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Quality Enhancement Program (QEP)

Primary care provider QEP guide (PDF)

Perinatal QEP guide (PDF)

 

What is the QEP?

  • The QEP became effective on July 1, 2014. This new program will enhance primary care reimbursement through a performance incentive payment, calculated based upon how well a primary care provider office scores on each bonus component relative to their peers of the same specialty type. This program was implemented with extensive input from our Clinical Care Committee which is made up of network physicians from across the state. 
  • The six performance components include: 
  1. Quality performance. 
  2. Severity of illness. 
  3. Cost efficiency management.
  4. Non-emergent emergency room (ER) utilization.
  5. Improvement incentive (awards will begin during the 2nd measurement period).
  6. Patient-centered medical homes.

Who can qualify for the QEP?

PCP practices with 50 or more linked members are eligible for the program. In order to be eligible for the maximum amount of the pool, a practice must have an open panel and be accepting new patients.

How is the performance measured?

  • The measures are based upon claims for services rendered during the reporting period.
  • Results are identified for each of the above five performance components and then aggregated for a total score.
  • Overall practice scores are calculated as the ratio of linked members who received the services as indicated by a submitted claim (numerator) to those linked members who were eligible to receive the services (denominator).
  • The final total score is then compared to all practices of the same specialty type to determine network ranking.
  • Provider performance is documented on a report card (see sample attached) that will be included with QEP payment each reporting period.

How often is this incentive paid?

  • This incentive is paid semi-annually on a per member per month (PMPM) basis.  The PMPM is calculated based on the number of AmeriHealth Caritas Louisiana members linked to your panel.
  • The initial incentive payment for qualifying practices covers a 6-month period, beginning January 1, 2013 and ending June 30, 2013. Thereafter, the incentive payments will be made on a semi-annual basis.

Why are you implementing a program at this time?

  • It is clear to us that the key to improving the health outcomes of our members lies in the strength of our collaboration with our PCPs.
  • We believe that aligning financial incentives and providing you with actionable data will enable us to develop a stronger provider partnership and improve the quality of care our members receive.
  • The first year and half of the Bayou Health program was used as a baseline to measure improvement in quality which can be rewarded through an incentive plan.

What kind of resources can I expect to receive with the QEP?

Your area network management account executive can familiarize you with the program overview and provide additional training to you and your staff.

  • A provider dashboard tool (see sample below) is available to provide actionable data that allows you to identify your linked members and services that they may need, referred to as a care gap.
  • When your patient arrives for services, your front desk staff can print individualized patient reports via NaviNet while checking member eligibility. The staff can attach the reports to the patient's chart so you will be aware of the needed services. Access a NaviNet user guide (PDF).
  • If you have questions related to the calculation and clinical measures, our network management team can assist, additional assistance can be provided by our network management medical director by calling 1-888-922-0007.
  • AmeriHealth Caritas Louisiana offers a HEDIS coding boot camp to you and your staff to ensure that they are billing appropriately for services. This will ensure your practice receives credit for services rendered and your scores reflect the correct calculation bases upon the services rendered. For more information about dates and to register, please contact your account executive.