Buckeye Health Plan does not reward practitioners, providers, or employees who perform utilization reviews, including those of the delegated entities for issuing denials of coverage or care. UM decision making is based only on appropriateness of care, service, and existence of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. Utilization denials are based on lack of medical necessity or lack of covered benefit.
Buckeye Health Plan and its delegated health plan partners have utilization and claims management systems in place in order to identify, track, and monitor the care provided and to ensure appropriate healthcare is provided to the members.
Buckeye Health Plan has implemented the following measures to ensure appropriate utilization of health care:
- A process to monitor for under and overutilization of services and take the appropriate intervention when identified.
- A system in place to support the analysis of utilization statistics, identification of potential quality of care issues, implementation of intervention plans and evaluation of the effectiveness of the actions taken.
- A process to support continuity of care across the health care continuum.
2021 Quality Performance Programs
We are happy to deliver our 2021 Quality Incentive Program to our Primary Care Physicians. This program supports closing HEDIS-based care gaps for our members. Closing these care gaps can improve the overall health and wellness of our members, your patients, and we appreciate your active participation in the program.
New in 2021, the Quality program has been designed for each individual Line of Business (LOB). There are separate Medicaid, Marketplace and Medicare programs, which will allow the programs to be based on the LOB’s own population. Separating out the programs allows you to focus on measures that matter most for each LOB.
All Primary Care Physicians, who have at least one Buckeye member that qualifies for a measure, are eligible. Please see detailed information in the 2021 Quality Performance Measures document for each LOB.
We appreciate the care you provide our members and look forward to strengthening our partnership with you to close care gaps and further improve health outcomes for your Buckeye Health Plan patients.
If you have questions, please reach out to your Provider Relations representative or call 866-296-8731.
- The P4P measures are based on Buckeye Medicaid State P4P measures and are consistent with NCQA and HEDIS quality performance standards
- Each measure is assigned an incentive dollar amount and target percentage
- 2 tier targets based on HEDIS 25th and 50th percentiles
- Target 1: 75% of incentive dollar amount
- Target 2: 100% of incentive dollar amount
- Each measure is evaluated independently and can qualify and receive an incentive payment for one, multiple or all of the measures
- Measures are intended to be closed with claims data, although supplemental data is accepted
- Payments are made via paper checks, based on TAX ID
Allwell from Buckeye Health Plan understands that the provider-member relationship is a key component in ensuring superior healthcare and the satisfaction of our members. Because we recognize these important partnerships, we are pleased to offer the 2021 Continuity of Care (CoC) Quality Bonus Program, which rewards PCPs for improving quality and closing gaps in care.
New in 2021, the CoC program includes an incentive enhancement to better align payment with quality. Providers can now earn incentives at multiple levels based upon Medicare Star Rating achievement for each measure.
Ambetter is proud to invite you to participate in our pay-for-performance (P4P) program. The program is designed to enhance quality of care through a focus on preventive and screening services while promoting engagement with our members. Based on program performance, you are eligible to earn compensation in addition to that which you are paid through your Participating Provider Agreement. The P4P program is “upside only” and involves no risk to you. Further, contract document is not required to participate in this program.
The P4P program provides financial incentives for engaging your members and closing care gaps based on NCQA and HEDIS quality performance standards. Each care gap has its own incentive amount and is paid for each compliant member event once the target has been achieved for that specific measure.
Incentives are paid based on member primary care assignment. In other words, a closed care gap results in an incentive to the tax identification numbers for the primary care provider of record for that member. Incentives are paid three times per year and providers will receive credit for all care gaps closed during the calendar year.