendations and have access to activities to help them improve their overall health. Activities include evidence-based videos, articles, and behavioral trackers, as well as Magellan’s digital cognitive behavioral therapy programs, FearFighter® for anxiety and MoodCalmer® for depression. These activities will provide members with personalized, self-directed behavioral health resources, tools, and support, all from the secure, anonymous convenience of NeuroFlow’s app and website.
  • Magellan Healthcare is offering resources to support the emotional wellness of first responders, health care workers, and the National Guard in Idaho who are serving on the front lines of the coronavirus pandemic. Magellan continues to make available a free, confidential 24-hour crisis line. This is available for all first responders, health care workers, and the Idaho National Guard citizen soldiers and airmen. Critical care workers coping with feelings of fear, sadness, anger and hopelessness can call the toll free 1-800-327-7451 (TTY 711) to speak directly with a licensed mental health clinician and receive information on community-based support.
  • Magellan Health launched eMbrace, an industry-first total wellbeing solution for employers with more than 500 employees, on April 1, 2022. The solution aims to help people move from suffering and struggling in their everyday life to thriving. eMbrace is built to address multiple areas of an individual’s life, proactively assessing if they are thriving, struggling, or suffering across six essential elements: career, social, financial, physical, community, and emotional. eMbrace also includes a special version of the Gallup® WellbeingFinder™ that offers employees a personalized wellbeing plan addressing all six elements. Employees are directed to services and resources that address their pressing needs first, from legal, financial, and identity theft services to digital cognitive behavioral therapy modules, coaching, and counseling.
  • Martin’s Point Health Care has released an update focused on helping men make mental health a priority. The update covers several steps men can take, including connecting with others, taking care of yourself, and talking to your doctor. Mental health struggles are linked to the increase in deaths related to alcohol and drugs, and 1 in 4 adults with mental health disorders also struggle with substance abuse.
  • Medica has introduced 2 new support programs to help simplify the mental health care experience and connect children and their families to the support they need. The Family Support Program provides clinical expertise and care navigation support to caregivers of children with complex mental health needs, while the Family Support Navigator is an interactive online tool that helps parents and caregivers find the right resources for children who may have autism or depression. Both programs are available to Medica members who have children with complex mental health needs.
  • MHS Indiana highlighted the mental health supports available to members, including access to MyStrength, a free resource that includes tools to hep reduce stress, anxiety, depression, and substance abuse. MHS also maintains a 24-hour crisis text line, where members can speak with trained crisis counselors, and offers members access to Teladoc for non-emergency issues.
  • Molina Healthcare of New Mexico has partnered with Pyx Health to expand access to behavioral health services for Molina’s Medicare members. Through a screening process, working with members and data, the Pyx Health platform gauges the emotional state of users. This data is then monitored by support staff that provides actionable recommendations for how to respond, such as calling a user to address their behavioral health needs or offering support during a rough time. By providing access to this platform, Molina will improve behavioral health outcomes for its members.
  • Molina Healthcare of California has partnered with WEconnect Health Management, giving Molina’s network providers access to the WEconnect Recovery mobile platform to support Molina members dealing with substance misuse and mental health challenges. The app provides a supportive environment to Molina’s Medi-Cal members engaged in the recovery process by delivering critical resources to their phones. WEconnect facilitates daily reminders, medical appointment alerts, and rewards milestones with incentives in the form of gift cards for CVS, Safeway, and Amazon, among others. Members also have access to mobile recovery meetings throughout the day and exclusive Molina-enabled peer recovery support services for on-demand, one-on-one support.
  • Molina Healthcare of California has partnered with BeMe Health, a digital behavioral health company, to provide Molina Medi-Cal members, ages 13 to 19, with access to digital tools, content, and support designed to tackle some of the most prevalent mental and social challenges facing today’s teens. The offering will provide young Molina members with activities, one-on-one coaching and more through an interactive mobile app designed to help teens feel acknowledged and empowered. The app features digital tools and interventions to teach teens coping skills, provide support for issues they may be facing, and offer engaging content that can help take the focus off daily struggles and challenges. In addition, teen members will have access to clinical services, with parental consent, and crisis support.
  • The MolinaCares Accord, in collaboration with Molina Healthcare of Washington, recently committed $400,000 to the University of Washington School of Nursing to help expand the behavioral health workforce in the state through the development and implementation of a blended family and psychiatric primary care curriculum for nurse practitioners.
  • The MolinaCares Accord, in collaboration with Molina Healthcare of Washington, has announced a $77,000 grant to SPARK, an organization dedicated to providing a career pathway for youth and students to become certified peer counselors in the state of Washington. The grant is just one component of MolinaCares’ Behavioral Health Initiative, an over $700,000 philanthropic effort to expand access to behavioral health care across Washington. The funds donated to SPARK will go toward the identification, outreach, training, and placement of youth peer supports in the state.
  • The Molina Healthcare Charitable Foundation, in conjunction with Molina Healthcare of Florida and in partnership with the Federation of Families of Central Florida, recently welcomed families to the MolinaCares Youth Festival. The event focused on supporting the growing number of young people and families affected by mental illness. This year, through a $15,000 grant from the Foundation, the Federation of Families of Central Florida is hosting monthly group meeting for teens and young adults centered on improving mental health. In those meetings, participants engage in activities and listen to speakers, while being encouraged to find creative outlets as part of the healing process.
  • The MolinaCares Accord, in collaboration with Molina Healthcare of Washington, has presented a $100,000 grant to support Compass Health’s Broadway Campus Redevelopment Project. The grant will help fund construction of a 72,000 square-foot facility that will expand community-based behavioral health care services and its workforce in northwest Washington. The grant is a part of The MolinaCares Behavioral Health Initiative to increase access to behavioral health across the state.
  • Eleanor Health, an outpatient addiction and mental health provider is collaborating with Point32Health on a program to support Tufts Health Plan MassHealth members with substance use disorders and other mental and physical health comorbidities. The value-based program uses a population health management model and provides patients with comprehensive care including access to medications for substance use disorder, psychiatry and mental health care, group and individual therapy, nurse care management and peer support.
  • Members of Regence Health Plans have access to a wide range of behavioral health care, from traditional in-person therapy to specialized virtual care. To improve access to care, Regence added more than 1,500 new behavioral health providers to its network in 2022. To support members in rural areas with little access to care, Regence has added virtual care providers available nationwide who specialize in everything from substance use disorder to individual therapy to child and family therapy, obsessive-compulsive disorder and more. Regence’s dedicated behavioral health team continually evaluates and contracts with virtual care providers that would add unique value to its array of resources for members seeking support. Regence is continuing an $11.5 million multi-year philanthropic initiative to increase access, improve quality of care, and reduce mental health stigma. Additionally, approximately $4 million of investments were made from its corporate foundation in 2021 to increase access to mental health support for people living in rural communities across Idaho, Oregon, Utah, and Washington.
  • Security Health Plan’s new partnership with Freespira, Inc., maker of the first FDA-cleared digital therapeutic treatment for panic attacks, panic disorder and post-traumatic stress disorder (PTSD), will provide many members with a clinical alternative to current treatments. Freespira works by addressing the underlying physiological factors behind panic attacks and post-traumatic stress disorder. As an adjunct to medications and counseling therapy, the treatment normalizes breathing irregularities developed in response to underlying carbon dioxide (CO2) hypersensitivity. The Freespira treatment provides users with real-time physiological feedback-based training to regulate their respiration rate and exhaled CO2 levels. Telehealth coaching guides patients throughout the 28-day care journey to deliver maximum benefits from the twice daily, 17-minute treatments.
  • Security Health Plan and Marshfield Medical Center-Rice Lake are investing in a mental health program from the Turtle Lake School District. School Pulse is an anonymous, interactive program that works to improve the mental health of students. The program provides social and emotional support to students through their cell phones and helps promote mental wellness and decrease suicide rates in young people. The School Pulse program uses texting to check in with students about their mental health 3 times a week, all year long. Students who wish to participate in the program will receive real-time help through open, anonymous communication through a platform that works just like texting.
  • Security Health Plan and Marshfield Clinic Health System are accepting applications from eligible school districts to implement b.e.s.t.® Universal Screening in the 2022-23 school year. b.e.s.t.® (Behavioral Emotional Social Traits) is an online screening tool designed to help education professionals build the emotional health of students and help identify students who may need additional positive behavioral support. The tool provides educators recommended actions to take with students based on their behaviors. Schools awarded a grant receive technical support, biannual screenings for students, and training consultation and support for teachers and staff.
  • Sharp Health Plan has released an update providing tips on finding the right mental health support. For example, there are many types of mental health professionals, including therapists and counselors, psychiatrists, and psychologists, all with distinct differences. Steps to take include thinking about your specific mental health needs, doing your research on what kind of mental health professional you’d like to see, and writing down question about things that are important to you before your appointment.
  • Sunflower Health Plan is partnering with the National Alliance on Mental Illness (NAMI) of Kansas to help increase access to educational resources for family members and supporters of those living with mental illness. Through the partnership, Sunflower will support NAMI’s Family-to-Family, a free, 8-session educational program for families, significant others, and friends of people with mental health conditions and Family Support Groups, peer-led support groups for adults with loved ones experiencing symptoms of a mental health condition. The groups allow family members to share their experiences and gain insight from the challenges and successes of others facing similar situations.
  • Sunshine Health recently sponsored the Volunteer Florida’s Healthy Minds Teen Summit, where roughly 75 Florida middle and high school student leaders gathered to talk about normalizing mental health as a critical self-care topic. Breaking the stigma was the number one topic for these teen leaders, who learned about strategies and resources to take back to their peers to help deal with everything from the stresses of everyday life, to dealing with severe trauma. Inspirational speakers helped motivate the teens and shared their stories about mental health. Former college basketball star turned business owner Iman MacFarland introduced three-time Olympic Gymnast Dominque Dawes.
  • Superior HealthPlan released a short video addressing mental illness and what Superior employees need to know about it. The video featured Dr. Sandy Vale, Superior’s lead behavioral health medical director, who talked about what mental illness is, warning signs, and potential treatments.
  • Sutter Health Plus members have premium access to Sanvello at no extra cost as part of their behavioral health care benefits through U.S. Behavioral Health Plan, California. Sanvello is an app that offers on-demand clinically proven techniques to manage symptoms of stress, anxiety, and depression as they happen. By answering a few questions in the Sanvello app throughout the week to assess mood and track activities like caffeine intake, sleep, and exercise, members can identify patterns in their behavior to make positive lifestyle changes. They can also create progress assessments using past mood and health ratings to discover new connections between their experiences and emotions.
  • Leaders at UCare and Kente Circle are seeking make it okay to discuss mental health issues with trusted barbers and stylists. The Confess Project – America’s First Mental Health Barbershop Movement – empowers frontline heroes to support their clients’ mental health and substance use disorder needs. The barbershop or hair salon is often a safe place for clients to discuss their concerns and needs. Armed with the Confess Project training, barbers and stylists will be able to say: “I am more than a pair of clippers. I am improving my community through the barber chair one client at a time.”
  • UCare and mental health providers Alluma and the Amherst H. Wilder Foundation have developed a pilot program to make it easier for prospective mental health professionals to join the field. Through the partnership, UCare will fund $100,000 in stipends for clinical interns as they complete the supervision necessary to graduate from and eventually be licensed in social work, clinical counseling, marriage and family therapy, and other mental health roles. Wilder and Alluma will provide thousands of hours of state mandated supervision at no cost. The pilot will focus on supporting clinical interns from cultural and ethnic minority groups, rural communities, and other underrepresented populations where the workforce needs are greatest.
  • UPMC Health Plan’s Special Needs Plan Severely Mentally Ill team provides community-based care management services to members with a serious mental illness diagnosis. The team services those with the highest needs of physical health and behavioral health indicators as identified by physical, behavioral and pharmacy claims utilization data in a rolling 12-month period. Goals of the program include: care integration for member physical health and behavioral health conditions, development of self-management skills and improved quality of life. Outcomes include improved HEDIS measures, as well as reductions in Emergency Department visits and inpatient admissions. UPMC’s Community Care Behavioral Health Organization, part of the UPMC Insurances Division, is also working with stylists and barbers to develop an innovative community engagement initiative known as Health Access Initiative for Recovery (Our HAIR). This initiative centers on partnering with barbers and stylists in Pittsburgh to build up black and brown communities through increasing familiarity with, comfort around and connection to resources related to behavioral health concerns seen within hair care settings. In the Our Hair initiative, hair stylists/barbers will have an opportunity to participate in a program that teaches them how to talk about and provide resources for mental health and drug/alcohol/substance use concerns within their communities. The goal is to increase engagement, education, and resource dissemination about behavioral health issues within historically underserved communities and to decrease the behavioral health care disparities between Black and White members.
  • UPMC Health Plan provides support to parents as they build resilience with their children to cope with the stresses of the pandemic and beyond. Teaching children the cognitive mental health techniques they need to excel will enhance their strength to overcome common psychological responses (such as insomnia or fear), health risk behaviors, and mental health conditions like depression and anxiety. UPMC providers continue to offer in-person and virtual appointments for members and UPMC Health Plan has several additional resources to assist in addressing children, youth, and parent/guardian behavioral health needs. RxWell, for example, is UPMC Health Plan’s evidence-based mobile app for ages 16 and older to help members become emotionally and physically healthy by building better lifestyle habits. The app combines health coaching support with provider-endorsed techniques, including self-guided exercises and other tools to help members manage stress, anxiety, and depression and reach their health-related goals. Currently there are 7 programs to choose from based on a member’s needs: Depression, Anxiety, Stress, Weight Management, Nutrition, Physical Activity, and Ready to Quit (tobacco cessation).
  • A team of investigators from UPMC Children’s Hospital of Pittsburgh found that a digital application may remove barriers to mental health care and is associated with reduced emotional distress when offered as part of routine pediatric care. The findings were published in Psychiatric Services. UPMC initially studied RxWell™, a digital application developed by UPMC Health Plan to support its members with management of depression and other health and wellness challenges and published positive outcomes in adult users.

How Are Physicians Paid?

Payors use a variety of reimbursement methodologies and reimbursement structures. Several reimbursement methodologies might be combined in a single arrangement with a payor, often as a means of transitioning to “value-based” payment. Reimbursement methodologies may include the following:

How Are Physicians Paid?

Payors use a variety of reimbursement methodologies and reimbursement structures. Several reimbursement methodologies might be combined in a single arrangement with a payor, often as a means of transitioning to “value-based” payment. Reimbursement methodologies may include the following:



Fee-for-service reimbursement –

fixed reimbursement amounts per item or service furnished, commonly negotiated in a physician participation agreement with the plan. At base, the “plan” pays the cost of medical care, while the “payor” is an entity responsible for the processing of patient eligibility, services, claims, enrollment, or payment.



Direct to Employer –

direct and unique arrangements between physicians and ERISA self-funded plans for discrete categories of care.



Care coordination –

payment for care coordination activities, often with a focus on population health management.



Quality incentives –

payment is based in part on achieving pre-set quality of care metrics across an assigned population of members.



Bundled payments –

fixed prospective or retrospective reimbursement for a defined bundle of services that can be furnished by different physicians (e.g., hip/knee replacement).



Shared savings –

potential upside-only reimbursement, in addition to fee-for-service reimbursement, when aggregate population health care costs are less than a predefined baseline amount. The “savings” are shared between the payor and the physician.



Shared risk –

potential upside or downside reimbursement, in addition to fee-for-service reimbursement, depending on whether aggregate population health care costs are more or less than a predefined baseline amount. The “savings” or “losses” are shared between the payor and the physician (or among physicians).



Full or partial capitated payments –

A per-member, per-month reimbursement to provide all (or a defined subset of) covered services without reference to volume, utilization, or costs. There is typically no separate fee-for-service payment from the payor, except for specified carved-out services.

Managed Care Contracts and Health System Operational Alignment

CASE EXAMPLE of how we breakdown contracts and tie the terms to operational alignment

Because the business of healthcare is to deliver the highest quality care to patients, improving clinical performance is the driving focus. However, understanding and responding to financial pressures through increased efficiency and enhanced revenue capture is what makes high-quality clinical delivery possible and sustainable.

Reimbursement StructureActivity triggering a more robust financial return
Reimbursed primarily on a fee-for-service basis, generate more revenue by using your care team as a provider–extender, enabling more patients to see the provider for a billable visit each day
The organization accepts full risk for patient costs, Ensuring patients are taught how best to manage their illness and avoid specialist or emergency room visits. 
Capitated fee for primary care services, experimenting with alternative visit types may maximize your ability to care for more patients
Nonphysician payment for CCMPractices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs.
“If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 ,00 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services.”
Non-visit-based payment for chronic care management (CCM)Measuring Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services.

CMS Bundled Payments for Care Improvement (BPCI) Initiative: A Discussion on Bundled Payments

There is a large disconnect between what occurs after a patient is discharged from a hospital (acute) and what occurs thereafter. The quality of care is entirely unmanaged, uncontrolled, and unmonitored. Moreover, the patient is placed at greater risk whe

Understanding the CMS Bundled Payments for Care Improvement (BPCI) Initiative

In recent years, healthcare has been undergoing a significant transformation, driven by the need to improve care delivery and reduce costs. One of the key initiatives in this transformation is the Bundled Payments for Care Improvement (BPCI) program, introduced by the Centers for Medicare & Medicaid Services (CMS). The BPCI program is part of a broader effort to move the U.S. healthcare system towards value-based care, focusing on quality outcomes rather than the volume of services.

What is the BPCI Initiative?

The BPCI initiative was launched as part of the Affordable Care Act (ACA), which allowed the establishment of the Center for Medicare and Medicaid Innovation. The goal of this center is to pilot and expand innovative payment models that improve healthcare quality while reducing costs. BPCI is one of the many alternative payment models (APMs) being tested to align financial incentives with the quality of care provided, particularly in the post-acute care (PAC) setting.

The BPCI program focuses on bundled payments, which means that instead of paying for each service separately, healthcare providers receive a single, comprehensive payment for an entire episode of care. This “bundle” covers all services related to a patient’s treatment, including post-hospitalization care, for a specified period (e.g., 30 or 90 days). The goal is to incentivize providers to deliver coordinated, high-quality care that reduces unnecessary services and prevents avoidable readmissions.

Why Focus on Post-Acute Care?

One of the most challenging areas of healthcare to manage, particularly within the Medicare Fee-For-Service (FFS) program, is post-acute care. After patients are discharged from the hospital, they often require further care in settings such as inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home health agencies (HHAs). The costs and quality of care in these settings vary significantly across the country, contributing to wide regional disparities in Medicare spending. In fact, 73% of the variation in Medicare spending is attributed to differences in post-acute care settings.

The BPCI initiative specifically targets these post-acute care settings because of the high cost and the potential for improvement. For example, about 20% of Medicare patients are readmitted to the hospital within 30 days of discharge, and research suggests that 75% of these readmissions could be prevented with better care coordination.

The BPCI Models

The BPCI initiative includes four different models, each offering a different approach to bundled payments:

  1. Model 1: Retrospective Acute Care Hospital Stay Only – This model focuses on hospital costs for acute care stays.
  2. Model 2: Retrospective Acute and Post-Acute Care Episode – In this model, hospitals are financially responsible for both the acute care and all post-acute care services provided within 30 or 90 days of discharge.
  3. Model 3: Retrospective Post-Acute Care Only – This model places post-acute care providers (e.g., SNFs, HHAs) at financial risk for the services they provide after a hospital discharge.
  4. Model 4: Prospective Acute Care Hospital Stay Only – In this model, hospitals receive a single, upfront payment for an acute care stay, and they cannot bill for any additional services, even if the patient is readmitted within 30 days.

Model 2 is the most complex and widely adopted model, as it requires hospitals to manage the entire episode of care, including both acute and post-acute services. The financial risk is reconciled retrospectively, meaning that CMS reviews the total cost of care after the episode is complete and compares it to a pre-determined target price. If the costs are lower than the target, the hospital may share in the savings; if the costs are higher, the hospital is responsible for the excess.

Implementation Strategies for Success

To succeed in the BPCI initiative, hospitals and post-acute care providers need to collaborate closely. Many hospitals are implementing strategies such as narrowing their networks to include only high-performing post-acute care providers. This ensures that patients are discharged to facilities with strong track records in quality care and low readmission rates.

Hospitals are also using tools like patient choice letters, which list all available post-acute care providers but highlight those that have been vetted for quality. This approach, known as “soft steerage,” helps guide patients toward the best providers without restricting their choices.

In addition to collaboration, data sharing and technology play a crucial role in the success of BPCI. Hospitals need visibility into the patient’s care journey after discharge, which can be facilitated through electronic health records and other data integration tools. This allows for better coordination and monitoring of patient outcomes across the continuum of care.

Challenges and Opportunities

While the BPCI initiative offers significant opportunities for improving care and reducing costs, it also presents challenges. One major issue is the complexity of managing bundled payments, especially with the retrospective reconciliation process that introduces delays in financial feedback. Hospitals need to track performance in real-time and adjust their strategies based on ongoing data, rather than waiting for quarterly reconciliations from CMS.

Another challenge is managing high-risk patients and outlier cases, which can significantly skew financial outcomes. However, as bundled payment models continue to evolve and expand, hospitals that proactively adapt to these challenges will be better positioned for success in the shifting healthcare landscape.

Conclusion

The BPCI initiative is an important step towards a value-based healthcare system, particularly in managing the costly and often fragmented post-acute care segment. By aligning financial incentives with quality outcomes, the BPCI program encourages providers to deliver more coordinated, efficient care, reducing unnecessary services and preventable readmissions.

As bundled payment models continue to expand, healthcare providers who embrace this shift now will be better prepared for the future. By focusing on collaboration, data integration, and patient-centered care, hospitals can succeed in the BPCI initiative and contribute to a more sustainable healthcare system.

1-Minute Pro Tip: How to Handle Claim Denials from Private Insurance Companies

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.


A denial of coverage because a PA performed the service is usually phrased as “service only covered when provided by an M.D. or D.O.” or “physician assistants not considered authorized providers under the plan.” In some cases, first assisting at surgery claims are denied for incorrect use of modifier codes (Do not assume that all companies use the same code; some use -AS, some use -80, -81, or -82.) and in other cases, those claims are denied because of the use of a restricted code or for performing a surgery not necessarily requiring a first assistant.


You may need to contact the insurance company to find out what modifier should have been used and, in some cases, you may need documentation that a first assistant was medically necessary for the surgery. Insurance companies strive to (1) retain their subscribers, (2) maintain or increase their market share, and (3) keep a positive corporate image. If the insurance company made the coverage decision and you believe that the coverage decision was unfair, enlist the help of the patient and, if applicable, the business that pays the insurance plan’s premium. Their dissatisfaction is

Subcontracting Opportunities

Carenodes contracts with physicians, facilities and other health care professionals to form our provider networks, which are essential for delivering quality, accessible and cost-effective health care services. In partnership with providers (medical and non-medical, behavioral, primary, substance abuse, and others), we have developed (and are growing) community-wide coalition efforts geared towards addressing larger systemic health, infrastructure or social determinant issues with a large impact on health.

Carenodes contracts with physicians, facilities and other health care professionals to form our provider networks, which are essential for delivering quality, accessible and cost-effective health care services. In partnership with providers (medical and non-medical, behavioral, primary, substance abuse, and others), we have developed (and are growing) community-wide coalition efforts geared towards addressing larger systemic health, infrastructure or social determinant issues with a large impact on health.

WORKFORCE MOBILIZATION INITIATIVE

Did you know that locating and securing subcontracting opportunities can be just as, if not more valuable, than administering direct contract awards? There are multiple ways to partner with other contractors to maximize your chances of securing contracts through Carenodes Opportunity Network and Workforce Mobilization Initiative.

  1. Workforce of the future,
  2. Second acts,
  3. Rural resurgence.
  4. A marketplace of healthcare providers
  5. An ecosystem of healthcare consultants
  6. Clinical executives

Our Workforce Mobilization Initiative calls for increasing opportunities for mid-career workers to get the upskilling they need to continue in their current jobs and have access to new jobs. This Program encourages state governments to improve infrastructure, such as broadband, in rural areas to allow workers to work remotely and remain in their communities if they choose.

TYPES OF OPPORTUNITIES

Non-Schedules Based Contracts

These procurements require a response to an RFP or RFQ. Check back or sign up for new opportunities.

Subcontracting and Other Partnerships

Subcontracting and other partnerships involve working with other contractors in order to implement a master agreement, project segments, joint ventures, and/or other specified engagement frameworks across the United States.

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Subcontractor Interest 

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TRICARE

Effective August 31, 2020

The U.S. Department of Labor’s (DOL’s or Department’s) Office of Federal Contract Compliance Programs (OFCCP) publishes this final rule to amend its regulations pertaining to its authority over TRICARE health care providers. The final rule is intended to increase access to care for uniformed service members and veterans and to provide certainty for health care providers who serve TRICARE beneficiaries. It is also anticipated that this final rule will result in cost savings for TRICARE providers. In a reconsideration of its legal position, the final rule provides that OFCCP lacks authority over Federal health care providers who participate in TRICARE. In the alternative, the final rule establishes a national interest exemption from Executive Order 11246, Section 503 of the Rehabilitation Act of 1973, and the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 for health care providers with agreements to furnish medical services and supplies to individuals participating in TRICARE. Thus, even if OFCCP had authority over Federal health care providers who participate in TRICARE (which this rule clarifies it does not), OFCCP has determined that special circumstances in the national interest justify granting the exemption as it would improve uniformed service members’ and veterans’ access to medical care, more efficiently allocate OFCCP’s limited resources for enforcement activities, and provide greater uniformity, certainty, and notice for health care providers participating in TRICARE. Under the final rule, OFCCP will retain authority over health care providers participating in TRICARE if they hold a separate covered Federal contract or subcontract that is not for providing health care services under TRICARE. TRICARE providers that fall outside of OFCCP’s authority under this final rule remain subject to all other Federal, state, and local laws prohibiting discrimination and providing for equal employment opportunity. This regulation is effective August 31, 2020.

Subcontracted Carenodes Advisory Services (Consulting Agreements)

ADVISORY SERVICES Subcontracted Carenodes Advisory Services (Consulting Agreements)

This agreement (“AGREEMENT”) establishes the terms under which the parties hereto agree that the consultant, who has already provided his or her corporate name (if any) and address (hereinafter, referred to as the “CONSULTANT”) will perform consulting work for a client of CARENODES, Inc. (the “CLIENT”), CARENODES’s offices are located at 3415 S Sepulveda Blvd 10th floor, Los Angeles, CA 90034, (“CARENODES”).  CARENODES and CONSULTANT may be individually referred to herein as a “PARTY” and collectively referred to herein as “PARTIES”.  CLIENT is an intended third-party beneficiary of this AGREEMENT, and CLIENT will be entitled to the rights and benefits enumerated below.

  1. Field of Consultation.  CARENODES wishes to engage CONSULTANT, as an expert in the field provided to CARENODES in the course of the on-line sign-up process, to consult with CLIENT regarding CLIENT’s work in the field(s) also provided in the sign-up process.
  • Term of Consultation.  The period of consultation will be as agreed between CARENODES and CONSULTANT beginning on the first day of the project with the CLIENT, and will continue until the project is complete, as determined by CLIENT in its sole discretion.  Consultation will take place during the term of this Agreement at times and places mutually agreed upon by CONSULTANT and CARENODES.
  • Fee.  CONSULTANT will receive the fees that have been specified separately by CARENODES, and which CONSULTANT agrees constitutes valid consideration for this AGREEMENT.
  • Termination.  CARENODES will have the right to terminate this AGREEMENT upon thirty (30) days written notice to CONSULTANT.
  • IRS Form 1099.  It is understood and acknowledged that the IRS Form 1099 that CONSULTANT will receive from CARENODES will indicate the total dollar amount that CARENODES will have paid CONSULTANT for the calendar year.  It will be CONSULTANT’s responsibility to file a Schedule C to deduct expense reimbursement so that these payments are not taxed.  CONSULTANT understands and acknowledges that this will require CONSULTANT to keep records that designate fee income versus expense reimbursements, including maintaining original receipts.  Note: For those contractors that are incorporated, this provision will not apply.
  • No Conflict.  CARENODES understands that CONSULTANT is available to perform the consulting services as provided herein for CARENODES.  CONSULTANT therefore warrants that this consultation will not cause CONSULTANT to breach any agreement or obligation CONSULTANT may have undertaken with others and that all consulting services to be performed by CONSULTANT under this AGREEMENT are fully consistent with the rules and regulations of his or her employer, if any.  All consulting services to be performed by CONSULTANT for CLIENT will be on CONSULTANT’s own time and without the support or use of the facilities of CONSULTANT’s employer.
  • No Third Party Confidential Information.  It is not CLIENT’s desire to be afforded access to, or to receive any information from CONSULTANT, which is confidential or in any way proprietary to any third party, nor to receive any information the receipt of which implies any obligations of confidentiality upon CLIENT.  CONSULTANT understands that any information provided by CONSULTANT can be freely disclosed and used for any CLIENT purpose including, for example, as incident to activities before the Food & Drug Administration, Federal Trade Commission, and U.S. Patent & Trademark Office.  CONSULTANT warrants that no other party, e.g. any employer, has any right, title or interest to or in any information, ideas, developments and inventions which may be submitted to CLIENT by CONSULTANT in CONSULTANT’s capacity as a consultant to CLIENT.  
  • Obligation of Confidentiality.  During CONSULTANT’s engagement as a consultant, it may be appropriate and necessary for CONSULTANT to have access to certain of CLIENT’s technical and business information and materials.  CONSULTANT agrees to consider as confidential all information disclosed to CONSULTANT and materials given to CONSULTANT by CLIENT during the period of this AGREEMENT, and any technical or business information CONSULTANT may learn, observe, or otherwise obtain concerning CLIENT incident to CONSULTANT’s performance under this AGREEMENT, including the fact that CLIENT may have interest in specific materials or areas of business, all of which is referred to as “INFORMATION”.  CONSULTANT agrees to take all reasonable precautions to prevent disclosure of INFORMATION or materials to third parties and not to use INFORMATION or materials without CLIENT’s express written consent.  These obligations of confidentiality and nonuse will continue beyond the term of this AGREEMENT, but will cease to apply as to any specific portion of CLIENT’s information or material which becomes available to the public. 
  • Term of Obligation of Confidentiality.  These obligations of confidentiality and non-use set forth in the section entitled “Obligation of Confidentiality” and all subsections thereof, will survive the termination of this AGREEMENT and any extensions thereof.
  • Disclosures Incident to On-Site Services.  If consulting is performed by CONSULTANT at a CLIENT facility, the obligations of confidentiality and non-use as set forth in the section entitled “Obligation of Confidentiality” and all subsections thereof, will extend to any and all confidential and proprietary information belonging to CLIENT and acquired by CONSULTANT as incident to performing such onsite services.  This information may include, for example, plant size, crew shifts, number of lines, product shipments, new product development testing, and the like.
  • Publication.  CLIENT will retain the results of CONSULTANT’s consulting work for CLIENT as confidential information.  Therefore, CONSULTANT will not publish or otherwise disclose the results of such work or other information concerning such work, without the express written consent of CLIENT.  In the event that work resulting from CONSULTANT’s consulting is published in the scientific literature, acknowledgement will be made to CONSULTANT in the accepted style, as appropriate.  CARENODES may share information collected from CONSULTANT with CLIENT, business partners, advertising companies, and other third parties.  CONSULTANT will not use CLIENT’s name without CLIENT’s concurrence.
  • Independent Contractor.  CONSULTANT understands and acknowledges that CONSULTANT is an independent contractor and not an employee of CARENODES or CLIENT.  As such CONSULTANT will not be considered an eligible participant in any CARENODES or CLIENT benefit plan other than benefits CONSULTANT was entitled to prior to the execution of this AGREEMENT.  Moreover, CONSULTANT disclaims all other disability programs and unemployment compensation programs in connection with CONSULTANT’s work with CARENODES or CLIENT.  In light of CONSULTANT’s status as a consultant, CONSULTANT understands that it is CONSULTANT’s personal responsibility to report CONSULTANT’s earnings under this AGREEMENT to both the Federal and any appropriate State or Local Governments.  Under some circumstances, however, CARENODES may be required to report payments made to CONSULTANT and/or withhold Income and/or Social Security taxes.  It is further understood and agreed that CONSULTANT is not a partner or joint venturer with CARENODES or CLIENT and has no authority to bind CARENODES or CLIENT to any contract with third parties. 
  • Inventions.  CONSULTANT agrees to disclose promptly and fully to an authorized representative of CLIENT all information, discoveries, works of authorship, designs, software, and inventions, whether or not patentable, conceived or reduced to practice by CONSULTANT as a result of CONSULTANT’s performance under this AGREEMENT (“INVENTIONS”).  All INVENTIONS will be the property of CLIENT.  Accordingly, CONSULTANT will assign outright to CLIENT the entire right, title and interest, both in the United States and abroad, to INVENTIONS, without payment other than that herein provided.  CONSULTANT will execute any documents which CLIENT deems reasonably necessary to secure its proprietary rights as set forth herein, such as to obtain patents, worldwide, or other protection covering INVENTIONS and to fully cooperate as requested to do so in the prosecution of such patents or other applications.  CLIENT will have the above-mentioned documents drafted at its own expense, as will also be the case with any patent or other applications which are filed, and with the prosecution and maintenance thereof.  CONSULTANT warrants that CONSULTANT has appropriate ownership rights in INVENTIONS to carry out CONSULTANT’s obligations under this paragraph.
  • Work for Hire.  Work done by CONSULTANT for CLIENT of a custom design and custom tailored nature will be considered work for hire.  Any materials, such as worksheets, exercises, case studies and videos, created by CONSULTANT for CLIENT as part of such custom design and/or custom tailored work, will be wholly owned by CLIENT, with all copyrights being obtained and retained by CLIENT.  
  • Personally Identifiable Information. CONSULTANT warrants that CONSULTANT will not be collecting or handling any personally identifiable information (“PII”) as a result of CONSULTANT’s consultations performed under this AGREEMENT.  PII means any information relating to a person that is sufficient to cause that person to be identified, directly or indirectly, in particular by reference to an identification number or to one or more factors specific to physical, physiological, mental, economic, cultural, or social identity.  If the scope of consultations under this AGREEMENT changes such that the collecting or handling of PII becomes necessary, CONSULTANT will promptly notify CLIENT in writing regarding such change. 
  • Indemnification.  CONSULTANT will indemnify, hold harmless and defend CLIENT and its AFFILIATES and CLIENTS’s officers, directors, shareholders, employees and agents from and against any and all claims, liabilities, losses, expenses (including, without limitation, fines, forfeitures, reasonable attorney’s fees, disbursements and administrative or court costs), penalties or damages (collectively, the “LIABILITIES”) from any third party claim arising from a breach of CONSULTANT’s privacy representations and warranties provided in the article entitled “Personally Identifiable Information”.
  • Compliance with Applicable Government Laws and Regulations. CONSULTANT will fully comply with all applicable governmental, legal, regulatory and professional requirements, including but not limited to anti-corruption and anti-bribery laws, such as the Foreign Corrupt Practices Act (collectively “LAWS”).   If CONSULTANT has operations physically located in the territorial United States which are involved in CONSULTANT’s performance under this AGREEMENT, then CONSULTANT will fully comply with the employee notice requirements set forth in 29 CFR Part 471, Appendix A to Subpart A and any applicable equal opportunity laws including the provisions in 41 CFR § 60-1.4 (a) (1)-(7), 41 CFR § 60-741.5(a), and 41 CFR § 60-250.5.  CONSULTANT will promptly notify CARENODES and CLIENT if CONSULTANT receives any notice, demand, summons or complaint from any governmental or regulatory authority, agency or other body relating to the subject matter of this AGREEMENT, and will take all steps, at CONSULTANT’s expense, to resolve any issues as promptly as practicable.
  • Anti-Corruption Compliance.  In addition to any other measures necessary to comply with LAWS as described above, CONSULTANT will not, and will ensure that any person or entity acting on its behalf will neither (i) offer to pay, pay, promise to pay, or authorize the payment of money or anything of value nor (ii) give or offer any “facilitating” or “grease” payments (i.e. payments given or offered in order to expedite or secure the performance of a routine government action) whether or not those payments may be considered lawful under the applicable anti-bribery laws to any (a) officer, employee or any person acting in an official capacity for or on behalf of a government or an entity owned or controlled by a government, or of a public international organization; or (b) political party or their officials; (c) candidate for a political office (“PUBLIC OFFICIAL”) in order to influence any act or decision of the PUBLIC OFFICIAL in his or her official capacity or to secure any other improper advantage in order to obtain or retain business or obtain any other business advantage.
  • AFFILIATES.  As used herein, the term “AFFILIATES” refers to any corporation, association, or other entity that directly or indirectly owns, is owned by, or is under common ownership with CLIENT, either currently or during the term of this AGREEMENT.  As used in this definition, the terms “owns”, “owned”, or “ownership” mean the direct or indirect possession of more than fifty percent (50%) of the voting securities, income interest, or a comparable equity in such business entity.
  • Entire Agreement.  This AGREEMENT constitutes the entire understanding between the PARTIES with respect to the subject matter contained herein and supersedes all prior agreements, understandings and arrangements whether oral or written between the PARTIES relating to the subject matter hereof, except as expressly set forth herein.  Nothing in this AGREEMENT may be changed or modified, nor may anything be added to this AGREEMENT, except as may be specifically agreed to in a subsequent writing executed with the same formalities as this AGREEMENT.  For their convenience, the PARTIES may use, from time to time, their standard purchase orders, invoices, or other similar preprinted forms.  The terms of this AGREEMENT shall take precedence over any standard Terms and Conditions language set forth in those forms.
  • Governing Law.  This AGREEMENT will be governed and construed in accordance with the laws of the State of California, United States of America.
  • Headings.  The headings or titles of articles, sections or paragraphs appearing in this AGREEMENT are provided for convenience and are not to be used in construing this AGREEMENT.
  • Notices.  All notices, authorizations, etc. relevant to this AGREEMENT may be personally served or sent by first class mail, postage pre-paid, to the respective PARTIES at the addresses provided and/or via email.
HEALTHCARE SERVICES: Provider / Healthcare Organizations

Carenodes contracts with physicians, facilities and other health care professionals to form our provider networks, which are essential for delivering quality, accessible and cost-effective health care services.

In partnership with providers (medical and non-medical, behavioral, primary, substance abuse, and others), we have developed (and are growing) community-wide coalition efforts geared towards addressing larger systemic health, infrastructure or social determinant issues with a large impact on health.

Click here to learn more about joining Carenodes Network.

Payer Contract Modeling

Contract modeling, or analyzing potential scenarios of reimbursements to understand financial outcomes, provides a proactive approach to financial management by analyzing the impact of different elements such as methodologies, rate changes, pricing, payor mix shifts and ever changing regulations on margins, rather than net revenue alone.

Do it like a Pro: Managed Care Payer Contract Analysis

Contract modeling, or analyzing potential scenarios of reimbursements to understand financial outcomes, provides a proactive approach to financial management by analyzing the impact of different elements such as methodologies, rate changes, pricing, payor mix shifts and ever changing regulations on margins, rather than net revenue alone.

To determine current and future performance, contract modeling can be applied to current contracts and various “what-if” scenarios.

Various Modeling Approaches

1. Medicare break-even computation

A simple way to evaluate the current state of contract performance is to conduct a basic Medicare break-even analysis. This analysis determines the financial impact if payment for all patient populations were according to Medicare rates. A Medicare break-even analysis is a way to benchmark how well commercial payers pay, and a way to evaluate the performance of key service lines, because it takes the payor mix out of the equation and instead uses a consistent reimbursement approach.

2. Assessment of performance of current contracts.

This straightforward analysis determines whether payment is in accordance with the terms of the commercial contract. The analysis will, for example, determine which service lines have the greatest variances between expected and actual payment.

3. Assessment of proposed contracts

This “what-if” analysis determines how changes in the rate and terms of a proposed contract would affect the yield. Changes in clinical services, types of products (i.e., HMO vs. PPO), or even payers can also be modeled. This provides an understanding of, either in actual dollars or percent, whether the proposed contract will result in shortcomings or whether it will improve the bottom line.4.

4. Comparison of traditional and non-traditional reimbursement methodologies.

Value-based payment models represent a new approach for providers. Many of these models put the provider at financial risk for meeting quality/outcomes targets, so understanding the financial implications of such methods before entering into a contract is critical. Likewise, modeling can help determine how implications of potential decreases in Medicaid funding resulting from changes or repeal of the Affordable Care Act, along with increased self pay and bad debt, will affect the bottom line.

5. Assessment of pricing changes.

Contract modeling can be used to better understand the impact of chargemaster pricing changes. For example, if the charge for a procedure increased by 10 percent, the modeling can show how reimbursement would be affected.

Digital Therapeutics and Healthcare Reimbursement

Many digital therapeutics (DTx) providers are working to obtain reimbursement from U.S. payers. The following post discusses stategy for reaching patients and partnerships. A reputable DTx company will have a strategy for reaching patients considering whether the therapeutic is curative or designed for chronic care.

  • Digital therapeutics (DTx) represent a novel approach to delivering improved clinical outcomes, but the unstructured nature of today’s DTx access process has presented a major hurdle to broader uptake
  • Payers are still at very different stages in their acceptance of DTx, and in contrast with traditional pharmaceuticals, buy-in from senior leadership will be an essential part of the top-down decision-making process for DTx prioritization
  • Pharmacy benefit managers (PBMs) have taken a leadership role in facilitating a pathway for digital therapeutics adoption, and they are likely to remain the optimal entry point for DTx coverage and reimbursement in the near term
  • Employer groups are likely to be early advocates for the benefits of DTx after running individual pilot programs, whereas managed care organizations (MCOs) may be less receptive to covering DTx until a national body of real-world evidence becomes available
  • Ultimately, payers still have limited willingness to pay for DTx that lack clear impact on plan expenditures, and they will expect to see risk-sharing contracts on the table that can address these uncertainties

PAYER REIMBURSEMENT

More developed DTx companies are coming to discover that payer acceptance and reimbursement is key to market viability and that preparations to engage payer support need to be made in the development stage. Typically, companies partner with pharma companies to leverage traditional insurance reimbursement and distribution pathways, as in the case of Pear Therapeutics benefiting from its partnership with Sandoz. However, are seeking alternative payer reimbursement pathways, looking instead to pharmacy benefit management plans or distributing directly to patients through employers as additional benefit programs.

PHYSICIAN ADOPTION
As the oldest of the DTx have begun to mature, physician adoption is the final hurdle to consumer adoption. There are three major approaches to gaining physician adoption. Pear Therapeutics is using the pharmaceutical model, leveraging pharmaceutical distribution partnerships to make physicians aware of and willing to prescribe the product. Better Therapeutics, which develops a product for insomnia, is partnering with a pharmacy benefit plan that specifically offers a digital dispensary – effectively curating benefit-covered products in a single platform that physicians can use when making therapeutic recommendations. Kaia Health is taking a less traditional approach – the company has been targeting physicians as part of a marketing campaign, but the app is on the App Store and offers three subscription packages for patients.

Physical Therapy Referrals: Not Needed

Physical therapist services are generally covered as a basic benefit by all major health insurance companies. Ask your physical therapist to contact your insurance company to determine your specific benefits.

Physical therapist services are generally covered as a basic benefit by all major health insurance companies. Ask your physical therapist to contact your insurance company to determine your specific benefits.

CAN I RECEIVE PHYSICAL THERAPY SERVICES WITHOUT A PHYSICIAN’S REFERRAL?

Consumers are not required to have a referral or diagnosis in order to receive physical therapist services in the State of California. Physical therapist services may be obtained without a physician’s referral if you are a cash carrying patient, receiving treatment for up to 45 calendar days/12 visits, receiving health and wellness services, or if you are a UnitedHealthCare or Medicare beneficiary.

Please note: some health insurance companies require a referral in order for your provider to be paid. Please confirm your benefit requirements by reviewing your coverage documents or calling member services of your respective insurance company. The contact number to your insurance company is listed on the back of your health insurance identification card.

The California Physical Therapy Practice Act requires all licensed physical therapists to disclose (in writing) the following information to all consumers receiving physical therapist treatment without a physician or surgeon referral or diagnosis:

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Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits whichever occurs first.


Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.

ADDITIONAL RESOURCES

Noridian Healthcare Solutions is the current Medicare Administrative Contractor for all healthcare services provided in California
Centers for Medicare and Medicaid Services
Health Insurance and Physical Therapy (For consumers)
Consumer Guide to Health Insurance