IPA Foundation presentation to IPAs Bankmed GP Provider Network & PHA
History Formation of IPAs – since early 1990’s Operational IPA offices with IT infrastructure Monthly CPD meetings Monthly newsletters, communications Many registered as MCOs with CMS Some products: – – – Capitation products (> 30 000 lives) Enhanced FFS product (> 90 000 lives) HIV Network Disability Grant assessments In-house Software Reps on the road Profiling and Peer Review conducted
INVITATION November 2006 – Summit – Bankmed and IPA and GP groups – Agreed to work together to promote the GP as the Coordinator of Care – Negotiating Team formed
IPA Foundation Structure Funded by member IPAs To become the Representative Contracting Body of IPA organisations Facilitate formation of a Nationally contracted GP Network Contract with all willing general practitioners (IPA & non-IPA providers) Provide Network Management Services Perform Profiling and Peer review
Organogram ASAIPA Bankmed SAMCC SPNet IPA Foundation – network management Administration Profiling Bankmed Contracted GP Network IPA Foundation Contracted GP Network
Profiling IPA Foundation National Peer Review Committee IPA Peer Review Committee Regional Peer Review Committee
Bankmed Goals Phase 1 – Formation of a DSP / PPN network – Enhanced remuneration (on Savings) – Cost containment – Profiling – Wellness Initiatives – Core option Coordination of Care Chronic disease management Phase 2 – Quality care – Preventative Care – Health Outcomes Phase 3 – Risk Sharing
Reimbursement Matrix Bankmed Reimbursement by Scheme Plan for 2009 Bankmed Contracted Provider Non-Contracted Provider Scheme Plans IPA Provider Non-IPA Provider Core Saver NHRPL R 250 R 230 Traditional NHRPL R 250 R 230 Comprehensive NHRPL R 250 R 230 Plus 300% of NHRPL Completion of PHA No Yes R 140
Bankmed Core Saver Plan Change from Carecross (2008) to IPA Foundation for 2009 Each beneficiary to be registered with Bankmed contracted provider Consultations – Contracted and IPA affiliated – R 250 – Contracted and non-IPA affiliated – R 230 Chronic disease management – Share in savings achieved
Other Bankmed Scheme Plans Basic option – managed by Carecross Traditional and Comprehensive – Consultations – differential reimbursement (NHRPL/R 230/R 250) – Profiling – Share in savings achieved – DSP for primary care portions of PMBs Plus option – No change from current year
Bankmed GP Provider Contract (Summary) Appropriate, cost-effective, quality, ethical, accessible healthcare Maintain records & provide clinical information No balance billing Entitled to benefits as agreed between Foundation & Bankmed Submit to practice profiling Agreement for 1 year, notice period 90 days
Bankmed PHA Contract (Summary) Personal Health Assessment (PHA) – Part of Wellness Initiative – Only Contracted providers may participate – Fee of R 140 per completed questionnaire paid to provider – Not paid from patients savings account – Complete PHA questionnaire online or submit by fax (cost from global fee) – Submit account to Bankmed – using unique tariff code – Follow instructions as per SOP/manual
IPA Foundation Contract (Summary) Conduct Profiling, utilisation & Peer Review Comply with minimum network requirements as may be determined Furnish all claims, data, clinical information to Foundation, as required from time to time Comply with HPCSA rules Personally responsible for treatment and well-being of patients Provide appropriate, cost effective, quality, ethical, accessible healthcare
IPA Foundation contract contd (Summary) Referrals are relevant, appropriate To sign Form of Accession (FOA) to participate in any IPAF contract with other schemes in future Endevour to maintain computer and EDI sunmission of claims – not compulsory Protect confidentiality of the patient Adhere to formulary, guidelines approved To inform IPAF of any changes to provider information
IPA Foundation contract contd (Summary) Be entitled, if provided for, to bonus, risk pools, alternative reimbursement Authorise IPAF to discuss with Funders to perfrom contract maintenance If continuosly fails Reviews, for penalty &/or termination of contract To carry medical indemnity / insurance Under no obligation to accept any contract negotiated bet IPAF and Funder – free to reject Enter into agreement in personal capapcity
Implementation Communication to providers Contracting with Providers Communication to Medical Scheme members Registration of members to providers
Thank you
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