Frequently Asked Questions: GRIPA Connect Provider Contracts

down to the details

In July of 2006, we sent out Physician Participation contracts and nearly 200 independent physicians signed up for GRIPA Connect. At the request of our physicians and the leadership of RGPO and WCPO, we made some changes to these contracts. On January 10, 2007, amended contracts were sent out to physicians who were already enrolled in GRIPA Connect’s Clinical Integration Network and new contracts were sent to physicians not yet participating. If you have not yet signed the participating provider contracts, we encourage you to do so soon so that your information can be loaded on the GRIPA Connect web portal.

We have spoken to hundreds of physicians over the past several months about GRIPA Connect Clinical Integration. Below are some of the most frequently asked questions about the contracts, including why the sharing of billing data with GRIPA is necessary for Clinical Integration.

We also sent out an Executive Summary with each contract, highlighting the most notable features of the contracts, and those that are unusual when compared to previous contracts. Download the Executive Summary.

For answers to more general questions about Clinical Integration, return to our main FAQ page.

Q: What is the responsibility for the office billing person or billing service for submitting billing info to GRIPA?

A: GRIPA has established a process for physicians using  several practice management systems to submit a copy of all billing data to GRIPA electronically, at no charge to the physician, and is actively working with others. GRIPA will offer technical assistance to any vendor interested in providing this service. If you want GRIPA to approach your vendor, please contact GRIPA Provider Relations at 585-922-1525.

Q: Isn’t it a HIPAA violation for offices to send billing info to GRIPA for insurance plans not contracted with GRIPA and for government programs such as Medicare and Medicaid?

A: No.  GRIPA has HIPAA Business Associate Agreements with each of its physicians, which allow for the sharing of patient information for treatment purposes.

Q: What type of information is GRIPA looking at in the billing data sent by the offices?

A: GRIPA will be looking at the ICD9 and CPT codes, as well as patient identifiers. GRIPA will use this information to create patient health records in the GRIPA Connect web portal, which will be used by GRIPA physicians to deliver and coordinate higher quality care as part of GRIPA Connect Clinical Integration. The data will help GRIPA to record diagnoses for patients and monitor whether patients receive the care recommended by the GRIPA Clinical Guidelines. For example, to establish a diagnosis of diabetes requires an appropriate ICD9 code, and to verify that a physician evaluated the diabetic patient 2-4 times per year requires CPT codes.

GRIPA will not be looking at charges from any providers’ offices. In the participating provider contract, GRIPA has agreed to retain an independent entity to periodically audit GRIPA’s compliance. This auditor will report all findings to RGPO and WCPO, as well as GRIPA.

Q: Is GRIPA planning to use billing data to compare productivity of one physician versus another?

A: GRIPA is primarily interested in quality and efficiency of care and has no interest in comparing productivity of one physician to another or in computing a physician’s gross income. Everything that GRIPA does with this information is under the direction of the Clinical Integration Committee comprised of six PCPs and six specialty physicians from our panel.

Q: Why are physicians not able to opt out of GRIPA products under Clinical Integration?

A: For its future PPO fee-for-service contracting, GRIPA needs to be able to offer a reliable, defined network in order to provide value in the marketplace and ensure that all members are cooperating in the improvement of the quality and efficiency of the care GRIPA members provide. Collaboration in the care of patients, an integration requirement of the FTC, can only be optimized when all GRIPA physicians participate in all GRIPA contracts. Administrative feasibility and marketplace acceptance of the program would also be diminished if physicians were allowed to opt out.

Q: What happens if a physician chooses not to enroll in the Clinical Integration Program?

A: He or she will be able to continue in our present risk contracts and be eligible for future fully capitated risk contracts as long as they are available. He or she will remain in our old PPO contracts only until the end of the current renewal period and would not be eligible for any future PPO contracts.

Q: What are the Clinical Guidelines? And who makes them up?

A: The Clinical Integration Committee (CIC), consisting of six PCPs and six specialists appointed by the GRIPA Board from the GRIPA panel for a three-year term, has the responsibility for choosing the guidelines that will be used to measure performance. GRIPA staff will present information from relevant national guidelines—including NCQA, HEDIS, AHRQ, as well as the Rochester Community Wide Guidelines—to meetings of Specialty Advisory Groups. The Specialty Advisory Groups will include GRIPA panel representatives from all specialties to be measured by each guideline.

The Specialty Advisory Groups will make recommendations to the CIC regarding modifications to these proposed guidelines. The CIC will then discuss each guideline, and any necessary modifications, during at least two separate monthly meetings before recommending approval, after which each guideline will be approved by the Board and then made available on the portal. Feedback will be solicited every six months from all affected physicians and each guideline will be formally reviewed by the CIC annually. Guidelines will likely be chosen to touch as many specialties as possible, touch the common disease states of our patients, include preventive care, and focus on quality and efficiency of care.

Q: How will GRIPA deal with poor performers?

A: GRIPA is primarily interested in improving quality and efficiency of care. Performing below the targets of the guideline measures will provide the physician, and his or her office staff, an opportunity to work with the GRIPA Care Management staff to improve care to high-risk patients and to help identify and correct the process issues that may be impacting performance. If a physician does not participate in these efforts and continues to have poor performance, his or her case will be discussed in detail at the monthly meeting of the Quality Assurance Council (comprised of 16 of his or her peers, selected by lottery from the entire panel for a one-year term) and a corrective action plan will be developed and overseen. If the Council’s expectations are not met, there will be sanctions in the form of loss of financial bonuses and the possibility of expulsion from the Clinical Integration Program.

Q: How can we deal with poor performance due to non-compliant patients?

A: GRIPA will be able to identify most of our non-compliant patients from the lab, imaging, and billing data and will also solicit names from physicians’ offices of their non-compliant patents. GRIPA is asking permission from our physicians for the GRIPA Care Management staff to directly contact these patients to identify and, if possible, correct the barriers to compliance and follow-up. The great services that the Care Management Services (CMS) provides—including disease, case, and pharmacy management—will now be available on a larger scale to help physicians and their patients.

Q: Why can’t we use the Community Wide Guidelines developed in the past by the Rochester Health Commission and now by the Monroe County Medical Society?

A: We are in fact using the Community Wide Guidelines as reference material along with those of national organizations such as NCQA and AHRQ. GRIPA must develop its own unique set of guidelines, agreed upon by committees of GRIPA physicians, with the opportunity of feedback from the entire panel. The guidelines must be as stringent as those we have used for our risk business; and where our physicians disagree with national or regional evidence-based guideline, we will use the opinions of our physicians.

Q: Aren’t you asking us to just trust GRIPA?

A: You can terminate your participation in the GRIPA Connect Clinical Integration Program on 90 days notice at any time. The Program is as “user friendly” as possible, while still maintaining the elements essential to achieving clinical integration. The purpose of the program as stated is to improve quality and efficiency of care, which cannot be achieved unless we contract together.

Q: What are the advantages of participating in the Clinical Integration Program?

A: Physicians will receive assistance in providing quality care, improving efficiency, and implementing evidence-based guidelines in their practices. They will also receive assistance integrating information technology into their practices, without having to absorb either the cost or the workflow disruption of a full EMR. They will receive the satisfaction of knowing that the investment of their time and effort will benefit their patients, their community, and their colleagues. Physicians will contract with payers as a group for the Clinical Integration Program, but will not need to accept a risk withhold or give up the independence of private practice. By providing a better, higher quality product to payers, GRIPA will be able to seek premium rates for its members.

Q: What about the referral relationships that some specialists maintain with out-of-network primary care physicians?

A: Through the participation contract, GRIPA physicians have agreed to refer patients in-network whenever medically reasonable. There are two advantages to keeping referrals in the GRIPA network. First, each referral presents an opportunity for collaboration in the care of GRIPA patients, which is an essential component of clinical integration. Second, the portal will only include information about the care provided, tests ordered, diagnostic images ordered, and prescriptions written by GRIPA physicians. In-network referrals optimize the availability of this information, giving GRIPA physicians the advantage of the most-complete information available on their patients. GRIPA does not, however, intend to disrupt existing referral relationships. Patients referred by non-GRIPA PCPs to GRIPA specialists should remain the patients of the non-GRIPA PCPs.

Q: If I sign the Clinical Integration contract, how long am I obligated to stay in the program?

A: A Physician may terminate his or her contract without cause upon 90 days prior written notice to GRIPA. The obligation for GRIPA is more long-term: after the contract has been in effect for at least one year, GRIPA may terminate the contract without cause upon at least 60 days prior written notice to the physician, and the termination will be effective on January 1 of the following year.