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Why health plans partner with vendors for Personal Health Visits

August 31, 2016

A Personal Health Visit (PHV) is a detailed, comprehensive clinical visit between a member and a clinician. During the visit, the nurse practitioner will review the member?s medications with them, discuss the importance of medication adherence, do a physical exam, and provide a summary of every diagnosis related to their entire medical history. As a health insurance provider, Independence does not directly provide hands-on care to members; therefore, Independence contracts with third-party entities to perform this service.

Background

The Centers for Medicare & Medicaid Services (CMS) requires all health plans to conduct health risk assessments on new Medicare Advantage members within 90 days of the member?s effective date. Independence performs outreach to new members through the PHV program, asking them questions that capture the health profile of the new member.

In addition, CMS rates health plans on a number of quality metrics through a measurement system called Star Ratings. A health plan?s rating is based on the following five categories:

  1. staying healthy: screenings, tests, and vaccines;
  2. managing chronic (long-term) conditions;
  3. member experience with the health plan;
  4. member complaints, problems getting services, and improvement in the health plan?s performance;
  5. health plan customer service experience.

As a result, health plans conduct PHVs to address the first category by performing assessments, which can include measuring body mass index (BMI), glycated hemoglobin (HbA1c) and microalbumin biometric tests, and dexa scans to address osteoporosis management in women. In addition, a PHV can indirectly impact other measures, such as screening measures and medication adherence. Please note that these gap closures will be credited to the provider office for Independence-participating providers in a pay-for-performance incentive program. PHVs will not limit a provider?s bonus payments.

The PHV is not meant to replace the member-physician relationship. In fact, it is meant to complement the relationship. All results are faxed to the primary care physician (PCP) for follow-up care, and members are called 3 ? 5 days after completing the PHV to assist them in scheduling an appointment with their PCP, if needed. In addition, the PHV does not replace the annual wellness visit or ePASS® submissions, which physicians are still encouraged to do and for which they will receive reimbursement.

If an issue is identified with the member, the vendor will notify Independence?s Case Management area for follow-up services.

Benefits of a PHV

For members:

  • a chance for members to discuss their health in detail with a clinician;
  • a convenient and accessible avenue for members to receive health care services;
  • an opportunity for Medicare Advantage members to receive a $50 gift card for completing a PHV (commercial members are ineligible for the incentive at this time);
  • ability for members to be transferred to Independence Customer Service at 1-800-ASK-BLUE to assist in answering benefit-related questions;
  • members can receive timely referrals to Case Management for health coaching or their PCP and/or 911 in emergency situations.

For providers:

  • provides PCPs with a snap-shot of the member?s health through a fax summarizing what occurred during the visit, allowing them to focus attention on members with pressing needs;.
  • offers assistance in educating members on preventive services and the importance of taking control of one?s health;
  • helps providers close Star Ratings gaps.

For more information on PHVs and Star Ratings, email us.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
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