Primary Health Care Renewal In Bc

The information contained in this manual is not intended to supercede the information provided in the Medical Services Commission Fee Schedule or in documentation produced by the Medical Services Plan or HealthNetBC Access Services.

Primary Health Care Organizations: Operations Manual i Version 1.0 – October 2004

ii Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

Table of Contents

Table of Contents

1. Introduction ............................................................................................................ 1-3

1.1. About this Guide..................................................................................................................1-3

1.2. What is Primary Health Care (PHC)?..................................................................................1-3

1.3. What is PHC Renewal?........................................................................................................1-4

1.4. What is the Primary Health Care Transition Fund (PHCTF)?...........................................1-5

1.5. What Constitutes a PHCO?.................................................................................................1-6

1.6. Benefits to PHCO Patients ..................................................................................................1-6

1.7. Benefits to PHCO Providers ...............................................................................................1-7

1.8. Overview of the Blended Funding Model ..........................................................................1-8

1.9. Contact Information...........................................................................................................1-10

2. Establishing a PHCO ............................................................................................. 2-3

2.1. Overview of the Process .....................................................................................................2-3

2.2. Funding for PHCOs .............................................................................................................2-4

2.3. Site Eligibility Requirements ..............................................................................................2-8

2.4. Developing the Patient Register.........................................................................................2-9

2.5. Interdisciplinary Teams.....................................................................................................2-13

2.6. Estimating the Funding Level (PHCO Site Analysis)......................................................2-14

2.7. Contracts ............................................................................................................................2-15

2.8. PHCO Site Set-up...............................................................................................................2-18

2.9. Ongoing Administrative Requirements ...........................................................................2-25

3. Managing a Patient Register................................................................................. 3-3

3.1. Overview...............................................................................................................................3-3

3.2. Registration Data Submission Overview...........................................................................3-3

3.3. Registering a Patient ...........................................................................................................3-8

3.4. Modifying Your Patient Register ......................................................................................3-14

Primary Health Care Organizations: Operations Manual iii Version 1.0 – October 2004

Table of Contents

3.5. De-Registering a Patient .................................................................................................. 3-18

3.6. Monthly Registration Reviews......................................................................................... 3-21

3.7. Verifying Your Patient Register ....................................................................................... 3-28

4. Submitting Claims.................................................................................................. 4-3

4.1. Overview.............................................................................................................................. 4-3

4.2. Basic Claim and Encounter Record Information.............................................................. 4-5

4.3. Submitting Encounter Records ......................................................................................... 4-8

4.4. Submitting Fee-for-Service Claims ................................................................................. 4-10

4.5. Conversion of Fee-for-Service Claims/Encounter Records .......................................... 4-11

4.6. Submitting Call-Out Services .......................................................................................... 4-14

4.7. Third Party Billings........................................................................................................... 4-15

4.8. Direct Patient Billing for Non-Benefit Services .............................................................. 4-16

4.9. Locums .............................................................................................................................. 4-17

4.10. Patients Referred to the PHCO for Pre-Natal Care......................................................... 4-18

4.11. Services Provided to a Newborn ..................................................................................... 4-19

4.12. Submitting Claims for Hospitalized Patients.................................................................. 4-20

4.13. Recording No Charge Referrals....................................................................................... 4-21

4.14. Recording Methadone Treatment for a Registered Patient ........................................... 4-22

4.15. Definition of Formal / Informal Case Management for PHCOs ..................................... 4-23

5. Payments ................................................................................................................ 5-3

5.1. Quarterly and Annual Payment and Reconciliation......................................................... 5-3

5.2. Calculations ........................................................................................................................ 5-8

6. Resources............................................................................................................... 6-3

6.1. Enhancing PHCO Service .................................................................................................. 6-3

6.2. Information Resources for PHCOs.................................................................................... 6-4

6.3. Complementary Initiatives ................................................................................................. 6-6

6.4. Health Information for Patients.......................................................................................... 6-9

iv Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

Table of Contents

APPENDIX A – Local Health Areas................................................................................ 1

APPENDIX B – Information Required for Site Analysis ................................................. 1

APPENDIX C – PHCO Site Analysis Report.................................................................. 1

APPENDIX D – Outflow Reduction Strategies.............................................................. 1

APPENDIX E – Patient Registration Reports................................................................ 1

APPENDIX F – Quarterly/Annual Payment Reports..................................................... 1

GLOSSARY...................................................................................................................... 1

INDEX............................................................................................................................... 1

Table of Figures

Figure 1-1 PHCO Blended Funding Model .................................................................... 1-9

Figure 2-1 PHCO Contractual Arrangements .............................................................. 2-15

Figure 3-1 Monthly Registration Review Schedule ...................................................... 3-22

Figure 4-1 Submission of Fee-for-Service Claims and Encounter Records .................. 4-4

Figure 5-1 Payments Process........................................................................................ 5-3

Figure 5-2 Population-Based Funding ........................................................................... 5-8

Primary Health Care Organizations: Operations Manual v Version 1.0 – October 2004

Table of Contents

vi Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

SECTION 1 – INTRODUCTION Section Contents

SECTION 1 – INTRODUCTION

Section Contents

1.1. About this Guide....................................................................................................................1-3

1.2. What is Primary Health Care (PHC)? ...................................................................................1-3

1.3. What is PHC Renewal? .........................................................................................................1-4

1.4. What is the Primary Health Care Transition Fund (PHCTF)?.............................................1-5

1.5. What Constitutes a PHCO?...................................................................................................1-6

1.6. Benefits to PHCO Patients....................................................................................................1-6

1.7. Benefits to PHCO Providers .................................................................................................1-7

1.8. Overview of the Blended Funding Model ............................................................................1-8

1.9. Contact Information ............................................................................................................1-10 1.9.1. Ministry of Health Services......................................................................................1-10

Primary Health Care Branch............................................................................................. 1-10 Medical Services Plan (Teleplan) and the Secure Web Site for Practitioners (HNWeb).. 1-10

1.9.2. Health Authorities ....................................................................................................1-11

Primary Health Care Organizations: Operations Manual 1-1 Version 1.0 – October 2004

Section Contents SECTION 1 – INTRODUCTION

1-2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

SECTION 1 – INTRODUCTION About this Guide

1. Introduction

1.1. About this Guide

This guide is a reference for Primary Health Care Organizations (PHCOs), Community Health Centres (CHCs), health authorities and other health care providers interested in the set-up and management of primary health care organizations.

For the purposes of this manual, the term PHCO includes CHCs.

This section of the guide gives an overview of primary health care renewal and the PHCO concept. It also offers contact information useful to both potential and existing PHCOs. Further information is broken into an additional five sections:

• Section 2, Establishing a PHCO, describes the overall funding model for PHCOs and the process for setting up a new site.

• Section 3, Managing a Patient Register, provides the information PHCOs require to manage the register of patients who use their practice for the majority of their primary health care services.

• Section 4, Submitting Claims, provides information on how PHCOs report patient services.

• Section 5, PHCO Payments Process, details the processes by which funding payments are made and provides specific information on funding calculations.

• Section 6, Resources, gives an overview of the complementary programs, funding opportunities and sources of health information that PHCOs may use to enhance their practice.

At the end of the document, there is also a glossary and detailed index.

1.2. What is Primary Health Care (PHC)?

Primary health care is the foundation of Canada’s health care system. For most British Columbians, it is the first and most frequent point of ongoing contact with the health care system.

The goal of PHC is to keep people healthier longer, by preventing serious illness and injury through education and timely treatment of short-term, episodic problems. It also works to help patients manage chronic illnesses appropriately, so they do not develop unnecessarily into medical crises.


What is PHC Renewal? SECTION 1 – INTRODUCTION

PHC is the point in the health care system where:

• short-term health issues are resolved;

• patients with chronic or complex health issues receive ongoing care and are linked to other services in their community; and

• health promotion and education efforts are most effective.

As expressed in the World Health Organization’s Alma Ata Declaration, Article IV, high-quality PHC should be “based on practical, scientifically sound…methods and technology” and, as such, has the potential to contribute significantly to the sustainability of the health care system as a whole.

Universally accessible by all individuals and families, the optimum PHC system delivers health care that is affordable to the community and country and offers quality, front line health care services close to where people live and work.

1.3. What is PHC Renewal?

PHC renewal consists of strategies designed to strengthen patient access to health care services, to increase provider and patient satisfaction, and to achieve measurable improvements in health outcomes.

A variety of PHC models are being developed across Canada. All offer more consistent, integrated and coordinated care for patients, a more collegial and rewarding working life for doctors and nurses, and more cost-effective care aimed at reducing the need for hospital admissions and promoting effective self-care strategies for patients.

In British Columbia, under the Primary Health Care Transition Fund (PHCTF), health authorities were encouraged to pursue PHC initiatives in accordance with the three key PHC goals:

• Support a range of practice models such as PHC networks of family doctors in different locations; shared care relationships between family doctors and specialists; augmented roles for nurses; and full service PHCOs based on interdisciplinary teams operating at one site.

• Improve health outcomes through measures such as chronic disease registries; integration of clinical practice guidelines aimed at standardizing treatment of certain diseases; targeted disease or population strategies; and targeted high-risk populations.

• Education and evaluation through ongoing support for both health care providers and patients as new models of care are implemented. Health care providers need easy access to information and require support to learn more about collaborative practice, team building and change management. Patients need to understand their role as clients of PHCOs and to have access to information and support to enable them to become active managers of their own health. Continued learning from PHC renewal initiatives depends on the establishment of a baseline and the coordination of information gathering to support evaluation at system, project and cross-health authority levels.


SECTION 1 – INTRODUCTION What is the Primary Health Care Transition Fund (PHCTF)?

1.4. What is the Primary Health Care Transition Fund (PHCTF)?

The PHCTF is an $800 million Health Canada initiative designed to facilitate systemic, long-term PHC renewal by supporting Canada’s provinces and territories in their efforts, over a four-year period (2002-2006), to improve their delivery of PHC services.

The common PHCTF objectives agreed to by both the federal and provincial/ territorial governments are:

• To increase the proportion of the population having access to PHCOs;

• To increase the emphasis on health promotion, disease and injury prevention, and high-quality chronic disease management;

• To establish interdisciplinary teams, so that the most appropriate care is provided by the most appropriate provider;

• To coordinate and integrate PHC organizations with other services, e.g., in institutions and in communities; and

• To expand 24-hour-a-day, seven-day-a-week access to a health care provider for core services.

The fund has two components: national and provincial/territorial.

The national component is 30 percent of the fund, or $240 million, which is being used to support common approaches to PHC enhancement and to improve PHC for priority populations.

The 70 percent provincial/territorial component, or $560 million, has been allocated to the provinces and territories on a per capita basis to advance PHC renewal.

British Columbia’s share of the provincial/territorial component is $74 million. The majority of this funding (93 percent) has been provided to the health authorities to plan and implement PHC enhancement initiatives that are appropriate for their regions.

British Columbia has focused on working collaboratively with health authorities to achieve key PHC goals.

The PHCTF has helped the province to build on the advances made under the Health Transition Fund, which the federal government established in 1997. It was the three-year Health Transition Fund that resulted in the formation of seven Primary Care Demonstration Project (PCDP) sites designed to test new and innovative models of PHC delivery. PCDP sites are now known as PHCOs.


What Constitutes a PHCO? SECTION 1 – INTRODUCTION

1.5. What Constitutes a PHCO?

A PHCO is a medical practice committed to providing comprehensive primary care services. It promotes interdisciplinary practice by encouraging clinicians to develop and strengthen the natural links between family medicine and other health professionals such as nurses, pharmacists, counselors, respiratory therapists and nutritionists. A PHCO provides extended hours of operation and availability of services and 24-hour-a-day, seven-day-a-week access to a health care provider.

PHCOs deliver patient care under a blended funding model. Unlike the fee-for-service only model, blended funding provides a “per person/per day” component that supports the delivery of common (“core”) services to those patients who use the PHCO for the majority of their PHC services. For patients who do not use the PHCO for the majority of their PHC services, the PHCO continues to submit fee-for-service claims.

Under the per person/per day funding component (known as “population-based” funding), the PHCO and its patients benefit most when the PHCO delivers targeted PHC services in a manner which promotes patient health, strengthens patients’ self-management strategies and reduces the need for critical interventions. The ongoing financial viability of a PHCO rests on its commitment to make effective use of personnel and to employ innovative patient care strategies to promote and sustain the health of its patient population.

Under the blended funding model, each PHCO is assigned a single Medical Services Plan (MSP) payment number to which all payments are allocated. The Ministry of Health Services directs all payments to the health authority or PHCO under this payment number.

1.6. Benefits to PHCO Patients

As patients of a PHCO, individuals and families receive improved access to primary health care services 24 hours a day, 7 days a week, and improved access to health care providers during extended practice hours. Patients also benefit from the delivery of coordinated, comprehensive services by the PHCO interdisciplinary team.

Through increased health education, promotion of self-care strategies and the implementation of guideline-based disease management protocols, patients secure measurable positive health outcomes, particularly in cases of chronic illness.

Patients also benefit from the PHCO’s sound knowledge of the needs of its particular patient population. Aggregate data reports on a PHCOs evolving patient population, issued by the Ministry of Health Services, provide PHCOs and health authorities with regular access to information. This information allows each PHCO to tailor its services, health promotion and health education activities to the particular needs of its patients.

Complementary initiatives, such as the Chronic Disease Management (CDM) Toolkit and patient registries, provide further support for targeted services.

For information on resources and complementary initiatives, please refer to Section 6.


SECTION 1 – INTRODUCTION Benefits to PHCO Providers

1.7. Benefits to PHCO Providers

Within an interdisciplinary team, and under the blended funding model, PHCO health care providers experience a measurable positive impact on the quality of their personal and professional lives.

For health care providers, the PHCO approach:

• promotes stronger links with specialists and with community and institutional services, which facilitates the management of patient care, especially in complex care situations;

• creates increased opportunities to develop innovative care plans such as involving patients in educational and self-help groups;

• provides, through supporting technologies, the ability to access and update patient medical histories;

• provides access, on a regular basis, to ministry analysis of the PHCO’s current patient population and service histories, allowing PHCO health care providers to focus their professional energies for maximum effectiveness;

• allows for better vacation and educational leave coverage; and

• offers increased income predictability.


Overview of the Blended Funding Model SECTION 1 – INTRODUCTION

1.8. Overview of the Blended Funding Model

PHCOs receive blended funding: a combination of fee-for-service payments and per patient, per day (population-based) funding. Because population-based funding constitutes the larger portion of its income, a PHCO’s success rests on its ability to deliver health care services efficiently and in a manner which promotes patient health.

Population-based funding is paid for patients who use the PHCO for the majority of their primary health care services. These patients, who usually live in the PHCO’s “catchment” area, become registered patients of the PHCO. Commonly provided primary care services (“core” services) and certain additional services (“extended” services) for these patients are covered under the population-based funding.

As shown in area of Figure 1-1 on the following page, population-based funding is based on the health status of the PHCO’s registered patients. Each patient is assigned an Adjusted Clinical Group (ACG) which indicates their “illness burden.” In conjunction with patient age and gender information, ACGs allow the Ministry of Health Services to analyze each patient’s past need for primary care health services. The ministry conducts ACG assignments each year to reflect patients’ evolving need for service.

Using the MSP Claims History, the value of the services that patients assigned a specific ACG are likely to require is used to calculate an appropriate Daily Rate for those patients.

As shown in area of Figure 1-1, the appropriate ACG Daily Rate is multiplied by the number of days a patient is registered to the PHCO. The result is the gross annual funding amount for the patient.

This is the amount that will be paid to the PHCO (usually through the health authority) providing the patient does not receive core services from another practice in the PHCO’s catchment area. If a registered patient does receive a core service from another practice within PHCO catchment area, the value of the fee-for-service claim submitted by the other provider is deducted from the annual funding amount. This deduction is known as a “service outflow.”

To prevent service outflows from resulting in less than zero population-based funding for a patient, a Stability Fund has been established. If, at year-end, service outflows have caused the funding for a patient to drop below zero, the Stability Fund is used to “top up” the funding to zero.

PHCOs continue to receive fee-for-service, third party and other payments (as shown in area of Figure 1-1). Fee-for-service claims are submitted for patients who are not registered to the PHCO and for any services not categorized as “core” services.

As indicated in areas , and of Figure 1-1, the formation and funding of a PHCO is a team effort involving the Ministry of Health Services, the health authority and the PHCO itself. For more information on the role of the Ministry of Health Services and the health authority, please refer to Section 1.9.


SECTION 1 – INTRODUCTION Overview of the Blended Funding Model

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Contact Information SECTION 1 – INTRODUCTION

1.9. Contact Information

Formation of a PHCO under the PHCTF is a team effort involving the PHCO, health authority and the Primary Health Care Branch of the Ministry of Health Services.

Following is a brief description of the role of each entity with which PHCOs will interact and the appropriate contact information.

1.9.1. Ministry of Health Services

Primary Health Care Branch

Through the Primary Health Care Branch (part of Clinical Innovation and Integration, Ministry of Health Services), the ministry provides direction and support, implements PHC policies and strategies in accordance with provincial goals and standards, and monitors performance.

The Primary Health Care Branch ensures that a potential PHCO meets the criteria for operation under the blended funding model. The branch conducts an analysis of the proposed site and its potential patient base. This provides the financial projections that the proposed PHCO and the health authority require to determine if the site would be a viable undertaking.

PHCOs may also contact the ministry for assistance with matters relating to education, office re-design or assessment, change management, etc.

For general information on PHCO set-up and operation, visit the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc.

For more specific information, contact:

Beverlee Sealey Manager, Primary Health Care Organizations and Networks Primary Health Care Branch Ministry of Health Services Telephone: 250-952-1290 Fax: 250-952-3486 E-mail: [email protected]

Medical Services Plan (Teleplan) and the Secure Web Site for Practitioners (HNWeb)

Submission of PHCO claims and patient registration information is effected through Teleplan and HNWeb. Teleplan is administered through the Medical Services Plan. HNWeb is administrated through HealthNetBC Access Services within the Ministry of Health Services.

As with the existing fee-for-service system, PHCOs submit claims and patient encounter records through the MSP Teleplan system. Patient registration information can be submitted either through Teleplan or through HNWeb.

If you require assistance with Teleplan, call the Teleplan Support Centre in Victoria at 250-952-2668, or, from elsewhere in British Columbia, at 1-800-663-7206.


http://www.healthservices.gov.bc.ca/phc/

mailto:[email protected]

SECTION 1 – INTRODUCTION Contact Information

Teleplan information is also available on the Medical Services Plan Web site at www.healthservices.gov.bc.ca/msp/infoprac/teleplan.html.

If you require assistance with HNWeb, contact the Ministry of Health Services Help Desk at 250-952-1234 or send an e-mail to [email protected].

1.9.2. Health Authorities

The health authorities identify health needs, plan appropriate programs and services and manage the delivery of services in their health regions.

As part of their overall planning for regional PHC enhancement, health authorities make the final determination of a site’s viability, deliver blended funding to the individual sites and administer the allocation of PHCTF funds to PHC enhancement initiatives within their regions.

Health care providers interested in the PHCO model should contact their local health authority as a first step.

If you are unsure of the appropriate contact within your local health authority, please contact the Primary Health Care Branch at the phone number or e-mail provided in Section 1.9.1 above.


http://www.healthservices.gov.bc.ca/msp/infoprac/teleplan.html

mailto:[email protected]

Contact Information SECTION 1 – INTRODUCTION


SECTION 2 – ESTABLISHING A PHCO Section Contents

SECTION 2 – ESTABLISHING A PHCO

Section Contents

2.1. Overview of the Process .....................................................................................................2-3

2.2. Funding for PHCOs .............................................................................................................2-4 2.2.1........Overview................................................................................................................2-4 2.2.2........Adjusted Clinical Groups........................................................................................2-4

Assigning Individual Patients to an ACG ...................................................................... 2-5 2.2.3........Payment for PHCO Services .................................................................................2-5 2.2.4........Adjusted Clinical Group Daily Rate........................................................................2-6 2.2.5........Service Outflows....................................................................................................2-6 2.2.6........Calculation of Population-Based Funding ..............................................................2-7

2.3. Site Eligibility Requirements ..............................................................................................2-8 2.3.1........Essential Components...........................................................................................2-8

2.4. Developing the Patient Register.........................................................................................2-9 2.4.1........Overview................................................................................................................2-9 2.4.2........Virtual Patient Registers and Community Service Profiles.....................................2-9 2.4.3........Catchment Areas ...................................................................................................2-9

Use of Catchment Areas in Developing the Initial Patient Register............................ 2-10 2.4.4........Determining the Proposed Initial Patient Register ...............................................2-10

PHCOs Based on an Existing Practice....................................................................... 2-11 PHCOs Not Based on an Existing Practice ................................................................ 2-11

2.4.5........PHCO-Proposed Patients....................................................................................2-12

2.5. Interdisciplinary Teams.....................................................................................................2-13

2.6. Estimating the Funding Level (PHCO Site Analysis)......................................................2-14 2.6.1........Overview..............................................................................................................2-14 2.6.2........Estimated Service Outflows.................................................................................2-14 2.6.3........Site Analysis Report ............................................................................................2-14

2.7. Contracts ............................................................................................................................2-15 2.7.1........Relevant Agreements—British Columbia Medical Association ............................2-15 2.7.2........Performance Agreements—Ministry and Health Authorities ................................2-15 2.7.3........Contracts—Ministry and Health Authorities .........................................................2-16 2.7.4........Blended Funding Contracts—Health Authorities and PHCOs..............................2-16

Blended Funding Contracts ........................................................................................ 2-16 2.7.5........Incentive Programs..............................................................................................2-16

Ongoing Incentives..................................................................................................... 2-16 Time Limited Incentives under the Primary Health Care Transition Fund .................. 2-17


Section Contents SECTION 2 – ESTABLISHING A PHCO

2.8. PHCO Site Set-up...............................................................................................................2-18 2.8.1........Site Set-Up Checklist...........................................................................................2-19 2.8.2........Making Contract Arrangements ...........................................................................2-20 2.8.3........Applying for an MSP Practitioner Number ...........................................................2-20 2.8.4........Applying for a Single Payee Number for the PHCO.............................................2-21 2.8.5........Assigning Practitioner Payments to the PHCO....................................................2-21 2.8.6........Applying for Transfer of Payments to a Single Bank Account..............................2-22 2.8.7........Applying for Teleplan Service (Opted-In) .............................................................2-22 2.8.8........Applying for Additional Facility Numbers..............................................................2-22 2.8.9........Upgrades Required to a PHCO’s Teleplan-Compliant Software..........................2-22 2.8.10......HNWeb - Secure Web Site for Practitioners ........................................................2-23 2.8.11......Designating PHCO Contacts ...............................................................................2-24 2.8.12......PHCO Listserv .....................................................................................................2-24

2.9. Ongoing Administrative Requirements ...........................................................................2-25 2.9.1........Modifications to PHCO Registration of a Practitioner or Locum...........................2-25

Adding a Physician/Practitioner to the PHCO............................................................. 2-25 Deleting PHCO Registration of a Physician/Practitioner/Locum................................. 2-25


SECTION 2 – ESTABLISHING A PHCO Overview of the Process

2. Establishing a PHCO

2.1. Overview of the Process

Organizations interested in forming a PHCO must work with the local health authority. If the health authority wishes to pursue the possibility, the Ministry of Health Services and the health authority work with the proposed PHCO to see if it would be a viable business undertaking under the blended funding model. The blended funding model is a combination of population-based (per patient, per day) funding and fee-for-service payments.

The ministry’s Primary Health Care Branch first ensures that the proposed site meets the basic requirements for operation as a PHCO. If these requirements are met, the next step is to estimate the level of funding that the health authority or PHCO would receive for the PHC services delivered by the PHCO.

To do this, an initial patient register (or “list”) is developed and patients on the register are categorized according to their “illness burden.” Categories, known as Adjusted Clinical Groups (or ACGs), allow the Primary Health Care Branch to estimate the level of medical services funding those patients have required in the past.

Each ACG is associated with a daily rate. By applying these daily rates to patients proposed for the initial patient list, the ministry can estimate population-based funding for those patients and then compare it to the actual historical fee-for-service income for those patients.

If, based on this analysis, the health authority decides to implement the PHCO, site set-up can begin. The necessary contractual, administrative and technical structure is put in place to:

• enable the health authority to direct payments to the PHCO rather than to individual practitioners; and

• enable the PHCO to manage its patient register and submit patient encounter records and fee-for-service claims.


Funding for PHCOs SECTION 2 – ESTABLISHING A PHCO

2.2. Funding for PHCOs

2.2.1. Overview

Unlike the fee-for-service system which pays physicians per service, a large portion of PHCO income consists of lump sum per patient, per day funding that covers the majority of a patient’s primary care services for a period of time. This population-based funding is predicated on the health status of each patient.

Common (“core”) primary care services and identified “extended” services to patients who use the PHCO as their main source of primary care (“registered patients”) are included in this population-based funding.

The list of core and extended services is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html#data.

All other services (those not designated as core services) to registered patients and all services to non-registered patients continue to be paid on a fee-for-service basis.

This combination of population-based and fee-for-service funding is called “blended funding.”

To determine the appropriate initial level of population-based funding, the Primary Health Care Branch works with the PHCO and health authority to draw up an initial patient list. The branch analyzes the level of funding that the listed patients have required in the past by grouping patients according to their past use of services and then assigning a daily rate for patients within each group.

2.2.2. Adjusted Clinical Groups

Adjusted Clinical Groups (ACGs) are health status categories defined by morbidity, age and gender. ACGs are based on the premise that the level of resources necessary to deliver appropriate health care to a population depends on the “illness burden" of that population.

The ACG system, developed by Johns Hopkins University, is widely used to determine the morbidity profile of patient populations, to assess provider performance and to pay health care providers based on the health needs of their patient population.

For PHCO purposes, each ACG (and age group within the ACG) is associated with a funding level that reflects the average value of the fee-for-service items that patients in the ACG received in the previous year.

Information on the ACG Case Mix System is available on the Johns Hopkins University Web site at www.acg.jhsph.edu/homepage.htm.


www.acg.jhsph.edu/homepage.htm

SECTION 2 – ESTABLISHING A PHCO Funding for PHCOs

Assigning Individual Patients to an ACG

Over time, a patient may develop a variety of conditions. Within the province of British Columbia, this information is captured by properly coded diagnoses in the fee-for-service claims or encounter records submitted through Teleplan to the Medical Service Plan (MSP) Claims System.

Under the Johns Hopkins ACG Case-Mix System, ICD-9 diagnostic codes are mapped to 32 Aggregated Diagnosis Groups (ADGs). Each ADG is a grouping of ICD-9 codes that are similar in terms of severity and likelihood of persistence of the health condition.

The ADGs for a patient, combined with the patient’s age and gender, are used to assign the patient to one of 93 ACGs, of which the Ministry of Health Services uses the 82 that are relevant to primary health care.

ACG assignments take place each year when the majority of MSP claims for a fiscal year have been received.

Note: New patients or patients who have been insured by MSP for less than 275 days during the fiscal year (including newborns) are assigned to a separate group determined solely by age and gender.

Additional funding is provided for patients diagnosed with HIV/AIDS.

If your PHCO serves patients diagnosed with HIV/AIDS, please advise the Primary Health Care Branch (refer to Section 2.8 for contact information). An adjustment to your site set-up will be made to allow you to set a “Special Needs” administrative code for these patients.

Note: The ministry does not disclose the ACG assignment of a specific patient.

2.2.3. Payment for PHCO Services

Not all services to registered patients are paid through population-based funding. Analysis by the Medical Services Plan (MSP) revealed that about 90% of fee-for-service claims for PHC services were associated with 97 core services (as of February 2004). These core services, such as 0100-General Office Visit, are those that would be commonly provided by a PHCO. Payment for services not typically provided by primary care physicians—for example, emergency treatment, anesthesia, minor surgery, and obstetrics—are paid on a fee-for-service basis.

The core services are a collection of existing fee-for-service items supplemented by a limited number of additional services referred to as “extended services.” Extended services are specifically designed to reflect the work of PHCO practitioners including, for instance, case conferencing, telephone follow-ups and patient education on a variety of topics.

The list of core and extended service codes is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html.


www.healthservices.gov.bc.ca/phc/infosites.html

Funding for PHCOs SECTION 2 – ESTABLISHING A PHCO

PHCO services are reported in the following manner:

• Core services and extended services for registered patients are funded through population-based funding (the delivery of such services to registered patients is referred to as a “patient encounter”).

• All other services, to both registered and non-registered patients, are reported and paid as fee-for-service. This includes services that are not insured by MSP (such as Workers’ Compensation Board, Insurance Corporation of BC) and services to patients who are not insured by MSP.

2.2.4. Adjusted Clinical Group Daily Rate

The Adjusted Clinical Group Daily Rate, also known as the “ACG Means”, is the amount of daily funding provided for each PHCO patient within a particular ACG morbidity category and age group within that ACG.

Once a year, usually in July, the Primary Health Care Branch calculates the ACG Daily Rate for all patients in the province. Using ACG assignments from two years before the current year and claims data from one year before the current year, the ACG Daily Rate is calculated as follows:

• For all patients assigned to a specific ACG, all fee-for-service claims for core PHCO services are totaled.

• This total is then divided by the number of MSP-insured days for the patients.

This provides the mean rate per patient/per MSP-insured day for that ACG (the ACG Daily Rate). To calculate the ACG income for a patient, the patient’s ACG Daily Rate is multiplied by the number of days the patient is registered with the PHCO. Actual population-based funding for a patient will be the calculated ACG income less any deductions for service outflows, as described in Section 2.2.5.

The specific ACG Daily Rate for each ACG is published on the Primary Health Care Branch Web site (www.healthservices.gov.bc.ca/phc/infosites.html) each year.

2.2.5. Service Outflows

In the normal course of business, PHCOs experience service outflows.

A service outflow occurs when a patient receives a core service from a general practitioner outside the PHCO but within the PHCO’s pre-defined catchment area (which sets the boundaries for patient registrations and service outflows). Payments for such services are deducted from the population-based funding for that patient.

Note: PHCOs may choose to operate under a “network agreement” with another PHCO. When such an agreement exists, service outflows do not occur when a patient registered with one PHCO receives core services from the other PHCO.



SECTION 2 – ESTABLISHING A PHCO Funding for PHCOs

To make certain that the minimum annual population-based funding that a PHCO receives for a registered patient for a complete fiscal year is not less than zero, a Stability Fund has been established.

For more information on the Stability Fund, refer to Section 5.2.4.

Each month, the ministry conducts a registration review for each PHCO. During this monthly review, the ministry will propose that patients associated with service outflows be de-registered from the PHCO if they meet certain criteria.

The final decision on whether to de-register a patient is made by the PHCO.

Similarly, the ministry may propose that a patient be registered with the PHCO based on specific criteria. For more information on the criteria for proposed registrations and de-registrations, please refer to Section 3.6.4.

2.2.6. Calculation of Population-Based Funding

The total population-based funding for the PHC services delivered through a PHCO is the total for all patients of:

The number of days a patient was registered with the PHCO

multiplied by

Patient’s ACG Daily Rate

less

Deductions for core service outflows (to a minimum population-based funding of $0 per patient per year).


Site Eligibility Requirements SECTION 2 – ESTABLISHING A PHCO

2.3. Site Eligibility Requirements

Based on its experience with existing PHCOs, the Primary Health Care Branch has developed a set of criteria that PHCOs should meet in order to run a sustainable and viable practice. The criteria are in keeping with the principles developed under the Primary Health Care Transition Fund.

2.3.1. Essential Components

The following characteristics are considered essential to the provision of effective, appropriate PHC services. A PHCO should:

• Operate under the blended funding model administered by the local health authority.

• Establish a group practice (sharing responsibility for patient care, patient records, on-call responsibilities, work space and support staff).

• Work as an interdisciplinary team.

• Have established, regular office hours for clinical services (a minimum of 35 hours per week).

• Provide some extended hours of clinical practice.

• Provide 24-hour-a-day, seven-day-a-week access to core services either by having physicians share on-call hours or by participating in an on-call group.

• Provide the full scope of PHC services including acute episodic care, continuing (proactive) care of chronic illness, management and coordination of comprehensive care (i.e., referral to specialists and other providers, case management, case conferences), patient advocacy, health promotion, case finding/screening, disease/injury prevention, patient education, counseling and palliative care.

• Be integrated with community services.

• Implement mechanisms to assure quality of service (such as setting health goals for their patient population, case finding, using clinical protocols, inviting peer review and patient input, etc.).

It is also recommended that a PHCO have:

• approximately one physician per 1500 patients, and

• a minimum of three physicians in the same location.


SECTION 2 – ESTABLISHING A PHCO Developing the Patient Register

2.4. Developing the Patient Register

2.4.1. Overview

After confirming that the proposed PHCO meets the basic criteria, the Primary Health Care Branch, in consultation with the PHCO and health authority, identify the potential patient base.

Patients who use the PHCO for the majority of their PHC services and who live within the PHCO catchment area will be proposed to be registered with the PHCO and be funded under population-based funding.

Patients who do not use the PHCO for most of their medical services will not be proposed for registration. Services to these non-registered patients will continue to be billed as fee-for-service.

For information on catchment areas, refer to Section 2.4.3, below.

2.4.2. Virtual Patient Registers and Community Service Profiles

A PHCO’s potential patient base is usually developed using a virtual patient register. The Primary Health Care Branch works with the health authority and PHCO to select the appropriate method for the initial analysis.

A virtual register, often used for practices with an established patient population, is based on the MSP claims history of individual patients. The claims history indicates the patients most likely to use the PHCO as their main source of primary care.

Sometimes, the first step is to develop a community service profile. A community service profile may be developed from a list of patients who live within a defined geographic area. This area is defined in consultation with the proposed PHCO and should accurately reflect the areas in which potential patients live.

2.4.3. Catchment Areas

A catchment area serves two purposes:

• It assists in developing the initial patient register for sites without an established patient base.

• It defines, on an ongoing basis, the boundaries for patient registration and service outflows.

For more information on service outflows, refer to Section 2.2.5.


Developing the Patient Register SECTION 2 – ESTABLISHING A PHCO

Use of Catchment Areas in Developing the Initial Patient Register

When the initial patient register is based on a community service profile, the Primary Health Care Branch consults with the health authority and PHCO to identify the areas from which a patient could reasonably be expected to use the PHCO as their main source of primary medical care. A carefully defined catchment area promotes a stable patient register and, therefore, a stable funding level.

A PHCO catchment area usually consists of:

• the local health area in which the PHCO is located, and

• any adjacent local health areas from which patients may be expected to use the practice as their main source of primary medical care.

B.C. health boundaries consist of six health authorities (5 regions +1) and 16 health service delivery areas. The 16 health service delivery areas are further divided into 89 local health areas. Refer to Appendix A for a map of British Columbia’s health areas.

2.4.4. Determining the Proposed Initial Patient Register

Careful determination of the proposed initial patient register promotes PHCO success by reducing subsequent service outflows that may affect funding levels, especially in the early months of operation.

If the PHCO is to be based on an existing practice, the Primary Health Care Branch examines the MSP claims history of patients who have attended the practice in the past and who live within the catchment area. The proposed PHCO is asked to provide the Primary Health Care Branch with, among other information, practitioner numbers for each practitioner whose patients will be considered for the patient register and the Teleplan Payee Number (also known as the MSP “Payment Number”) of the existing clinic.

For a complete list of the information that may be required for accurate development of the initial patient register, please refer to Appendix B.

If the PHCO is not based on an existing practice, primarily geographical information on patients is used. The Primary Health Care Branch and the proposed PHCO may also refine the initial patient register by looking at the claims history of patients of any PHCO practitioner who has worked for another practice within the geographic area.

Note that only patients insured by MSP can be added to the patient register.

For MSP eligibility information, visit the MSP Web site at www.healthservices.gov.bc.ca/msp/infoben/eligible.html#enroll.


SECTION 2 – ESTABLISHING A PHCO Developing the Patient Register

PHCOs Based on an Existing Practice

If the initial patient list is for a PHCO based on an existing practice, all patients who have received one or more core services from the practice in the previous three years are reviewed.

The remaining list is divided into non-registered and registered patients.

Non-registered patients are identified as patients who:

• are “transient” patients—those who live outside the practice’s catchment area or who only occasionally receive medical care from the practice.

• have received three consecutive core services outside the practice.

• have received less than 50% of their last seven core services from the practice during the previous three years.

• are not registered with MSP.

• are now deceased.

• are already registered with another PHCO.

Registered patients—those most likely to use the PHCO as their main source of primary care—are identified as patients:

• whose two most recent core services during the previous three years were from the practice.

• whose most recent service during the previous three years was from the practice and who have received 51% or more of their core services (to a maximum of seven services) from the practice during the previous three years.

The proposed lists of registered and non-registered patients are used, in consultation with the PHCO, to determine the final patient register.

PHCOs Not Based on an Existing Practice

To develop an initial patient list for a potential PHCO that is not based on an existing practice, the Primary Health Care Branch may start by identifying all patients who live within the PHCO catchment area. MSP claims history may not provide a patient’s most current address, so the initial list may also include patients who have received services in the area.

The Primary Health Care Branch reviews the MSP claims history of each patient for the previous three years.

The following patients are removed from the list:

• Patients who have recently moved out of the catchment area.

• Patients whose two most recent core services in the previous three years occurred outside the catchment area.


Developing the Patient Register SECTION 2 – ESTABLISHING A PHCO

• Patients who live in the catchment area but who have had no claims in the catchment area.

• Patients who live in the catchment area but who are already registered with another PHCO.

The following patients are added to the list:

• Patients who have moved into the catchment area within the past three years but who have not yet received services from any practice.

The resulting information is compiled into three lists that, in consultation with the proposed PHCO, are used to determine the final patient register. The lists are of:

• Patients who have an address in the catchment area.

• Patients who would qualify for registration if they lived in the catchment area.

• Patients recommended for the register by the PHCO or health authority.

2.4.5. PHCO-Proposed Patients

The PHCO and the health authority are given the opportunity to review the initial patient lists and advise the Primary Health Care Branch of any misclassification of patients or of patients missing from the list. The PHCO and health authority may propose the registration of any patient who meets basic registration requirements. Normally, only patients who live in the PHCO catchment area can be registered.

Note: PHCO-proposed additions to the register may result in increased service outflows. Although an estimated service outflow amount is factored into the initial PHCO funding level, actual outflows may result in reductions to population-based funding.

For more information on service outflows, refer to Section 2.2.5, and Appendix D, Outflow Reduction Strategies.


SECTION 2 – ESTABLISHING A PHCO Interdisciplinary Teams

2.5. Interdisciplinary Teams

The interdisciplinary team approach promotes more efficient, effective patient care and enhances the professional life of both physicians and other PHCO practitioners.

Physicians continue to deliver all services (including those not defined as core services), to registered, non-registered and transient patients.

Normally, non-physician practitioners cannot bill MSP for services provided to patient. However, under a special agreement with MSP, non-physician PHCO practitioners are assigned a specialty code and a unique MSP billing number. These practitioners can then deliver and report (via the Teleplan system) both core and extended services to PHCO registered patients.

For more information on the assignment of MSP billing numbers to non-physician PHCO practitioners, refer to Section 2.8.3.

Be aware, however, that MSP accepts and pays fee-for-service claims only if a physician delivers the service. Furthermore, an encounter record cannot be converted to a fee-for-service claim (or vice versa) unless a physician is identified as the primary practitioner. Conversion of claims may be necessary as a result of:

• the inadvertent submission of a fee-for-service claim for a core or extended service to a registered patient; or

• the inadvertent submission of an encounter record for a service not defined as a core or extended service to a registered patient, or any service to a non-registered patient; or

• the backdating of a patient’s registration date.

For more information on the conversion of claims, refer to Section 4.5.

PHCOs can report multiple practitioners for a single encounter record. However, to permit any necessary conversion of claims, the ministry recommends that, whenever a physician is involved in a patient encounter, he or she be listed as the primary practitioner.

For more information on reporting multiple practitioners, refer to Section 4.2.3.


Estimating the Funding Level (PHCO Site Analysis) SECTION 2 – ESTABLISHING A PHCO

2.6. Estimating the Funding Level (PHCO Site Analysis)

2.6.1. Overview

When the Primary Health Care Branch conducts the site analysis, it uses the initial patient register to build a financial picture of the PHCO and compares it to the historical fee-for-service revenues of the practitioners (and, if applicable, the existing practice).

The Site Analysis Report, described in Section 2.6.3, provides the proposed PHCO with valuable information on expected funding levels.

2.6.2. Estimated Service Outflows

To provide the most accurate funding projection, the Primary Health Care Branch includes estimated service outflows in the Site Analysis Report.

PHCOs should have a firm understanding of service outflows, as described in Section 2.2.5, before reviewing the report.

2.6.3. Site Analysis Report

The Site Analysis Report provides a clear financial picture for the proposed PHCO.

The Patient Analysis section provides a detailed breakdown of the patients reviewed in the site analysis. It indicates the number of patients eligible and ineligible for registration under each of the specific registration criteria.

Careful review of this section of the report by the PHCO and health authority is required as the total number of registered patients identified in this section forms the basis for the Income Analysis section.

The Income Analysis section of the report provides:

• a breakdown of the projected ACG income for the PHCO, including estimated service outflows (which results in the projected total population-based funding) and third party payment income (e.g., Insurance Corporation of BC and Workers Compensation Board billings); and

• a comparison of the PHCO’s projected blended funding plus third party payment income with fee-for-service plus third party payment income.

An example of this report is provided in Appendix C.


SECTION 2 – ESTABLISHING A PHCO Contracts

2.7. Contracts

Paym

ent

PHCO Health Authority

Ministry of Health Services

Interdisciplinary teams

Payment

Contract *

Cont

ract

*

Communication

* Some existing PHCO sites have contracts directlywith the ministry.

Paym

ent

PHCO Health Authority



Payment

Contract *

Cont

ract

*

Communication

* Some existing PHCO sites have contracts directlywith the ministry.

Figure 2-1 PHCO Contractual Arrangements

2.7.1. Relevant Agreements—British Columbia Medical Association

The two main agreements relevant to the delivery of services through PHCOs are the Second Master Agreement and the Working Agreement.

The Second Master Agreement establishes the framework for negotiation and consultation.

The Working Agreement is the economic agreement between the province and doctors. It sets out the provisions for fees, on-call payments and physician benefits, including disability and malpractice insurance, education funds, RSP contributions and maternity leave. It addresses all matters of common interest to physicians.

Additional information on these agreements is available on the MSP Web site at www.healthservices.gov.bc.ca/msp/legislation/mscagree.html.

2.7.2. Performance Agreements—Ministry and Health Authorities

Each health authority has signed performance agreements with the Ministry of Health Services that hold them accountable for the delivery of patient care, health outcomes and how health dollars are spent. These agreements define expectations, performance deliverables and service requirements in the areas of emergency care, surgical services, home and community care, and mental health services.

For additional information on these agreements, visit the Health Authorities Web site at www.healthservices.gov.bc.ca/socsec.


www.healthservices.gov.bc.ca/msp/legislation/mscagree.html

www.healthservices.gov.bc.ca/socsec

Contracts SECTION 2 – ESTABLISHING A PHCO

2.7.3. Contracts—Ministry and Health Authorities

For each new PHCO, the Ministry of Health Services and the health authority enter into a contract.

2.7.4. Blended Funding Contracts—Health Authorities and PHCOs

Historically, payment for physician services has been made on a fee-for-service basis. As such, each service has a specific fee associated with it and the level of income a physician earns relates directly to the number and complexity of services he or she provides.

Under a fee-for-service contract, MSP accepts claims for MSP benefit services provided by practitioners who are enrolled with MSP and in good standing with the licensing body governing their profession.

MSP pays practitioner claims in accordance with the provisions of the Medicare Protection Act and Regulations, the relevant payment schedule, and MSP claims policies and procedures. The fees in the payment schedules are established through consultation between Medical Services Commission and the respective professional associations.

For PHCOs, however, the health authority enters into a blended funding contract with each individual PHCO.

Blended Funding Contracts

PHCOs operate under a combined fee-for-service and population-based funding arrangement, combining the duties and related income from both fee-for-service and alternative payment models. As such, PHCOs will have clear, written policies in place in the form of a blended funding contract. The policies within the contract clearly distinguish the services claimed under each payment model.

Under a blended funding contract, PHCOs cannot claim population-based funding for physician expenditures that have been, or will be, billed to MSP by a physician as fee-for-service.

2.7.5. Incentive Programs

Ongoing Incentives

Incentives such as the Full Service Family Practice Incentive Program, and rural health programs such as the Rural Retention Program, may offer additional funding to qualifying practices or physicians.

For more information on these and other incentives, please refer to Sections 6.3.2 and 6.3.3.


SECTION 2 – ESTABLISHING A PHCO Contracts

Time Limited Incentives under the Primary Health Care Transition Fund

Health Canada’s Primary Health Care Transition Fund supports activities that promote the renewal of primary health care. Incentives under the fund are time limited (funds cannot be used as ongoing funding) and Health Canada has defined the costs that are eligible for support under the transition fund.

Specific distribution of the fund is administered at discretion of the health authority.

For more information on specific incentives that may be offered, contact the local health authority. If you are unsure of the appropriate contact within your local health authority, please contact the Primary Health Care Branch at the phone number or e-mail address provided on page 2-18.


PHCO Site Set-up SECTION 2 – ESTABLISHING A PHCO

2.8. PHCO Site Set-up

To expedite set-up of your site, the Primary Health Care Branch coordinates the implementation of the reporting, billing, payment and information technology infrastructure for your new PHCO.

Mail or fax all forms (including Medical Services Plan forms) and information itemized in Sections 2.8.2 through 2.8.12 to:

Beverlee Sealey Manager, Primary Health Care Organizations & Networks Primary Health Care Branch Ministry of Health Services Telephone: 250-952-1290 Fax: 250-952-3486 E-mail: [email protected]


SECTION 2 – ESTABLISHING A PHCO PHCO Site Set-up

2.8.1. Site Set-Up Checklist

1. Before site set-up can begin, a contract must be in place between the Ministry of Health Services and the relevant health authority, and between the health authority and the PHCO.

Refer to Section 2.8.2, Making Contract Arrangements.

2. All PHCO practitioners (both physicians and non-physicians) must register with MSP if they have not already done so.

Refer to Section 2.8.3, Applying for an MSP Practitioner Number.

3. The PHCO must apply for a new single Payee Number (MSP Payment Number) for the PHCO.

Refer to Section 2.8.4, Applying for a Single Payee Number for the PHCO.

4. MSP payments for each individual PHCO practitioner must be assigned to the PHCO’s Payee Number.

Refer to Section 2.8.5, Assigning Practitioner Payments to the PHCO.

5. The PHCO must apply to have MSP transfer semi-monthly payments to a single PHCO bank account.

Refer to Section 2.8.6, Applying for Transfer of Payments to a Single Bank Account.

6. The PHCO must apply to submit claims electronically to MSP through Teleplan. Submitting claims through Teleplan ensures the capture of the diagnostic information that is essential for accurate ACG assignment of patients.

Refer to Section 2.8.7, Applying for Teleplan Service (Opted-In).

7. PHCOs that will provide services at more than one location will require additional Facility Numbers.

Refer to Section 2.8.8, Applying for Additional Facility Numbers.

8. The PHCO must ensure that its billings/claims submission software is compliant with Teleplan specifications for the submission of information regarding core and extended services and patient registration data.

Refer to Section 2.8.9, Upgrades Required to a PHCO’s Teleplan-Compliant Software.

9. The PHCO must be set-up to use HNWeb (the Secure Web Site for Practitioners) that allows PHCOs to view patient registration information and receive patient registration and financial reports from the ministry.

Refer to Section 2.8.10, HNWeb - Secure Web Site for Practitioners.



10. The PHCO must designate specific practitioners or staff members as formal points of contact for PHCO issues.

Refer to Section 2.8.11, Designating PHCO Contacts.

11. PHCO staff members should be subscribed to the PHCO Listserv, an e-mail forum used to exchange information between the Primary Health Care Branch and PHCOs.

Refer to Section 2.8.12, PHCO Listserv.

2.8.2. Making Contract Arrangements

The Manager, Primary Health Care Organizations and Networks, Ministry of Health Services coordinates all the necessary contracts between the ministry and health authorities and between health authorities and PHCOs.

Through the Manager, Primary Health Care Organizations and Networks, PHCOs may also arrange to enter into a network agreement with another PHCO. Network agreements allow the registered patients of one PHCO to receive services from the other PHCO without a resulting service outflow.

Please refer to page 2-18 for contact information.

2.8.3. Applying for an MSP Practitioner Number

Each practitioner enrolled with MSP is assigned a billing number that consists of:

• a practitioner number, which identifies the practitioner rendering the service, and

• a payee (payment) number, which identifies the person or group (e.g., clinic, hospital) to which payment is to be made.

The practitioner and payee numbers are usually the same. However, they differ in cases in which a practitioner designates another practitioner or group, such as a clinic or hospital, to receive that practitioner's MSP fee-for-service payments.

PHCO practitioners use their practitioner number in conjunction with a PHCO Payee Number when submitting fee-for-service claims and encounter records for patients of their PHCO.

Note: If a PHCO practitioner wishes to submit claims for services outside the PHCO, those claims should be submitted with (a) the Payee Number originally assigned to the practitioner by MSP or (b) the Payee Number of the facility at which the services are delivered.

Non-physician PHCO practitioners cannot use the usual MSP forms to apply for a practitioner number. These practitioners (including counselors, educators, home support workers, licensed practical nurses, medical office assistants, nurse practitioners, nutritionists, dietitians, registered nurses, respiratory therapists and pharmacists) must use a separate form, as indicated below.



• Physicians who do not have an existing MSP billing number: Complete the Application for MSP Billing Number form (HLTH 2991).

This form is available on the MSP Web site at www.healthservices.gov.bc.ca/exforms/mspprac/index.html.

• Other PHCO practitioners: Complete the Primary Health Care Practitioner Registration Form.

This form is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html.

2.8.4. Applying for a Single Payee Number for the PHCO

When the funding for your PHCO is forwarded from Medical and Pharmaceutical Services of the Ministry of Health Services to the health authority, it will be identified by a single Payee (Payment) Number assigned for your PHCO.

• Complete the Application for Additional Payment Number form, available by contacting the Primary Health Care Branch at 250-952-1081.

In Section A, enter the information for the physician who will be signing the form. Do not complete Section D if you will be applying for a new Data Centre Number through Teleplan. In Section E, the effective date specified should be the date your PHCO will open.

For more information on the Data Centre Number, refer to Section 2.8.7, Applying for Teleplan Service (Opted-In).

2.8.5. Assigning Practitioner Payments to the PHCO

All PHCO practitioners (including physician locums) must arrange for all claims and records submitted with their practitioner number and the PHCO Payee Number to be assigned to the PHCO Payee Number.

• Complete the Assignment of Payment Due to Practitioner Under the Medical Services Plan form (HLTH 2870).

In the space for “Locum Name,” enter the name of the physician who is assigning their payments to the PHCO. In the space for “Principle Practitioner Name,” enter the PHCO name. For the “Effective Date,” enter the date the PHCO will open. The “Cancel Date” should be no more than five years after the effective date.

This form is available on the MSP Web site at www.healthservices.gov.bc.ca/exforms/mspprac/2870fil.pdf.


www.healthservices.gov.bc.ca/exforms/mspprac/index.html


www.healthservices.gov.bc.ca/exforms/mspprac/2870fil.pdf


2.8.6. Applying for Transfer of Payments to a Single Bank Account

PHCOs must request that MSP electronically transfer semi-monthly payments to a specified bank account.

• Complete the Application for Direct Bank Payment from MSP or Request for Change of Banking Information (HLTH 2832).

In the Personal Data section, enter your PHCO information. The same physician who signed the Application for Additional Payment (described in Section 2.8.4) must also sign this form.

The form is available on the MSP Web site at www.healthservices.gov.bc.ca/exforms/mspprac/index.html.

2.8.7. Applying for Teleplan Service (Opted-In)

PHCOs must be able to submit claims electronically to MSP through Teleplan. If your practice does not already submit claims through Teleplan:

• Complete the Application for Teleplan Service (Opted-In) (HLTH 2820).

Use your PHCO information when completing the form.

This form is available on the MSP Web site at www.healthservices.gov.bc.ca/exforms/mspprac/index.html.

This form authorizes claims submissions and payments under your PHCO Payee Number to be processed through your Data Centre number. If you do not have an existing Data Centre number, complete the contact information under the New Data Centre section of the form.

Ensure that the form is signed and dated and that you have included, in the top portion of the form, the name of the most appropriate contact person within your PHCO for claims-related questions. We recommend that the contact person be your Office Manager or Medical Office Assistant.

2.8.8. Applying for Additional Facility Numbers

When you submit an application for Teleplan service, the Primary Health Care Branch will also have a “facility number” assigned to your PHCO. The facility number identifies the actual geographic location at which services are delivered and is reported when submitting claims and encounter records.

If your PHCO will deliver service at more than one location, please advise the Primary Health Care Branch. An additional facility number will be assigned for each location.

2.8.9. Upgrades Required to a PHCO’s Teleplan-Compliant Software

Revisions to the MSP Teleplan Specifications were made to support data submission of PHCO patient encounters (i.e., core and extended services to registered patients)





and patient registration data (including increased capability to report additional diagnostic data to support accurate ACG assignments).

Not all software vendors have upgraded their software to meet these specifications. Contact your software vendor to ensure their software is compliant or can be upgraded to be compliant.

The MSP Teleplan Specifications document, including Appendix C which details the specific PHCO requirements, is available on the MSP Web site at www.healthservices.gov.bc.ca/msp/infoprac/teleplanspecs/index.html.

2.8.10. HNWeb - Secure Web Site for Practitioners

Through HNWeb, PHCOs can access primary health care registration transactions and reports and the Client Registry/Health Registry system.

HNWeb enables PHCOs to:

• view or change the registration status of a patient;

• view a patient’s registration status history;

• update a practitioner assignment and/or administrative code;

• complete the Monthly Registration Review process; and

• view patient register reports and download PHCO Quarterly Reports.

Client Registry/Health Registry, the central repository of demographic information for individuals who access health services in British Columbia, is used to:

• Look up and assign Personal Health Numbers (PHNs) for patients.

• Record demographic information, client identification documentation and eligibility indicators (to assist care providers in maintaining a longitudinal health record for clients). This is the first step toward an Electronic Health Record (EHR).

• Confirm a patient’s MSP coverage status.

To access HNWeb, PHCOs require:

• a digital certificate issued by HealthNet Access Services at the Ministry of Health Services, and

• HNWeb User IDs and passwords.

Please advise the Primary Health Care Branch of the PHCO staff who will require access to HNWeb (normally your Office Manager and/or Medical Office Assistant). The Primary Health Care Branch will work with your health authority to arrange the necessary access rights.

PHCO physicians who participate in Chronic Disease Management Collaboratives may also require access to HNWeb. Contact the Primary Health Care Branch for additional information.


http://www.healthservices.gov.bc.ca/msp/infoprac/teleplanspecs/index.html

www.healthservices.gov.bc.ca/msp/infoprac/teleplanspecs/index.html


2.8.11. Designating PHCO Contacts

To begin operations, the Primary Health Care Branch and the PHCO must agree on specific contacts within the PHCO who will handle various aspects of PHCO management.

The Office Manager will usually act as the Access Administrator who works with Teleplan staff to administer PHCO user accounts (e.g., set-up and removal of User IDs and passwords) and will serve as the primary contact for Primary Health Care Branch/PHCO, health authority/PHCO and MSP Teleplan/PHCO communications.

The Financial Contact will, in cooperation with the Primary Health Care Branch and health authority, coordinate all PHCO financial matters. The financial contact should have the authority to make decisions as required.

The Contract Contact coordinates all contractual matters and should have the authority to execute contractual tasks.

2.8.12. PHCO Listserv

The PHCO Listserv is an automated e-mail forum through which PHCOs, health authorities and the Primary Health Care Branch share information pertinent to PHCO operations.

For the initial subscription, identify the staff members you wish to have subscribed and provide their e-mail addresses. The Primary Health Care Branch will subscribe these individuals to the Listserv and issue a “welcome” e-mail. The e-mail provides instructions for participating in the Listserv and for contacting the List Administrator.

From time to time, PHCOs are asked to update their list of Listserv users and to confirm that the e-mail addresses are current.


SECTION 2 – ESTABLISHING A PHCO Ongoing Administrative Requirements

2.9. Ongoing Administrative Requirements

Over time, staff changes at the PHCO will necessitate modifications to the registration of its physicians and other health care practitioners.

The PHCO must notify the Primary Health Care Branch when:

• the PHCO retains new practitioners to provide services at the PHCO; or

• a practitioner stops providing services at the PHCO.

This notification is effected through the usual MSP procedures.

2.9.1. Modifications to PHCO Registration of a Practitioner or Locum

Adding a Physician/Practitioner to the PHCO

After PHCO operation has begun, physicians joining the PHCO must assign their payments to the PHCO Payee Number using the same process described in Section 2.8.5.

Deleting PHCO Registration of a Physician/Practitioner/Locum

When a physician or practitioner leaves the PHCO:

• the physician or practitioner should no longer use the PHCO’s Payee Number.

• PHCOs who have elected to assign individual patients to a specific practitioner will need to submit a new registration for any patient assigned to the departing physician, providing the Primary Health Care Branch with the information regarding the change in the patient’s primary practitioner assignment.


Ongoing Administrative Requirements SECTION 2 – ESTABLISHING A PHCO


SECTION 3 – MANAGING A PATIENT REGISTER Section Contents

SECTION 3 – MANAGING A PATIENT REGISTER

Section Contents

3.1. Overview ................................................................................................................................3-3

3.2. Registration Data Submission Overview ............................................................................3-3 3.2.1. Teleplan ....................................................................................................................3-3 3.2.2. HNWeb .....................................................................................................................3-3

Logging into HNWeb .......................................................................................................... 3-4 Accessing the HNWeb Help Function ................................................................................ 3-5 Performing a Personal Health Number (PHN) Search ....................................................... 3-5

3.2.3. Teleplan and HNWeb Assistance .............................................................................3-7

3.3. Registering a Patient ............................................................................................................3-8 3.3.1. When to Register a Patient .......................................................................................3-8 3.3.2. Introducing New Patients to the PHCO.....................................................................3-8 3.3.3. Submitting Registration Data ....................................................................................3-9

Teleplan.............................................................................................................................. 3-9 HNWeb ............................................................................................................................. 3-10

3.3.4. Assigning Patients to a Specific PHCO Practitioner................................................ 3-11 3.3.5. Setting an Administrative Code............................................................................... 3-12

HNWeb ............................................................................................................................. 3-12 3.3.6. Ministry Changes to Registration Dates.................................................................. 3-13

3.4. Modifying Your Patient Register........................................................................................ 3-14 3.4.1. Modifying an Administrative Code........................................................................... 3-14

Teleplan............................................................................................................................ 3-14 HNWeb ............................................................................................................................. 3-14

3.4.2. Reassigning a Patient to Another PHCO Practitioner ............................................. 3-15 Teleplan............................................................................................................................ 3-15 HNWeb ............................................................................................................................. 3-16

3.5. De-Registering a Patient..................................................................................................... 3-18 3.5.1. Submitting De-Registration Data............................................................................. 3-18

Teleplan............................................................................................................................ 3-18 HNWeb ............................................................................................................................. 3-19

3.6. Monthly Registration Reviews ........................................................................................... 3-21 3.6.1. Overview................................................................................................................. 3-21 3.6.2. Monthly Registration Review Schedule................................................................... 3-22

List of Proposed Registrations/De-Registrations Made Available to PHCO..................... 3-22 PHCOs Respond to Proposed Registrations/De-Registrations........................................ 3-22 Ministry Finalization .......................................................................................................... 3-22 PHCOs to Synchronize Patient Registers ........................................................................ 3-22


Section Contents SECTION 3 – MANAGING A PATIENT REGISTER

3.6.3. Reviewing Proposed Registrations and De-Registrations .......................................3-23 Pending Registration Changes Report ............................................................................. 3-23

3.6.4. Registration and De-Registration Reason Codes....................................................3-24 Reasons for Proposed Patient Registrations .......................................................................... 3-24 Reasons for Proposed Patient De-Registrations .................................................................... 3-24

3.6.5. Submitting Registration and De-Registration Override Requests............................3-25 Teleplan............................................................................................................................ 3-25 HNWeb ............................................................................................................................. 3-26

3.6.6. Application of Patient Register Changes .................................................................3-27 3.6.7. Submitting an Administrative Code for Accepted Registrations...............................3-27

3.7. Verifying Your Patient Register..........................................................................................3-28 3.7.1. HNWeb Patient Registration Reports ......................................................................3-28

Pending Registration Changes Report ............................................................................. 3-28 PHC Current Registrations Report ................................................................................... 3-28 PHC Complete Registration History Report ..................................................................... 3-29 Recently Applied Registration Changes Report ............................................................... 3-30

3.7.2. HNWeb Report Download .......................................................................................3-30 Accessing HNWeb Patient Registration Reports.............................................................. 3-30


SECTION 3 – MANAGING A PATIENT REGISTER Overview

3. Managing a Patient Register

3.1. Overview

Managing your patient register involves:

• Registering patients;

• De-registering patients;

• Changing patient registration information; and

• Accepting or declining the registrations or de-registrations proposed by the ministry during the monthly registration review.

3.2. Registration Data Submission Overview

PHCOs can submit patient registration and de-registration information using either Teleplan or HNWeb. Regardless of the method your PHCO uses, your data is submitted to the Ministry of Health Services.

3.2.1. Teleplan

Teleplan is a secure Web-based telecommunications system that provides an encrypted Internet connection. Practitioners use Teleplan to securely submit claims, notes and eligibility requests to the Medical Services Plan (MSP) and to receive payment statements, rejected claims and patient eligibility data from the MSP.

Data submitted using your local (in-PHCO) billing software is processed overnight by the MSP Claims Processing system. If a record cannot be processed, you receive a Teleplan refusal record in the next remittance that you access through Teleplan.

For more information on the Teleplan specifications for PHCOs, visit the MSP Web site at www.healthservices.gov.bc.ca/msp/infoprac/teleplanspecs.

3.2.2. HNWeb

The Secure Web Site for Practitioners, HNWeb, is hosted by the ministry’s HealthNet Access Services (HAS) on behalf of Primary Health Care Branch. It provides:

• Patient registration management transactions;

• Patient register reports; and

• Audit trails, recording historic changes to your patient register.

Although changes submitted through HNWeb are applied to the ministry version of your patient register immediately (not overnight), the copy of the patient register stored in your local (in-PHCO) software will not be updated.


www.healthservices.gov.bc.ca/msp/infoprac/teleplanspecs

Registration Data Submission Overview SECTION 3 – MANAGING A PATIENT REGISTER

Any changes submitted through HNWeb should also be entered directly into your local software and it is strongly recommended that you synchronize your own version of the patient register with the ministry version on the 17th each month. In all matters relating to claims, encounters and payments, the ministry version of the register is considered the definitive register for your PHCO.

For more information on verification of your patient register, refer to Section 3.7.

When your PHCO is established, the Primary Health Care Branch registers your staff for HNWeb, assigning both User IDs and passwords.

For more information on site set-up, refer to Section 2.8.

To request HNWeb User IDs for new staff or to notify the ministry of changes to staff, contact the Teleplan Support Centre at the numbers provided in Section 3.2.3.

Logging into HNWeb

1. Ensure that your PHCO’s digital certificate is installed on each computer that will be used to access HNWeb.

If you need assistance in installing your certificate, contact the Ministry of Health Services HelpDesk at 250-952-1234 or send an e-mail to [email protected].

2. Access HNWeb at https://healthregistry.moh.hnet.bc.ca/.

3. Enter your Userid and password.

4. Click on the Log In button.

The healthnetBC Services menu is displayed.


https://healthregistry.moh.hnet.bc.ca/

SECTION 3 – MANAGING A PATIENT REGISTER Registration Data Submission Overview

5. Select the Primary Health Care Application.

The Welcome screen is displayed.

Accessing the HNWeb Help Function

The HNWeb Help function (accessed from the Contents menu) provides full information on the various HNWeb functions. HNWeb Help is screen-specific; when you click on Help, the information provided is specific to the HNWeb screen you are working in at the time.

Performing a Personal Health Number (PHN) Search

For most transactions on HNWeb, you will need the patient’s Personal Health Number (PHN). After logging in to HNWeb, you can perform a search for a patient’s PHN, if necessary.


Registration Data Submission Overview SECTION 3 – MANAGING A PATIENT REGISTER

1. If you have not already done so, login to HNWeb as described on page 3-4.

2. From the Contents menu on the left-hand side of the screen, click on Health Registry.

The Health Registry Transactions screen is displayed.

3. Select Name Search.

The R09 – Name Search screen is displayed.

4. Enter, at a minimum, the patient’s Surname, Date of Birth and Gender (or as much confirmed demographic information regarding the patient as is available).

5. Click on Submit.

Records matching your search criteria are displayed. Results include Surname, First Name or Initial, Second Name or Initial, Gender, Birth Date (year/month/day), Personal Health Number and Address.


SECTION 3 – MANAGING A PATIENT REGISTER Registration Data Submission Overview

3.2.3. Teleplan and HNWeb Assistance

If you require assistance with Teleplan, call the Teleplan Support Centre in Victoria at 250-952-2668, or, from elsewhere in British Columbia, at 1-800-663-7206.

If you require assistance with HNWeb, contact the Ministry of Health Services Help Desk at 250-952-1234 or send an e-mail to [email protected].


Registering a Patient SECTION 3 – MANAGING A PATIENT REGISTER

3.3. Registering a Patient

You may register a patient at any time using the methods described in Section 3.3.3, Submitting Registration Data.

Note: In addition to your ad hoc patient registrations, each month, the Ministry of Health Services will provide you with a list of proposed patient registrations and de-registrations. For more information on accepting or declining these registration changes, refer to Section 3.6.3, Reviewing Proposed Registrations and De-Registrations.

3.3.1. When to Register a Patient

To be eligible for registration a patient must:

• be a Canadian citizen or lawfully admitted to Canada for permanent residence (exception: foreign students);

• make his/her home in British Columbia;

• be resident in British Columbia at least 6 months in each calendar year;

• possess a British Columbia Medical Services Plan personal health number;

• be enrolled with the Medical Services Plan; and

• live in your catchment area.

3.3.2. Introducing New Patients to the PHCO

When you register a patient, you are required to inform them that you have done so. When notifying the patient, you must explain that your funding is not based upon the number of services provided but rather on a blend of population-based funding and fee-for-service funding.

You may also choose to advise the patient that, when they elect to access primary care services from another practice within your catchment area, it will affect the funding your PHCO receives for their care. However, patients must also be informed that, in accordance with the Canada Health Act, they are free to access medical services outside the PHCO or to change their family physician at any time.

A PHC Renewal information sheet for patients can be downloaded from the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/pdf/phc_primer.pdf. You may also call the branch at 250-952-1081 to request printed copies.


www.healthservices.gov.bc.ca/phc/pdf/phc_primer.pdf

SECTION 3 – MANAGING A PATIENT REGISTER Registering a Patient

3.3.3. Submitting Registration Data

As mentioned earlier in this section, there are two means by which to submit patient registration data—Teleplan or HNWeb.

Teleplan

Your local billing software should provide functions for submitting registration and de-registration records with regular Teleplan claim submissions. Your software vendor can provide information regarding these functions.

Your patient registration records are submitted as specially formatted Teleplan Note Records that accompany MSP Claims Records. Each registration record must contain the following information:

• Patient Identifying Information—The patient’s Personal Health Number (PHN or CareCard number) and a name verification code are captured in the MSP Claims Record.

• PHCO Payment Number—Identifies the PHCO to which the patient is being registered.

• Patient’s Practitioner—The practitioner specified in the MSP Claims Record should indicate the PHCO practitioner (physician or non-physician) who is primarily responsible for the patient.

Note: Identifying the primary physician is a Teleplan claims requirement. It does not affect funding allocation within the PHCO.

• Registration Effective Date—Enter the date you would like the patient registration to take effect (for example, the date of the patient’s first visit to your PHCO). The date entered can be up to 45 days before, or 30 days after, the current system date.

The “system date” is the date on which the ministry receives and processes the claim. For instance, records entered late at night on the 14th may not be processed until the 15th. In this case, the 15th is the system date.

Under certain circumstances, the ministry may change the registration effective date. For more information, refer to Section 3.3.6.

• Registration Cancellation Date—Enter a registration cancellation date only if the registration is to be temporary, for example, if a student will be registered with the PHCO for the school term but will be de-registered when he returns to his hometown (outside the PHCO catchment area) in the summer.

• Patient Address—Always include the postal code when entering a patient address.

• Patient Administrative Code—The default code is 0. For patients with HIV/AIDS, (for whom higher funding is provided), change the code to 1–Special Needs. Refer to Section 2.2.2 for information on this code.

Note: Because registration records are always processed first, you can submit a patient’s registration information on the same day you first submit an encounter record for the patient.



HNWeb

When using HNWeb, note that all fields marked with an asterisk are required fields.

To submit registration data through HNWeb:

1. Login to HNWeb as described in Section 3.2.2.

2. If you do not know the patient PHN, perform a PHN search as described in Section 3.2.2.

3. In the Contents menu on the left-hand side of the screen, click on PHC Registrations.

The Patient Registration Transaction Screen is displayed.

4. Select Register a Patient.

The Register a Patient screen is displayed.

5. Enter the patient’s PHN and, it if is not already entered by default, your PHCO Payee number.



6. Click on Submit.

If the patient is already registered with your PHCO, details of the patient's registration history are displayed, but you will not be able to submit a new registration for that patient. If you want to change the registration date, contact Teleplan. For contact information, refer to Section 3.2.3.

If the patient is already registered to another PHCO, the patient's registration history is displayed (with all details other than registration and de-registration dates suppressed). You will not be able to submit a new registration for that patient.

If the patient is not currently registered to a PHCO, the Enter New Patient Registration Information area is displayed at the bottom of the screen.

7. In the Enter New Patient Registration Information area, the Registration Date displayed is the current system date. If necessary, you may change this date.

If you wish to assign the patient to a specific practitioner, refer to Section 3.3.4. If the patient has been diagnosed with HIV/AIDS, refer to Section 3.3.5 for information on setting the “special needs” administrative code.

3.3.4. Assigning Patients to a Specific PHCO Practitioner

If your PHCO was originally set-up to enter patient assignments to specific practitioners, you may continue to do so. However, to keep the assignment information current, you must enter updates, as required. This information is not updated by any other process. All PHCOs may elect to leave this field blank. It does not affect the population-based payment to the PHCO.

To assign a patient to a specific PHCO practitioner:

1. In the Enter New Patient Registration Information area, in the Practitioner Assignment field, enter the Practitioner Number of the most responsible physician.

All non-physician PHCO practitioners must apply for an MSP practitioner number if they do not already have one.



2. If you also wish to set a “special needs” administrative code, refer to Section 3.3.5.

Otherwise, click on Submit.

3.3.5. Setting an Administrative Code

As described in Section 3.3.3, Submitting Registration Data, the default Administrative Code is 0 – Normal, whether you use Teleplan or HNWeb.

For patients diagnosed with HIV/AIDS, change this code to 1 – Special Needs using Teleplan or, as described below, HNWeb.

HNWeb

1. At the bottom of the Register a Patient screen, in the Enter New Patient Registration Information area, click on the arrow to the right of the Administrative Code field.

2. From the drop-down selection list, select 1 – Special Needs.

3. Click on Submit.



3.3.6. Ministry Changes to Registration Dates

When you submit a patient registration record through Teleplan or HNWeb, the ministry may adjust the registration date if you have submitted one or more fee-for-service claims for a core service to a patient during the current fiscal year (or, if it remains open, the previous fiscal year).

As described in Section 5.1.1, annual reconciliation (closing) of a fiscal year occurs in November of the following fiscal year.

In these cases, the ministry proposes that the registration date be changed to the date of the patient’s earliest fee-for-service claim from your PHCO in the current fiscal year or, if remains open, the previous fiscal year.

If you accept this registration date, your PHCO receives population-based funding for the patient from the registration date onwards less the value of any fee-for-service claims submitted after the registration date (i.e., any fee-for-service claims for core services to the patient submitted after the registration date are converted to encounter records).

For more information on ministry changes to patient registration dates, refer to Section 4.5.4.

If you have not submitted any core service fee-for-service claims during the current or previous (open) fiscal year, the patient registration date is set to:

• the date you specify when you submit the registration record; or

• if no date is entered, to the system date on which the registration record is submitted (i.e., the date the registration record is received by the ministry); or

• if you submit a fee-for-service claim for a core service for that same patient (in the same, or a later, Teleplan submission), to the date the core service was delivered to the patient.

Proposed changes to both registrations and de-registrations are put forward by the ministry in the Monthly Registration Review. For more information, refer to Section 3.6.


Modifying Your Patient Register SECTION 3 – MANAGING A PATIENT REGISTER

3.4. Modifying Your Patient Register

You can modify the Administrative Code assigned to a patient, or the practitioner to whom the patient is assigned, using Teleplan or HNWeb.

3.4.1. Modifying an Administrative Code

Modifications to the Administrative Code are required only if a patient is diagnosed with HIV/AIDS. The modified special needs funding amount, backdated to the date of the change in patient status, is included in the next quarter’s population-based funding.

Teleplan

1. Submit a new PHC registration record (fee item 96090), specifying the Administrative Code status as 1 and specifying the desired registration effective date.

The registration date cannot be:

• Earlier than the patient’s current registration effective date; or

• More than 45 days before the current system date; or

• More than 30 days after the current system date.

The MSP database is automatically updated overnight and the registration record for the patient then reflects the new administrative code status. If your billing software has the capability, the patient record on your local software is also automatically updated. Contact your software vendor for more information on this function.

HNWeb

1. Login as described in Section 3.2.2.



4. Click on Change a Patient Registration.

5. Enter the patient PHN and your PHCO’s MSP Payee Number.

Your billing software may submit your MSP Payee (Payment) Number by default.

6. Click on Submit.

The Change a Patient Registration screen is displayed with the patient’s registration history. If the patient is not currently registered to your PHCO, no input form is displayed.

7. At the bottom of the screen, in the Set Practitioner Assignment and/or Administrative Code Value section, from the drop-down selection list for the Administrative Code field, select the appropriate value (e.g., 1 – Special Needs).


SECTION 3 – MANAGING A PATIENT REGISTER Modifying Your Patient Register

8. Click in the Apply Change check box (to select it).

9. Click on Submit.

10. Enter the change in patient registration information directly into your local software to ensure your patient register matches the ministry’s version.

3.4.2. Reassigning a Patient to Another PHCO Practitioner

If your PHCO has entered assignments to a specific practitioner in the past, ensure that all changes in these assignments are submitted using Teleplan or HNWeb. Ministry processes do not update the information.

All PHCOs may leave this field blank. It does not affect the population-based funding to your PHCO.

Teleplan

1. Send in a new registration record (fee item 96090) with the new practitioner number and effective date.

The effective date cannot be:




Changes submitted through your billing software are processed overnight in the MSP Claims Processing system. If either the de-registration or registration record cannot be processed by MSP, you will receive a Teleplan refusal record in the next remittance you pick up through Teleplan.

If your billing software has the capability, the patient record on your local software is also automatically updated. Contact your software vendor for more information on this function.


Modifying Your Patient Register SECTION 3 – MANAGING A PATIENT REGISTER

HNWeb




4. Select Change a Patient Registration.

5. Enter the patient PHN and, if not already entered by default, your PHCO MSP Payee Number.

6. Click on Submit.

7. Toward the bottom of the Change a Patient Registration screen, under the Set Practitioner Assignment and/or Administrative Code Value section, in the Effective Date of change(s) field, enter the effective date of the change.

This date cannot be:




8. In the Practitioner Assignment field:

• Enter the practitioner number of the practitioner to whom you want to assign the patient, or

• Leave the field blank to reassign the patient to the PHCO as a whole.

If entering a practitioner number, the practitioner does not have to be a physician.

You may see the practitioner number 99999 in the practitioner assignment field. This is a default setting and does not impact the patient’s registration.

9. Click in the Apply Change checkbox (to select it).

10. Click on Submit.


SECTION 3 – MANAGING A PATIENT REGISTER Modifying Your Patient Register

11. Enter the changed information directly into your local software to ensure your patient register matches the ministry’s version.

If you wish to confirm that the changes have been applied:

12. In the Contents menu, click on PHC Registrations.

13. Click on View a Patient Registration.

14. Enter the patient PHN and your PHCO’s MSP Payee Number.

Your billing software may submit your MSP Payee (Payment) Number by default.


The View a Patient Registration History screen is displayed with the patient’s registration history at the bottom of the screen. Changes to your patient register are reflected in the patient’s registration history.


De-Registering a Patient SECTION 3 – MANAGING A PATIENT REGISTER

3.5. De-Registering a Patient

You may de-register a patient at any time if the patient:

• has moved outside of the catchment area; or

• is deceased; or

• is no longer receiving the majority of their primary care services from the PHCO.

Additionally, each month the ministry makes recommendations for de-registration. Proposed de-registrations are based on a wider range of reasons (refer to Section 3.6.4).

3.5.1. Submitting De-Registration Data

Teleplan

Your patient de-registration records are submitted as Teleplan Note Records which accompany MSP Claims Records. To successfully de-register a patient, the record must contain the following information:

• Patient Identifying Information. Personal Health Number (PHN) and a name verification code that are captured in the MSP Claims Record.

• PHCO Payment Number—Identifies the PHCO from which the patient is being de-registered.

• Registration Cancellation Date. The date you would like the patient de-registration to take effect.

• Registration Cancellation Reason. A code indicating the reason for the de-registration. Current valid cancellation reason codes are:

D Deceased. S Services being received outside the PHCO. L Left the area. A Another reason (when using this code, you must provide a short note explaining the

reason). N Changing practitioner assignment.


SECTION 3 – MANAGING A PATIENT REGISTER De-Registering a Patient

HNWeb




4. Select De-Register a Patient.

The De-Register a Patient screen is displayed.

5. Enter the patient PHN and, if it is not already entered by default, your PHCO’s Payee number.

6. Click on Submit.

7. At the bottom of the De-Register a Patient screen, in the Enter Patient De-Registration (Cancellation) Information area, accept the default (current) date or enter another date.

The registration cancellation date cannot be:





De-Registering a Patient SECTION 3 – MANAGING A PATIENT REGISTER

8. Click on the arrow to the right of the Cancellation Reason field.

9. From the drop-down selection list, select the reason for de-registration.


11. Enter the de-registration information directly into your local software to ensure your patient register matches the ministry’s version.


SECTION 3 – MANAGING A PATIENT REGISTER Monthly Registration Reviews

3.6. Monthly Registration Reviews

3.6.1. Overview

Each month, the ministry analyzes all claims for all patients who received services from your PHCO. This analysis of MSP claims data and patient MSP coverage data results in a list of patients who appear to meet the criteria for registration or de-registration.

This list, the Pending Registration Changes Report, is:

• sent to your PHCO via Teleplan, as a Data Centre Mailbox Message Record, which you can retrieve from your Teleplan mailbox; and

• made available via HNWeb, under the Request a Report option, where it will be saved to your secure mailbox.

Using a special function of your local software, your PHCO reviews the proposed changes to your patient register and advises the ministry if you wish to decline (“override”) any of these proposed changes.

When all changes to the patient register that have been accepted by your PHCO are applied to the ministry copy of your patient register, you will need to ensure that the version of the patient register on your local system is synchronized with the ministry version.

The ministry’s copy of your updated patient register is used to calculate your population-based funding.


Monthly Registration Reviews SECTION 3 – MANAGING A PATIENT REGISTER

3.6.2. Monthly Registration Review Schedule

Figure 3-1 below, illustrates the key dates in the monthly registration review cycle. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Pending Registration

and De-Registration file available to

PHCO

PHCO required response

Ministry finalization

PHCOs to synchronize

patient registers

Figure 3-1 Monthly Registration Review Schedule

List of Proposed Registrations/De-Registrations Made Available to PHCO

5th day of the month: On or before this date, a list of proposed registration and de-registration records is sent to your PHCO.

PHCOs Respond to Proposed Registrations/De-Registrations

6th to 15th day of the month: If you disagree with a proposed registration or de-registration, you must submit an “override” record via Teleplan or HNWeb, as described in Section 3.6.3 to prevent MSP from making the proposed change.

If you agree with all proposed changes to your patient register, use the function provided in your local software to apply the changes to your local patient register (or, if necessary, enter the changes directly into your local software).

Ministry Finalization

16 to 17th (before 8 a.m.): MSP updates the ministry copy of your patient register with all pending registrations and de-registrations for which no “override” record was received.

PHCOs to Synchronize Patient Registers

17th (after 8:00 a.m.): The ministry strongly recommends that PHCOs verify the copy of the patient register stored in their local computer with the ministry register. For more information, refer to Section 3.7.



3.6.3. Reviewing Proposed Registrations and De-Registrations

When you access the Pending Registration Changes Report (described below) on or after the 5th day of the month, review the records and submit any necessary overrides for the proposed registrations and de-registrations before the override deadline:

• For overrides submitted through Teleplan, the deadline is 7 p.m. on the 15th of each month (or the last business day before the 15th).

• For overrides submitted through HNWeb, the deadline is 3 a.m. on the 16th.

Important: If the ministry does not receive an override record for a patient before the deadline, the ministry assumes you wish to accept the proposed change and applies it to the ministry copy of your patient register.

Pending Registration Changes Report

For the current registration review period, this report includes all proposed registrations and de-registrations for your PHCO. It is available only from the 5th to the 15th day of the month.

You can access the Pending Registration Changes Report via Teleplan or HNWeb.

For information on accessing reports on HNWeb, refer to Section 3.7.2.

For each patient, the report specifies:

• the patient’s name, PHN, birth date and gender;

• the practitioner number of the practitioner under whose name the patient is registered (if applicable);

• the patient’s current address;

• the patient’s registration effective date and, if applicable, de-registration date;

• the patient’s Administrative Code;

• Pending Registration Action Code, specifying either a registration or de-registration reason code (as shown in Section 3.6.4);

• Registration Action Reason Code, specifying the reason for the proposed change; and

• Registration Override Code (for ministry use).



3.6.4. Registration and De-Registration Reason Codes

The following reason codes appear on the Pending Registration Changes Report.

Reasons for Proposed Patient Registrations

01 Patient received two consecutive primary care services from the PHCO. 02 At least 51% of the patient’s reviewed primary care services were from the PHCO. 03 Patient was registered through the PHCO/MSP register synchronisation process. M Patient is/was registered to your PHCO and their registration effective date is being

backdated by the ministry. For more information on the backdating of registration dates by the ministry, please refer to Section 4.5.4.

Reasons for Proposed Patient De-Registrations

03 Patient was de-registered through the PHCO/MSP register synchronisation process. A0 Ministry records indicate the patient is deceased. A1 Patient no longer has MSP coverage. B Patient has moved outside your catchment area and has received no services from the

PHCO since their move. B1 Patient has moved outside your catchment area but has received at least one service

from your PHCO since their move. C Patient has received at least three primary care services in the last three years and

none of the most recent services (up to a maximum of the last seven services) were received at your PHCO.

D Less than 51% of the patient’s reviewed primary care services were provided by your PHCO. Specifically: Patient has received two services in the last three years and neither were at your PHCO, or

Patient has received four services in the last three years and only one was at your PHCO, or

Patient has received 3, 5, 6, 7, or more services in the last three years and less than 51% of the most recent services (up to a maximum of the last seven services) were received at your PHCO.

F Patient received five or more of their last seven services outside your PHCO but within your catchment area.

L0 Patient was registered on your PHCO’s Initial Patient Register but does not appear to be a patient of your PHCO (has received no services from your PHCO).

M Patient had been de-registered from your PHCO, but their de-registration date is being revised by the ministry. Explanatory note: The patient may have died (in which case the de-registration date is set to the reported date of death) OR the patient may no longer have MSP coverage (in which case the de-registration date is set to the date of the last day the patient was covered by MSP).

X1 Patient has received three or more primary care services in the past three years and the most recent seven services were received outside your catchment area.

X2 Patient’s last two primary care services were outside your catchment area.



3.6.5. Submitting Registration and De-Registration Override Requests

Each billing software company provides a specialized registration review function. Please refer to your software documentation (or speak with your vendor) for specific instructions on accepting or overriding proposed changes.

Teleplan

Your local billing software’s override function may be used only to override ministry-proposed registrations or de-registrations; it cannot be used for day-to-day patient registrations or de-registrations.

Important: If you do not send any override requests, use the function provided in your local software to update your local patient register with all proposed changes (i.e., to accept all changes) or, if necessary, enter the changes directly into your local software.

1. If you disagree with a proposed registration, submit a Registration Override record (to prevent patient registration).

2. If you disagree with a proposed de-registration, submit a De-Registration Override record (to prevent de-registration).

3. If you disagree with the effective date proposed for a registration or de-registration, submit a Registration or De-registration Override, then submit a new registration/de-registration record with the desired effective/cancel date or contact Teleplan to request a change in the effective/cancel date.

The effective/cancel date requested cannot be:




Each override you submit through Teleplan must contain an override reason code:

To prevent patient registration (“Registration Override” reasons)

C A PHCO physician was covering for a vacationing physician.

D Patient is deceased.

F PHCO is full and not accepting new patients.

I Patient expressed his/her intent to see another general practitioner.

M Patient has moved.

N Patient is not known to the PHCO.

R Patient has been referred to another general practitioner.

T Patient is/was being seen as a temporary patient referral from another general practitioner.

V Patient is/was visiting the catchment area.

A Another reason (when using this code, you must provide a short note explaining the reason).



To prevent patient de-registration (“De-registration Override” reasons)

C Patient saw another general practitioner while their usual PHCO/general practitioner was on vacation.

E Ministry records are incorrect, and the patient has MSP coverage.

I Patient lives outside the catchment area but works or attends school in the catchment area.

S Patient lives outside the catchment area but requires special care available in the PHCO.

T Patient was temporarily referred to another practitioner for a special condition.

U Ministry address for the patient is incorrect and the patient lives in the catchment area.

V Patient was on vacation.

W Patient lives outside the catchment area, but has declared the intention to obtain all services from the PHCO.

A Another reason (when using this code, you must provide a short note explaining the reason).

HNWeb

Changes submitted through HNWeb are applied immediately but the patient register stored in your local (in-PHCO) software will not be updated. Changes submitted through HNWeb must also be entered directly into your local software.


2. If you do not know the patient PHN, perform a PHN Search as described in Section 3.2.2.


4. Click on Override a Pending Registration/De-Registration.

Override transactions are available only if a current pending registration or de-registration exists.

5. Enter the patient PHN and, if not already entered by default, your PHCO’s MSP Payee number.



6. Click on Submit.

The Override Pending Registration/De-Registration screen is displayed with the patient information at the top.

7. In the lower portion of the screen, click on the arrow to the right of the Override Reason field.

8. From the drop-down selection list, select the appropriate override reason.

9. If you select override reason A, enter the details of the reason for the override in the Comments field.


3.6.6. Application of Patient Register Changes

Between the 16th and 17th of the month, the ministry copy of your patient register is updated with the proposed registrations and de-registrations for all patients for whom you did not submit an override.

Registrations and de-registrations accepted by the PHCO become effective on the dates specified in the Pending Registration Changes Report.

3.6.7. Submitting an Administrative Code for Accepted Registrations

The default Administrative Code (0 – Normal) is applied to all registrations accepted by your PHCO. If you wish to change the Administrative Code, you cannot submit the change until the 17th day of the month, after both patient registers (PHCO and ministry copy) have been synchronized.

For more information on administrative codes, refer to Section 3.3.5.


Verifying Your Patient Register SECTION 3 – MANAGING A PATIENT REGISTER

3.7. Verifying Your Patient Register

The ministry strongly recommends that you perform monthly synchronization and verification of the patient register stored in your local software against the ministry’s copy on the 17th day of each month.

This recommendation applies even if your local software provides automatic synchronization. Your PHCO funding is based on the ministry register. A difference in the registers will complicate your verification of payments and ongoing submission of claims.

3.7.1. HNWeb Patient Registration Reports

Through HNWeb, you can access four patient registration reports, as described below.

Pending Registration Changes Report

This report includes all proposed registrations and de-registrations for your PHCO for the current registration review period. The current month’s report is available only from the 5th to the 15th day of the month.

For more information, refer to Section 3.6.3.

PHC Current Registrations Report

This report includes a row of data for each patient currently registered to your PHCO. The data includes an effective date on, or before, the date the report was created and an open-ended cancellation date (indicated by 9999/12/31 in the Cancellation Date field).

This report constitutes the ministry version of your current patient register.

A listing of both current and past registrations is available on the PHC Complete Registration History Report (refer to description below).

For each patient, the PHC Current Registrations Report specifies the:

• patient’s name, PHN, birth date and gender;

• practitioner number of the physician under whose name the patient will be registered (or “99999” if no practitioner is specified);

• patient’s current address, as per MSP/Client Registry records;

• patient’s registration effective date (de-registration date is always 9999/12/31 for open registration records);

• patient’s Administrative Code;

• Cancel Reason Code;

• Registration Reason Code; and

• De-Registration Reason Code.


SECTION 3 – MANAGING A PATIENT REGISTER Verifying Your Patient Register

Use this report to verify that your local copy of the patient register is consistent with the ministry version.

Note: Your local billing software may include a method that allows you to use this file to replace the local data in your system. This is the most accurate way to ensure your local copy is synchronized with the ministry register.

PHC Complete Registration History Report

This report lists all your PHCO’s registration records for the current funding year as of the date the report is run, including:

• all patients currently registered to your PHCO; and

• any patients previously registered to your PHCO in the current funding year, whether or not they are currently registered.

For this reason, there may be multiple rows of data for a patient. For example:

• If a patient was previously registered to your PHCO, de-registered in the current funding year and then re-registered, two registration records will be included in the report showing both the original and latest registration dates.

The cancellation date for open-ended (current) registrations is 9999-12-31.

A patient who was previously registered to your PHCO, but who was de-registered before the current funding year (and has not subsequently been re-registered), will not be listed in the report because the patient's registration history does not impact the current funding year.

The Complete Registration History Report specifies:


• the practitioner number of the practitioner under whose name the patient will be registered (or “99999” if no practitioner is specified);

• the patient’s current address, as per MSP/Client Registry records;

• the patient’s registration effective date (de-registration date is always 9999/12/31 for open registration records);







Recently Applied Registration Changes Report

This report is an audit file of changes to your patient register since the beginning (April 1st) of the current funding year. This date coincides with the earliest date MSP permits changes to your patient registration effective and cancellation dates.

The report contains a “snapshot” of each registration record for your patients as of the instant before a change was made to that record. For instance, if you submit a de-registration record for a patient, this report would show the previous (existing) registration record (without the de-registration effective date or reason) as of the instant before the de-registration was applied. The same is true for registrations and de-registrations applied by the ministry.

HNWeb or Teleplan registration and de-registration transactions permit you to make changes effective only up to 45 days in the past; changes to earlier registration effective and cancellation dates can be made only with the permission of the Primary Health Care Branch. If you wish to change a registration or de-registration date more than 45 days in the past, please contact the Teleplan Support Centre for assistance.

The Recently Applied Registration Changes Report specifies:


• the practitioner number of the practitioner under whose name the patient is registered (or “99999” if no practitioner is specified);

• the patient’s current address, as per MSP/Client Registry records;

• the patient’s registration effective date (de-registration date is always 9999/12/31 for open registration records);





3.7.2. HNWeb Report Download

Accessing HNWeb Patient Registration Reports


2. In the Contents menu on the left-hand side of the screen, click on Request a Report.

3. Click on PHC Current Registrations.

A list of available reports is displayed.



4. Click on the name of the report you wish to request.

The Request a Report – Select Parameters screen is displayed.

5. Change the HNFTP Account, if necessary, by clicking on the down arrow to the right of the HNFTP Account field and selecting an account from the drop-down selection list.

Your HNFTP Account is the electronic mailbox assigned to your PHCO. If you have only one HNFTP Account, the account information is presented in a format that cannot be edited. If you have more than one HNFTP account, the accounts are listed in the drop-down selection list.

PHCO HNFTP accounts consist of a four-character account name, followed by the name of the organization or individual to whom the account is assigned (for example, “paab: Acme Primary Health Care Centre”).

6. If it is not already entered by default, enter your PHCO MSP Payee Number.



7. Select the appropriate Report Format.

Currently all reports are produced in .csv format only.

8. Click on Submit.

It may take several minutes for the report to be created and downloaded to your HNFTP account.

If the request is successful, the message “Report PHC Current Registrations was successfully submitted” is displayed.

9. To see if the report has been downloaded to your HNFTP Account, in the Contents menu, click on File Delivery Service.

The healthnetBC Services Menu is displayed.

10. Click on Secure File Delivery Service.

The Secure File Delivery Screen is displayed showing the contents of your secure inbox.



If the requested report is not listed, wait a few minutes, then click on your Internet browser’s Refresh button to update the list of reports.

A list of the report(s) available is displayed. Each report filename consists of five parts.

For example: sendpaaa.12345rpt01t20030212.csv

sendpaaa “Send” plus the HNFTP account to which the file was directed.

12345 Your PHCO Payee number.

rpt01 A brief title for the report.

T or X “T” = comma separated (.csv) text file; "X" = any other supported file format.

20030212 The date the report was created. If more than one report of the same name is created on the same date, the filename will also include a timestamp.

.csv or .other file extension

csv = comma separated value text file. Other examples include: .doc = Microsoft Word document; .xls = Microsoft Excel spreadsheet; and .pdf = Adobe Acrobat file format.

Note: Other files in your account (for example, physician-specific Chronic Disease registers, performance measures or PHCO quarterly reports) may not use this naming convention.

11. To open a report, click on the report name.

The Open/Save window is displayed, allowing you to open the report or save it to your computer.

The report most recently added to your HNFTP Account appears at the top of the list; any other reports are listed in descending order by date.

12. To clear any checkboxes selected in error, click on Clear (before clicking on Delete.)

13. To permanently delete a report, place a checkmark in the checkbox to the left of the name of the report(s) you wish to delete, then click on Delete.

This causes the files to be permanently deleted from your HNFTP account.

14. To update the list of files in HNFTP Account (to be sure you are receiving the most current contents), click on your Internet browser’s Refresh button.



15. To return to the healthnetBC Services menu (from which you can select the Primary Health Care application), on the menu at the left-hand side of the screen, click on Application List.


SECTION 4 – SUBMITTING CLAIMS Section Contents

SECTION 4 – SUBMITTING CLAIMS

Section Contents 4.1. Overview...............................................................................................................................4-3

4.1.1........Encounter Records Versus Fee-for-Service Claims ..............................................4-3

4.2. Basic Claim and Encounter Record Information ..............................................................4-5 4.2.1........PHCO Single MSP Payee Number........................................................................4-5 4.2.2........Patient Personal Health Number (PHN).................................................................4-5 4.2.3........Practitioner Number...............................................................................................4-5 4.2.4........Services Provided During Patient Encounters .......................................................4-6 4.2.5........ICD-9 Diagnostic Codes ........................................................................................4-6 4.2.6........Facility Identifier.....................................................................................................4-7 4.2.7........Payment Mode.......................................................................................................4-7 4.2.8........Service Location Code...........................................................................................4-7

4.3. Submitting Encounter Records..........................................................................................4-8 4.3.1........Special Fee items ..................................................................................................4-8 4.3.2........MSP Service Verification Audits of Encounter Records.........................................4-9

4.4. Submitting Fee-for-Service Claims ..................................................................................4-10 4.4.1........Fifty Percent Payment Rule .................................................................................4-10

4.5. Conversion of Fee-for-Service Claims/Encounter Records ...........................................4-11 4.5.1........Overview..............................................................................................................4-11 4.5.2........Conversion of Fee-for-Service Claims to Encounter Records..............................4-11 4.5.3........Conversion of Encounter Records to Fee-for-Service Claims..............................4-12 4.5.4........Conversion of Claims after Backdating of a Registration .....................................4-12

Backdating of Registrations by the Ministry................................................................ 4-12 Backdating of Registrations by a PHCO..................................................................... 4-13

4.6. Submitting Call-Out Services ...........................................................................................4-14

4.7. Third Party Billings............................................................................................................4-15

4.8. Direct Patient Billing for Non-Benefit Services ...............................................................4-16

4.9. Locums...............................................................................................................................4-17

4.10. Patients Referred to the PHCO for Pre-Natal Care..........................................................4-18

4.11. Services Provided to a Newborn ......................................................................................4-19

4.12. Submitting Claims for Hospitalized Patients...................................................................4-20

4.13. Recording No Charge Referrals .......................................................................................4-21

4.14. Recording Methadone Treatment for a Registered Patient............................................4-22

4.15. Definition of Formal / Informal Case Management for PHCOs ......................................4-23


Section Contents SECTION 4 – SUBMITTING CLAIMS Section Contents SECTION 4 – SUBMITTING CLAIMS



SECTION 4 – SUBMITTING CLAIMS Overview

4. Submitting Claims

4.1. Overview

Accurate submission of claims data, accompanied by appropriate and detailed diagnostic codes, is critical to a PHCO’s business. Correct submission of claims data ensures accurate funding payments. Comprehensive diagnostic coding ensures appropriate ACG assignments for registered patients.

PHCOs report each service delivered (core, extended or other service) to each patient (registered or non-registered) using their single PHCO MSP Payee Number.

The requirements for reporting patient data fall within the bounds of the Adequate Medical Record as set out in the Medicare Protection Act. All PHCOs are required to establish and maintain an adequate medical record for each patient seen and to record each encounter with a patient.

Information must be reported whether the service is delivered by a PHCO physician, locum or another PHCO practitioner, such as a social worker, dietician, physical therapist or administrative support staff member.

PHCOs submit fee-for-service claims or encounter records, depending upon the patient’s insurer, the type of service provided and whether or not the patient is registered to the PHCO.

Encounter records have a paid amount of $0. Fee-for-service claims submitted by PHCOs are paid at the usual fee-for-service rate unless the claim is subject to the 50% payment rule.

For more information on the 50% payment rule, refer to Section 4.4.1.

To assist PHCOs, the Medical Services Plan (MSP) examines each claim submitted by a PHCO to verify that it has been submitted appropriately. If necessary, and if the claim or record meets certain criteria, MSP will automatically convert an encounter record to a fee-for-service claim, or vice versa.

For more information on the conversion of records and claims, refer to Section 4.5.

4.1.1. Encounter Records Versus Fee-for-Service Claims

PHCOs submit either encounter records or fee-for-service claims depending on:

• the patient’s insurer (Medical Services Plan or a third party such as the Insurance Corporation of BC or the Workers’ Compensation Board);

• whether the patient is registered or non-registered; and

• the type of service provided (core, extended or other service).


Overview SECTION 4 – SUBMITTING CLAIMS

Data Collection / Reporting

TelePlan / MSP Claims

Health Registry Secure Web Site

Patients

Patient Register for PHCO

Entire Patient population covered by BC Medical Services Plan

Catchment area for PHCO

PHCO

Billing & Data Submission

Encounter Record

Fee for Service


Patient Register Modification

Delive

rs Serv

iceCore Services – 50% rule applies

Core and Non-Core Services

Core Services

Non-C

ore S

ervic

es

Non-Core Services

Registration Record


Data Collection / ReportingData Collection / Reporting

TelePlan / MSP Claims

Health Registry Secure Web SiteHealth Registry Secure Web Site

Patients

Patient Register for PHCOPatient Register for PHCO

Entire Patient population covered by BC Medical Services Plan


PHCO

Billing & Data SubmissionBilling & Data Submission

Encounter Record

Fee for ServiceFee for Service


Patient Register Modification

Delive

rs Serv

iceCore Services – 50% rule applies

Core and Non-Core Services

Core Services

Non-C

ore S

ervic

es

Non-Core Services

Registration Record


Figure 4-1 Submission of Fee-for-Service Claims and Encounter Records

The situations in which a fee-for-service claim or encounter record is appropriate are indicated below:

Services provided by a physician

Patient Status Core Service Extended service Other Service

Registered $0 Encounter record* $0 Encounter record* Fee-for-service Non-Registered Fee-for-service Fee-for-service

*MSP converts fee-for-service claims submitted for core services to registered patients into encounter records if the insurer is the Medical Services Plan and the primary provider specified is a physician. Fee-for-service claims should not be submitted for extended services (MSP will refuse the claim). For more information on the conversion of claims, refer to Section 4.5.

Services provided by a non-physician

Patient Status Core Service Extended service Other Service

Registered $0 Encounter record* $0 Encounter record* Non-Registered

*Non-physicians should be identified as the primary provider only on encounter records submitted for core or extended services to registered patients. Specifying a non-physician under any other circumstance (indicated by the shaded areas in the table above) will result in loss of income to your PHCO.

Complete Teleplan Specifications, including Appendix C: Primary Health Care Project Teleplan Specifications and Special Record Formats, are available on the MSP Web site at www.healthservices.gov.bc.ca/msp/infoprac/teleplanspecs/index.html.


www.healthservices.gov.bc.ca/msp/infoprac/teleplanspecs/index.html

SECTION 4 – SUBMITTING CLAIMS Basic Claim and Encounter Record Information

4.2. Basic Claim and Encounter Record Information

PHCO fee-for-service claims and encounter records follow the usual Teleplan fee-for-service claim record format. However, PHCOs may use certain standard fields differently than non-PHCOs; other fields have been expanded to allow PHCOs to enter more information than is normally included in a fee-for-service claim. These differences are described below.

4.2.1. PHCO Single MSP Payee Number

Submit all fee-for-service claims and encounter records using your PHCO’s MSP Payee Number. If you use any other Payee Number for a fee-for-service claim for a registered patient, it will be treated as a service outflow (i.e., the paid amount of the claim will be deducted from your population-based funding).

4.2.2. Patient Personal Health Number (PHN)

To facilitate the recording of patient participation in group counseling or other group sessions, PHCOs may enter up to ten PHNs for a single fee-for-service claim or encounter record.

Currently, payment of fee-for-service claims is made only for the first PHN reported.

4.2.3. Practitioner Number

The Practitioner Number is a required field for both fee-for-service claims and encounter records. On fee-for-service claims, the practitioner must be a physician.

However, PHCOs operate under an interdisciplinary team approach and a registered patient may be treated by both physicians and non-physicians in a single encounter. To reflect this, PHCOs can report up to four practitioner numbers, both for physicians and non-physicians, in a single encounter record.

Physicians continue to use their existing MSP practitioner numbers. As explained in Section 2.8.3, other PHCO practitioners must apply to MSP for a practitioner number, if they have not already done so.

When PHCO practitioners work as a team (serving different team functions) during a patient encounter, submit one encounter record identifying all practitioners. For example, if a nurse completes all the preparatory work for a physician, identify the physician as the primary practitioner and the nurse as the secondary practitioner when submitting a single encounter record.

When PHCO practitioners work independently (regardless of whether they provide identical, similar or unrelated services), submit a separate encounter record for each practitioner and service.


Basic Claim and Encounter Record Information SECTION 4 – SUBMITTING CLAIMS

All services count equally, whether you submit a single encounter record listing multiple practitioners or multiple encounter records, each listing only one practitioner.

Important: If a physician participates in the treatment of a registered patient, report the physician as the primary practitioner. This allows the encounter record to be converted, if necessary, to a fee-for-service claim.

For more information on the conversion of claims and records, refer to Section 4.5.

Note: A summary of payments to each practitioner is included in each semi-monthly remittance (payment) statement returned to the PHCO via Teleplan.

4.2.4. Services Provided During Patient Encounters

In addition to the fee codes defined in the Medical Services Commission’s fee-for-service payment schedule, which includes PHCO core services, additional codes have been defined for PHCO extended services. When submitting encounter records, PHCOs should use core and extended service codes, as appropriate.

The list of core and extended service codes is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html under the Data Submission section.

4.2.5. ICD-9 Diagnostic Codes

PHCOs can record up to three ICD-9 codes for each fee-for-service claim or encounter record.

Only one ICD-9 code is required per claim or record, however, it is strongly recommended that all diagnoses established during a patient encounter be reported. Population-based funding is predicated on ACG assignments based on ICD-9 codes, so precise reporting of diagnostic codes results in more accurate funding calculations.

When submitting an ICD-9 code, enter all five digits of the code to ensure the most accurate ACG assignments for the patient.

Use the following definitions as a guide when reporting up to three ICD-9 codes:

Main Diagnostic Code: Mandatory

This code represents the principle diagnosis; the patient’s condition as established after assessment. It should indicate the diagnosis that is the primary reason for the patient’s visit to the PHCO, the most severe diagnosis and the diagnosis demanding the most resources.

Second Diagnostic Code: Optional

This code represents a patient condition that co-exists with the main diagnosis (e.g., a chronic underlying condition).

Third Diagnostic Code: Optional

This represents another patient condition identified during the visit at the PHCO.

Diagnostic coding guidelines are available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html under the Data Submission section.




SECTION 4 – SUBMITTING CLAIMS Basic Claim and Encounter Record Information

4.2.6. Facility Identifier

MSP assigns a unique facility identification number to each PHCO. This identifier captures the location at which service is provided. Most PHCOs have only one Facility Identifier. Your billing software may allow you to set a default facility identifier for all claims and records.

A PHCO with more than one Facility Identifier (i.e., one which delivers services to patients at more than one location) must have software capable of allowing them to select the appropriate facility for each record submitted.

4.2.7. Payment Mode

When submitting an encounter record, use Payment Mode E. Fee-for-service claims use the default Payment Mode 0.

The payment mode may be automatically applied by your software. For more information, contact your software vendor.

4.2.8. Service Location Code

This field indicates the location at which service was provided to the patient. As of February 2004, the following service location codes were available:

R Patient’s residence

O Physician’s office

C Continuing Care Facility H Hospital

I Hospital Inpatient E Hospital Emergency Department or Diagnostic and Treatment Centre P Outpatient D Diagnostic Facility S Community Location (e.g., temporary clinic, school or church)

Z None of the above (e.g., an ambulance, accident site)

Note that MSP discourages the use of the service location code H. Wherever possible use the more specific code I, E or P.

For the most current list of service location codes, contact the Teleplan Support Centre at the telephone number provided in Section 1.9.1.


Submitting Encounter Records SECTION 4 – SUBMITTING CLAIMS

4.3. Submitting Encounter Records

The term “patient encounter” refers to any event in which a physician or other PHCO practitioner provides a core or extended service to a registered patient, in person or by telephone.

Payment for services to registered patients is provided under your population-based funding agreement, so encounter records have a paid amount of $0.

Submit an encounter record when:

• the insurer is MSP;

• the patient is a registered with your PHCO;

• the practitioner providing the service is a PHCO physician or other PHCO practitioner; and

• the service provided is a core or extended service.

Submit all encounter records with:

• a Claim Payment Mode of E

• a billed amount of $0.

The payment mode may be automatically applied by your software. For more information, contact your software vendor.

Under certain circumstances, MSP may convert an encounter record to a fee-for-service claim or vice versa. For more information on the conversion of claims and records, refer to Section 4.5.

4.3.1. Special Fee items

Normally, core services to registered patients are paid only under population-based funding, not fee-for-service. To compensate PHCOs appropriately, however, the ministry has identified five core services as “special fee items” for which PHCOs receive an additional amount for each encounter recorded.

Each special fee item has a corresponding base fee item in the Medical Services Commission fee schedule. When a PHCO submits an encounter record for a special fee item, they are credited with their regular population-based funding plus the difference between the scheduled amount and the base fee code scheduled amount.

If, for example, your PHCO submits an encounter record for a long-term care institution visit (fee code 13114), your PHCO is credited with the difference between the scheduled amount for that fee code ($43.48) and the scheduled amount for the base fee code 00114 ($21.74)—resulting in an additional payment of $21.74.


SECTION 4 – SUBMITTING CLAIMS Submitting Encounter Records

The following table indicates how the premium for each special fee item is calculated.

Fee Code

Fee Item Description

Scheduled Amount

Related Base Fee

Code

Base Fee Code

Scheduled Amount

Premium Paid (per reported encounter)

13015 HIV/AIDS Primary Care Management performed in or out of office – Per ½ hour or major portion

$50.00 00100 $27.90 $22.10

13108 Hospital Visit - First routine visit of the day

$62.62 00108 $31.31 $31.31

13114 Long Term Care Institution Visit – First visit of the day

$43.48 00114 $21.74 $21.74

13127 Hospital Visit For Terminal Care –First visit of the day

$62.62 00127 $31.31 $31.31

13128 Supportive Care – First in-hospital visit of the day

$53.02 00128 $26.51 $26.51

The above information is current as of May 2004.

The total amount credited for special fee items is included on the summary page of your Quarterly Report under Adjustments for Special Fee Items.

4.3.2. MSP Service Verification Audits of Encounter Records

Each year, MSP conducts Service Verification Audits which consist of letters sent to a sampling of patients asking them to confirm that a service was provided by a specific practitioner on a specific date.

The MSP Service Verification Audit group has access to the complete list of PHCO core and extended service codes and is aware of the PHCO interdisciplinary and blended funding model policies. Therefore, services provided to a registered patient by a non-physician are not treated as an irregularity.


Submitting Fee-for-Service Claims SECTION 4 – SUBMITTING CLAIMS

4.4. Submitting Fee-for-Service Claims

Submit a fee-for-service claim when:

• the insurer is MSP, or a third party such as ICBC, WCB, or another province;

• the practitioner providing the service is a PHCO physician;

• the service provided is:

• a core or extended service to a non-registered patient, or

• any service other than a core or extended service to any patient.

Under certain circumstances, MSP may convert a fee-for-service claim to an encounter record.

For more information on the conversion of claims and records, refer to Section 4.5.

4.4.1. Fifty Percent Payment Rule

If a non-registered patient lives in your PHCO catchment area:

• Your PHCO receives 100% of the fee-for-service payment only for the first two core services provided to the patient during a half calendar year (January through June or July through December).

• For any additional core services provided to the non-registered patient within the same half calendar year, your PHCO receives 50% of the fee-for-service payment.

• In the next half calendar year, the fee-for-service payments for the first two core services will again be paid at 100%.

Under the circumstances described above, the ministry may propose the patient for registration during the monthly registration process, if the patient has not also received core services outside the PHCO but within the PHCO catchment area.

For more information on the monthly registration process, refer to Section 3.6.


SECTION 4 – SUBMITTING CLAIMS Conversion of Fee-for-Service Claims/Encounter Records

4.5. Conversion of Fee-for-Service Claims/Encounter Records

4.5.1. Overview

To reduce the number of refusals a PHCO receives and to accommodate the backdating of patient registrations, MSP has the ability to convert fee-for-service claims to encounter records and vice versa when:

• the claim or record meets normal processing rules; and

• the practitioner specified is a physician.

When MSP identifies a PHCO as the originator of a fee-for-service claim or encounter record, it analyzes the claim or record according to specific criteria. If a fee-for-service claim or encounter record meets the criteria for conversion, MSP automatically converts it appropriately.

Not all extended service codes can be converted. The twenty-two extended service codes that can be converted to their fee-for-service code equivalent, subject to the criteria above, are identified on the core and extended service list. The list is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/pdf/phc_core_extended_codes.pdf.

Most conversions occur as part of regular claims processing. The remainder occur as a result of backdated registration dates proposed by the ministry during the monthly registration review.

Claims converted through the regular claims processing and remittance process are returned to the PHCO with an explanatory code indicating the type of conversion. The explanatory codes used are provided in Sections 4.5.2 and 4.5.3, below.

If a patient’s registration is backdated, fee-for-service claims for core services to the patient as far back as the most recent open fiscal year may be converted to encounter records. The number of converted claims is reported quarterly, however, some of the conversions indicated may be for a claim(s) submitted before the timeframe of the report.

4.5.2. Conversion of Fee-for-Service Claims to Encounter Records

A fee-for-service claim is converted to an encounter record if:

• the patient is insured by MSP;

• a physician provided the service; and

• the fee-for-service claim is for a core service to a registered patient.

Note: Fee-for-service claims converted to encounter records are flagged with the explanatory code “RK.” All converted claims and records appear on the semi-monthly Teleplan remittance as “Paid with Adjustment” claims.


www.healthservices.gov.bc.ca/phc/pdf/phc_core_extended_codes.pdf

Conversion of Fee-for-Service Claims/Encounter Records SECTION 4 – SUBMITTING CLAIMS

4.5.3. Conversion of Encounter Records to Fee-for-Service Claims

An encounter record is converted to a fee-for-service claim if:

• the patient is insured by MSP;

• a physician provided the service; and

• the encounter record is for a core service or extended service1 to a non-registered patient or for a non-core service to a registered patient.

Note: Encounter records converted to fee-for-service claims are flagged with the explanatory code “RG.” All converted claims and records appear on the semi-monthly Teleplan remittance as “Paid with Adjustment” claims.

4.5.4. Conversion of Claims after Backdating of a Registration

Backdating of Registrations by the Ministry

If your PHCO has registered a patient during the previous month, the ministry may propose an earlier registration effective date during the monthly registration review process.

When the ministry receives a registration record, it reviews previous fee-for-service claims for core services to the patient (by all providers) in reverse chronological order. If your PHCO has provided the patient with one or more consecutive core services (uninterrupted by services from other providers) immediately preceding the registration date you submitted, the ministry backdates the registration effective date.

The registration effective date proposed will be the date of the earliest consecutive service provided by your PHCO, bounded by the start of the earliest open fiscal year. If the earliest consecutive service occurred before the start of the fiscal year, the ministry will backdate the registration effective date to the start of the fiscal year (April 1).

Note: As described in Section 5.1.1, annual reconciliation (closing) of a fiscal year usually occurs in November of the following fiscal year.

If your PHCO accepts the backdated registration date, at the end of the next quarter, your PHCO’s population-based funding for the patient will be calculated from the accepted registration date. Any fee-for-service claims for core services to the patient that your PHCO submitted after the registration effective are converted to encounter records. The value of the fee-for-service claims is deducted.

1 If no fee-for-service equivalent exists for an extended service, the encounter record is accepted as submitted.


SECTION 4 – SUBMITTING CLAIMS Conversion of Fee-for-Service Claims/Encounter Records

Example:

Fee-for-service claims for a

non-registered patient

PHCO Visit Non-PHCO Visit

Fiscal Year A January 1

Fiscal Year A February 1

Fiscal Year A March 1

Fiscal Year B June 1

In the above example, Fiscal Year A remains open. Therefore, the ministry would propose a registration effective date of March 1, Fiscal Year A.

If the PHCO accepts the backdated registration, the PHCO’s population-based funding for that patient is re-calculated after the end of the next quarter to reflect the change in the patient’s registration effective date. The PHCO therefore receives population-based funding for the patient from March 1, Fiscal Year A.

The fee-for-service claims for core services submitted on March 1 of Fiscal Year A and June 1 of Fiscal Year B are converted to encounter records (i.e., the fee-for-service payments for those services is deducted from the PHCO’s quarterly payment).

Backdating of Registrations by a PHCO

PHCOs may also backdate registrations. When submitting a registration record, a PHCO can select a date up to 45 days before the system date.

When a registration is backdated, any fee-for-service claims for core services that the PHCO submitted for that patient after the date of the registration are converted to encounter records. The PHCO receives population-based funding for the patient.


Submitting Call-Out Services SECTION 4 – SUBMITTING CLAIMS

4.6. Submitting Call-Out Services

Under Medical Services Commission (MSC) rules, call-out charges apply only when:

• a physician is specially called to render emergency or non-elective services, and

• only if the physician must travel from one location to another to attend to the patient(s).

MSC rules also state that the call-out charge applies:

• only to the first patient examined or treated on any one visit, and

• to each special call-out whether or not a previous call-out charge has been billed for the same patient on the same day.

As of February 2004, only the following call-out fee codes are treated as PHCO core services and only if the call-out is for a core service to a registered patient:

01200 Service Charge 01205 Surcharge 01201 Service Charge 01206 Surcharge 01202 Service Charge 01207 Surcharge

For example, submit a call-out for a core service to a registered patient as an encounter record; submit a call-out for any other service to a registered patient as a fee-for-service claim.

Submit separate claims/records for the call-out and the service performed. You cannot record both the call-out and the service in the same fee-for-service claim or encounter record because each record supports only a single fee code.

When service is provided to a patient by a PHCO practitioner on a call-out, record it as follows:

Service provided on the call-out Record as

Core service to a registered patient Record both the call-out and the service separately, as encounter records.

Other service to a registered patient Record both the call-out and the service separately, as fee-for-service claims.

Core service to a non-registered patient Record both the call-out and the service separately, as fee-for-service claims.

Other service to a non-registered patient Record both the call-out and the service separately, as fee-for-service claims.


SECTION 4 – SUBMITTING CLAIMS Third Party Billings

4.7. Third Party Billings

Third party billings include claims for medical services provided to out-of-province residents and for ICBC and WCB claims.

When the insurer is a third party, PHCOs submit a fee-for-service claim through MSP and retain 100% of the funds paid.

Third party fee-for-service billings are paid as per usual MSP processing; MSP recovers payment directly from the third party agency (e.g., ICBC). If the third party insurer refuses responsibility for the claim and the claim is for a core service to a registered patient, MSP will debit the PHCO for the fee-for-service payment and create an encounter record (showing $0 payment) to PHCO.

Any such changes would be reflected in the next PHCO remittance statement.

For more information, refer to the “Teleplan Explanatory Codes - PHC Specific” document which is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc /infosites.html under the Teleplan section.


www.healthservices.gov.bc.ca/phc

Direct Patient Billing for Non-Benefit Services SECTION 4 – SUBMITTING CLAIMS

4.8. Direct Patient Billing for Non-Benefit Services

Physicians may bill registered and non-registered patients directly:

• for services that are not a benefit established under the Medical Services Commission (MSC) Payment Schedule.

• under the usual guidelines as established by the MSC and MSP (for example, if the patient has opted out of MSP or has no coverage).

For information on non-benefit services, visit the MSP Web site at www.healthservices.gov.bc.ca/msp/infoben/benefits.html.


www.healthservices.gov.bc.ca/msp/infoben/benefits.html

SECTION 4 – SUBMITTING CLAIMS Locums

4.9. Locums

When a physician temporarily stands in for another physician, compensation for the replacing physician (locum) must be negotiated between the locum and the PHCO.

To ensure that the services that locums provide to your registered patients are not treated as service outflows:

• Assign the locum’s Practitioner Number to the PHCO MSP Payee Number, specifying the period for which the locum will provide service to PHCO patients.

For more information on assignment of payments to the PHCO MSP Payee Number, refer to Section 2.8.5.

• Ensure that encounter records and fee-for-service claims for the services provided by the locum are submitted using the locum’s practitioner number and the PHCO Payee Number.

Locums working under the PHCO Payee Number are not paid on a fee-for-service basis for core services they deliver to registered patients. If fee-for-service claims are submitted for these services, the claims will be converted to encounter records and paid at $0.

The ministry policy regarding locums is as follows:

• Locums cannot submit fee-for-service claims for core services to registered patients if they are billing under the PHCO Payee Number.

• Locums working under another Payee Number will submit fee-for-service claims for services to registered patients and those billings will be treated as service outflows to the PHCO.

• If a locum uses the PHCO Payee Number to bill fee-for-service for two or more consecutive services to non-registered patients, those patients will be automatically recommended for registration as part of the monthly registration review.

For more information on the monthly registration review, refer to Section 3.6.

• If a locum uses the PHCO Payee Number to bill fee-for-service for two or more consecutive core services to a non-registered patient, fee-for-service payment for the third and subsequent core service will be reduced to 50% (as per the standard policy on fee-for-service billings for core services to non-registered patients).



Patients Referred to the PHCO for Pre-Natal Care SECTION 4 – SUBMITTING CLAIMS

4.10. Patients Referred to the PHCO for Pre-Natal Care

Women who are referred to your PHCO for prenatal care by their family physician and who will return to their family physician after delivery will not become registered patients of your PHCO.

Because these patients will remain non-registered, submit fee-for-service claims.

To ensure the fee-for-service claims are processed without reduction to 50% payment for the third and subsequent claims, ensure that each fee-for-service claim contains the appropriate information:

• Your PHCO Payee Number.

• A valid referring Practitioner Number identifying the physician who referred the patient to your PHCO.

The referring Practitioner Number allows the claim to be processed by MSP and prevents the payment from being reduced to 50%.

• A service location code of P (Outpatient).



SECTION 4 – SUBMITTING CLAIMS Services Provided to a Newborn

4.11. Services Provided to a Newborn

If you have a Personal Health Number (PHN) for the newborn:

• Use the newborn’s PHN and register the newborn to your PHCO as soon as possible.

Do not register a newborn until you have a PHN for the child.

If the newborn does not have a PHN:

If you believe a PHN may have been assigned for the infant, conduct a PHN search using HNWeb as described in Section 3.2.2. If no PHN is found:

• Submit a fee-for-service claim:

• Use the mother’s PHN with dependent code 66

• Include a note record explaining that the newborn does not have a PHN.

If you require information on how to submit information in a note record, please contact your software vendor.

Claims for newborns not registered to your PHCO are subject to the 50% payment rule.


• When the newborn has a PHN:

• Use the newborn’s PHN and register the newborn to your PHCO.

• Backdate the registration date to the newborn’s date of birth.

If the newborn’s date of birth is more than 45 days earlier than the date on which you will submit the registration, contact the Teleplan Support Centre in Victoria at (250) 952-2668 or, from elsewhere in BC, 1-800-663-7206.

Your PHCO will receive population-based funding for the newborn from the date of registration.


Submitting Claims for Hospitalized Patients SECTION 4 – SUBMITTING CLAIMS

4.12. Submitting Claims for Hospitalized Patients

Services delivered to hospitalized patients are reported in the usual manner; that is, as encounter records or fee-for-service claims according to the service provided and the registration status of the patient.

The only change to normal submission occurs when a hospitalized patient’s general practitioner is unavailable or does not have hospital privileges and the patient is therefore treated by a PHCO physician acting as a hospital’s “Doctor of the Day.”

When a PHCO physician who is acting as “Doctor of the Day” at a hospital delivers a core service to a non-registered patient, submit the following additional information to ensure the fee-for-service claim will not be subject to the 50% payment rule:

• A valid referring Practitioner Number identifying the physician who referred the patient to the PHCO practitioner for in-hospital care.

If no valid referring Practitioner Number is available, use the Practitioner Number 99997. This ID may be used only as a referring physician ID and does not belong to an actual practitioner.

By providing the referring Practitioner Number, the claim can be processed by MSP and the 50% payment rule will not be applied.

• The service location code H (Hospital), I (Inpatient), E (Emergency or Diagnostic and Treatment Centre) or P (Outpatient).

Note that MSP discourages the use of the more non-specific service location code H. Wherever possible use the more specific code I, E or P.

• A note record containing a brief description of the nature of the service (e.g., “doctor of the day patient” and the name of the hospital at which service was provided).



SECTION 4 – SUBMITTING CLAIMS Recording No Charge Referrals

4.13. Recording No Charge Referrals

In order for a specialist to be paid, a patient must be referred to the specialist by another physician. For this reason, whenever a patient is referred to a specialist, whether or not other services are provided to the patient simultaneously, the referring physician must submit a $0 charge claim or record for the referral.

PHCOs should submit a No Charge Referral (fee code 03333) for any patient as a fee-for-service claim.


Recording Methadone Treatment for a Registered Patient SECTION 4 – SUBMITTING CLAIMS

4.14. Recording Methadone Treatment for a Registered Patient

Methadone Treatment (fee code 00039) is not a core PHCO service.

Therefore:

• If methadone treatment is the only reason for a registered patient’s visit to the PHCO, submit a fee-for-service claim.

• If methadone treatment is provided to a registered patient as part of a single encounter that included other services, report each service separately (i.e., for any core or extended service, submit an encounter record. For other services, submit fee-for-service claims).

Note: If separate fee-for-service claims are submitted for the same patient on the same day, the fee-for-service claim for methadone treatment will be refused on the basis that it constitutes a second visit. This does not occur when the core or extended services are submitted as encounter records.

For example, submit an office visit with a registered patient using the most appropriate core service encounter code (e.g., 96xxx series, 00100, 13100); report the methadone treatment as a separate fee-for-service claim (00039).


SECTION 4 – SUBMITTING CLAIMS Definition of Formal / Informal Case Management for PHCOs

4.15. Definition of Formal / Informal Case Management for PHCOs

Both formal and informal case management are PHCO extended services.

Formal case management refers to contact with health or non-health professionals or agencies external to the patient’s environment.

Informal case management involves contact with the patient’s family, friends or non-professional care providers to arrange for services or support for the patient.

The definitions of these services are:

Formal Case Management (96008): Multiple telephone calls to develop a comprehensive service plan, link the patient to the required services, coordinate and maintain links with formal (health or non-health professionals or agencies) resources/services/supports external to the patient’s environment, and evaluate services provided. May include activities such as searching for appropriate resources and negotiating with potential providers (e.g., probation officers, child and family services, social assistance, education, housing, etc.).

Informal Case Management (96009): Multiple telephone calls to develop a comprehensive service plan, link the patient to the required services, coordinate and maintain links with informal (i.e., family, friends, or non-professional care providers) resources/services/supports within the patient’s environment, and evaluate services provided.

Definitions for extended service codes are available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html, under the Data Submission section.



Definition of Formal / Informal Case Management for PHCOs SECTION 4 – SUBMITTING CLAIMS Definition of Formal / Informal Case Management for PHCOs SECTION 4 – SUBMITTING CLAIMS



SECTION 5 – PHCO PAYMENTS PROCESS Section Contents

SECTION 5 – PHCO PAYMENTS PROCESS

Section Contents

5.1. Quarterly and Annual Payment and Reconciliation..........................................................5-3 5.1.1. .....Payment Process...................................................................................................5-3 5.1.2. .....Quarterly Reports ..................................................................................................5-5

Calculation of Adjustment Report ............................................................................ 5-5 List of Adjustment Payments Report ............................................................................ 5-6 Financial Reports ........................................................................................................ 5-6 Patient Registrations ................................................................................................. 5-6 Service Outflows ........................................................................................................ 5-6 Service Utilization ...................................................................................................... 5-6

5.1.3. .....Annual Reconciliation Reports...............................................................................5-7

5.2. Calculations .........................................................................................................................5-8 5.2.1. .....Overview................................................................................................................5-8 5.2.2. .....Adjusted Clinical Group (ACG) Daily Rate.............................................................5-9

ACG Assignments ........................................................................................................ 5-9 Annual Calculation of the ACG Daily Rate ................................................................... 5-9 “Special Needs” Patients ............................................................................................ 5-10

5.2.3. .....Estimated Service Outflow Calculations ..............................................................5-10 5.2.4. .....Actual Service Outflows and the Stability Fund ...................................................5-11


Section Contents SECTION 5 – PHCO PAYMENTS PROCESS


SECTION 5 – PHCO PAYMENTS PROCESS Quarterly and Annual Payment and Reconciliation

5. Payments

5.1. Quarterly and Annual Payment and Reconciliation

5.1.1. Payment Process

Projected annual ACG income for the PHCO is calculated at the outset of the fiscal year. This projection is included in the PHCO contract, however, actual payments are revised based on quarterly estimates as described below.

Estimated ACG income for the first quarter of the fiscal year is calculated at the outset of the fiscal year (April 1). It is then re-calculated quarterly to provide the estimated ACG income for the remaining quarters in the fiscal year.

CURRENT FISCAL YEAR

Quarterly AdvanceCalculated:

Estimated ACGIncome for Next

Quarter Calculated

Bi-MonthlyInstallments of

Quarterly Advancepaid via Teleplan -

Adjustment 65

Perform AnnualAssignment of ACGs& Calculation of ACG

Daily Rate

Calculate PreviousYear's Stability Fund,

AnnualReconciliation &Final FundingAdjustments

Perform QuarterlyReconciliation:

Actual ACG Incomeversus Estimate -paid via Teleplan

Adjustment 67

Apr. May Jun July Aug Sep Oct Nov Dec Jan. Feb. Mar. Apr May Jun July Aug Sep Oct

NEXT FISCAL YEAR

Nov

Payout of PreviousYear's Stability Fund,Annual Reconciliatiion& Final Adjustments

via TeleplanAdjustment 67

Figure 5-1 Payments Process


Quarterly and Annual Payment and Reconciliation SECTION 5 – PHCO PAYMENTS PROCESS

As shown in Figure 5-1, each quarterly advance is divided into six equal installments which are paid semi-monthly to the health authority/PHCO (as per contractual arrangements) through Teleplan, in accordance with the payment schedule established by the Medical Services Plan (MSP). Quarterly payments are identified as Adjustment Code 65.

The semi-monthly remittances include:

• estimated ACG income (minus estimated service outflows) for core and extended services to registered patients insured by MSP (Adjustment 65);

• actual fee-for-service income for other services to registered patients and all services to non-registered patients; and

• payments for third party billings submitted under the PHCO Payee Number.

Quarterly reconciliation occurs approximately six weeks after the end of each quarter (e.g., August 15, November 15, February 15 and May 15). At these times, ACG income is re-calculated to account for actual patient registrations and de-registrations and for service outflows.

If the actual ACG income earned is greater than the amount that was estimated and paid in the previous quarter (Adjustment 65), a payment adjustment is generated for the difference. This amount (identified as an Adjustment 67) is paid to the PHCO on the semi-monthly remittance directly following quarterly reconciliation (i.e., the second semi-monthly remittance of the next quarter). If the actual ACG income earned for that period is less than the amount that was paid, the adjustment (a deduction) will be made on the final payment at fiscal year end.

Note: When a patient is registered or de-registered for a date in the past, the PHCO may have submitted claims for the patient after the new effective date of their registration or de-registration but before the day it was entered into the system. This will result in conversion of encounter records or fee-for-service claims that necessitate a funding adjustment. The number of converted claims and records is indicated in the Quarterly Reports. For more information on the conversion of encounter records to fee-for-service claims, refer to Section 4.5.

The annual assignment of ACGs and the calculation of the ACG daily rate (which determines ACG income for the current fiscal year) occurs in July. Adjustments resulting from changes in ACG daily rates are incorporated into the August quarterly reconciliation. The rates are applied retroactively to the start of the fiscal year.

Annual reconciliation is undertaken seven months after the end of the fiscal year (November), when the majority of claims for the previous fiscal year have been processed. Annual funding adjustments include:

• ACG Funding: The total ACG income for all registered patients.

• Service Outflows: The total value of service outflows.

• Quarterly Advances (Adjustment Code 65): The total amount advanced to the health authority/PHCO for each quarter during the fiscal year.



• Payments for Quarterly Adjustments (Adjustment Code 67): Amounts credited for actual ACG income earned in excess of the quarterly advances that have been paid throughout the year.

• Adjustments for Claims Conversions: The total value of fee-for-service claims converted to and paid as encounter records (paid at 0) and the total value of encounter records converted to and paid as fee-for-service.

• Adjustments for Special Fee Items: The total value of the Special Fee Items claimed during the fiscal year.

• Stability Fund Amount: The amount credited to the PHCO if the total service outflow per patient has exceeded the patient’s annual ACG amount. The Stability Fund ensures that the PHCO will never receive less than zero funding for a patient.


The Teleplan remittance in which the year end adjustments appear also includes the usual semi-monthly advance (Adjustment 65) to the PHCO for the current quarter.

Year end adjustments (identified as Adjustment 67) appear on the Teleplan remittance immediately following the year end close off (usually November 15th or 30th).

5.1.2. Quarterly Reports

Quarterly reports for the year-to-date are prepared for PHCOs and made available through HNWeb approximately six weeks after the close of the fiscal quarter (after the 16th day of the relevant month). PHCOs and health authorities are notified through the PHCO Listserv when the reports are available. The reports detail services provided and income generated from all sources, including fee-for-service payment.

Calculation of Adjustment Report

REPORT ITEM DESCRIPTION

Net ACG Income This is ACG income for the year to date less the amount for service outflows.

Payments Received for the Period

Amounts paid during the year to date.

Adjustment 65: The quarterly advance paid to the PHCO.

Adjustment 67: An adjustment that reflects actual ACG income for the year to date and actual service outflows.

Pay Mode Adjustments The amounts for any fee-for-service claims that were converted to encounter records and vice-versa.

Adjustment for the Period Ending…

The Amount of Adjustment is the final adjustment for the year to date. This amount reflects adjustments for outflows, advances, and special fees and pay mode adjustments.

Status of the Stability Fund The status of the Stability Fund as of the year to date. The Stability Fund ensures that a PHCO never receives less than zero ACG income for a patient as a result of service outflows.


Quarterly and Annual Payment and Reconciliation SECTION 5 – PHCO PAYMENTS PROCESS

List of Adjustment Payments Report

REPORT ITEM DESCRIPTION

Not applicable A listing of all amounts paid and advanced to the PHCO by the adjustment code and paid date, for the year to date.

Financial Reports

REPORT DESCRIPTION

Payments for Service of Registered Patients By Number of Episodes with PCO

A breakdown of ACG income and service outflows for the PHCO’s registered patients by number of episodes or days a patient received one or more core or encounter services, during this year to date.

Outflows for Registered and Deregistered Patients

Service outflows information for both registered and de-registered patients during the year to date.

Outflow as a Percentage of ACG Amount

For the year to date, a breakdown of service outflows per month as a percentage of the ACG amounts.

Total Income Over Time For the year to date, a breakdown by month of the number of registered patients, corresponding amounts for ACG income, service outflows, Stability Fund, and fee-for-service and Special Fee Item income.

Patient Registrations

REPORT DESCRIPTION

Registered Patients Over Time For the year to date, a breakdown by month of patient registrations and de-registrations.

PCO Quarterly Review Activity The number of additional patient registrations for the most recently completed monthly patient review and the number of patient de-registrations, by reason, for the year to date.

Distribution of Registered Patients Distribution of registered patients by age/gender for the year to date.

Service Outflows

REPORT DESCRIPTION

Outflow of Registered Patients Service outflow information by gender and age group for the year to date.

Distribution of the Number of Outflow Episodes for Registered Patients

The number and percentage of registered patients by the number of outflow episodes or days that a patient received a core or encounter service outside of their PHCO, during the year to date.

Outflow of Registered Patients - Top 25 Service Items

The top 25 service items associated with the service outflows for the year to date.

Outflow of Registered Patients - Top 25 Diagnostic Codes

The top 25 diagnostic codes associated with service outflows for the year to date.

Outflow of Registered Patients –By Week Day

The number of patients and services for service outflows by the day of the week for the year to date.

Service Utilization

REPORT DESCRIPTION

Services for ALL Patients The utilization of services provided by physicians and non-physicians by type of service (encounter and fee-for-service) and patient registration status (registered and not registered), for the year to date.



REPORT DESCRIPTION

Nursing Services for ALL Patients The number and type of services provided by nurse practitioners for the year to date.

Services – Top 25 Service Items

The top 25 services delivered to PHCO patients, in total numbers and as a percentage of overall services, and the percentage of each of the services delivered by nurse practitioners, for the year to date.

Services – Top 25 Diagnostic Codes

The top 25 diagnostic codes for the year to date, itemized as for the top 25 services (above).

A sample of the quarterly reports is provided in Appendix F.

5.1.3. Annual Reconciliation Reports

Annual reconciliation reports include all standard financial, patient registration, service outflow and service utilization reports provided to the PHCO during quarterly reconciliation, however, the information provided is for the entire fiscal year, ending with the most recent quarter. The financial report will provide the Stability Fund calculation for the fiscal year.

A sample annual reconciliation (Year End) report is provided in Appendix F.



Calculations SECTION 5 – PHCO PAYMENTS PROCESS

5.2. Calculations

5.2.1. Overview

Population-based funding consists of the ACG income a PHCO receives minus any service outflows. Figure 5-2, below, provides an overview of how population-based funding is determined from the ACG assignments of a PHCO’s registered patients.

Patients

Patient Register for PHCO

Entire patient population coveredby BC Medical Services Plan

A

E

B

D

C

Population-Based Funding

Patient Age Days ACG Registered

152

235

98

197

365

ACG per p

atien

t

4410

0100

5110

2400

5340

1

0200: $ 0.22

* Rates used in 2002/2003

ACG Daily Rates*

0100 (2-59): $ 0.25

2

4110 (60-69): $ 0.63

5110 (70-79): $ 0.38

5340 (00-01): $ 0.84

SUM Across All Registered Patients:

The number of days the patient isregistered with PHCO

Multiplied by

The Patient’s ACG Daily Rate

Less

Any deductions for service outflows

Patient Days X ACG - Outflows = Population-Based Registered Daily Rate Funding


Patient Service Outflows

$25.00

$27.00

$0.00

$0.00

$30.00

3A

B

C

D

E

Find corre

sponding

ACG Daily

Rate

A 152 $0.63 ($25.00)

($27.00)

($30.00)

$70.76

B 235 $0.25 $31.75

C 98 $0.38 $0.00 $37.24

D 197 $0.21 $0.00 $41.37

E 365 $0.84 $276.60

Total: $457.72

1

2

3

A

B

C

D

E

2400 (2-59): $ 0.21

60-69

2-59

70-79

2-59

00-01

Days r

egist

ered w

ith PH

CO and

Figure 5-2 Population-Based Funding


SECTION 5 – PHCO PAYMENTS PROCESS Calculations

5.2.2. Adjusted Clinical Group (ACG) Daily Rate

ACG Assignments

After the end of each fiscal year (March 31), once the vast majority of claims for the fiscal year have been received (usually July of the following year), MSP assigns each person in the province to one of 82 ACGs based on patient age, gender and diagnostic history. For the purpose of calculating funding, patients in each ACG are further divided into five age ranges (0 -1, 2 - 59, 60 - 69, 70 - 79 and 80+).

New patients or those who have been insured by MSP for less than 275 days (75%) during the fiscal year, and who cannot therefore be readily assigned an ACG, are assigned to a provincial age-sex cluster.

Funding for registered patients who have not yet been assigned an ACG is calculated as the number of days the patient was registered with the PHCO multiplied by the provincial age/sex payment rate. Once the new patient has been insured by MSP for 274 days in a given year, they will be assigned an ACG for use in calculating funding for the following year.

Annual Calculation of the ACG Daily Rate

The ACG Daily Rate (also known as the “ACG Means”) associated with each ACG is the amount paid for each patient assigned a specific ACG and age range for each day that patient is registered with the PHCO.

The ACG Daily Rate is derived from the billing records and the number of MSP-insured days for every patient assigned an ACG for a 12-month period.

The calculation is prospective, using ACG assignments from two years before the current year and claims data from one year before the current year.

The ACG Daily Rate is calculated as follows:

• For all patients assigned a specific ACG, all fee-for-service claims for core PHCO services are totaled.

• This total is then divided by the number of MSP-insured days for the patients.

This provides the mean rate per patient/per MSP-insured day for that ACG (the ACG Daily Rate).

To calculate the annual ACG income for a patient registered to a PHCO, the patient’s ACG Daily Rate is multiplied by the number of days the patient is registered with the PHCO.

The Daily Rate for each age range within each ACG is e-mailed to PHCOs once a year.


Calculations SECTION 5 – PHCO PAYMENTS PROCESS

“Special Needs” Patients

Additional funding is provided for patients diagnosed with HIV/AIDS.

Special Needs funding rates are published regularly by the Primary Health Care Branch.

For more information on modifying an Administrative Code to indicate that a patient qualifies for Special Needs funding, refer to Section 3.4.1.

5.2.3. Estimated Service Outflow Calculations

For the purpose of calculating quarterly advances, the ministry estimates the service outflows for the upcoming quarter for each PHCO. The estimated service outflow percentage is calculated as:

( 100 PaymentsACG TotalOutflows ServiceTotal

× ) from the past two fiscal years.

During quarterly reconciliation, the difference between the estimated outflows and actual outflows from the previous quarter is calculated. The resulting adjustment may be positive or negative.

A newly established PHCO will have no history of outflows, however, the preliminary site analysis for a PHCO includes estimated annual service outflows. Advances to the newly established PHCO will reflect this estimated percentage of outflows until a history of actual outflows is available.

For established PHCOs, the ministry calculates expected service outflows by examining actual outflows and total ACG income for the previous two fiscal years. The percentage of total ACG income that service outflows comprised in the previous two years is deducted from the next quarterly advance, minus the difference between the estimated and actual outflow amounts for the previous quarter.

As described in Section 5.2.4, the Stability Fund ensures that deductions for actual service outflows never exceed the total annual ACG income allocated for a patient.


SECTION 5 – PHCO PAYMENTS PROCESS Calculations

5.2.4. Actual Service Outflows and the Stability Fund

As a stop-loss provision, a Stability Fund has been established to ensure that the minimum ACG income for a patient for a complete fiscal year is never less than zero.

The Stability Fund works as follows:

• Each quarter, when the ministry calculates ACG income to date, it accounts for each patient who had service outflows that exceeded the ACG income for that patient.

The difference between the ACG income and service outflow amount is reported in the Stability Fund. The amount reported in the Stability Fund for a patient is either zero or the amount by which service outflows exceeded the ACG income.

• At year-end, each PHCO is credited with the amount in the Stability Fund.

A PHCO’s annual net income from population-based funding is therefore equal to ACG income minus service outflows plus the Stability Fund amount.

The actual amount by which the gross ACG is reduced because of service outflows is sometimes referred to as the “practitioner adjustment.”

The Stability Fund has no impact on the money paid to PHCOs during the year. At the time of each quarterly review, the full value of service outflows is deducted from the year-to-date funding even if this results in negative funding amount. Service outflow amounts reported in the Stability Fund are credited only during annual (“year end”) reconciliation.


Calculations SECTION 5 – PHCO PAYMENTS PROCESS Calculations SECTION 5 – PHCO PAYMENTS PROCESS



SECTION 6 – RESOURCES Section Contents

SECTION 6 – RESOURCES

Section Contents

6.1. Enhancing PHCO Service ...................................................................................................6-3

6.2. Information Resources for PHCOs.....................................................................................6-4 6.2.1........Primary Health Care Branch Web Site ..................................................................6-4 6.2.2........Primary Health Care Compendium ........................................................................6-4 6.2.3........Electronic Medical Summaries (e-MS) Initiative.....................................................6-4 6.2.4........Medical Practice Access to PharmaNet.................................................................6-5 6.2.5........Medical Practice Access to Medical Laboratory Reports .......................................6-5

6.3. Complementary Initiatives ..................................................................................................6-6 6.3.1........Chronic Disease Management...............................................................................6-6

Chronic Disease Management (CDM) Toolkit for Practitioners.................................... 6-6 6.3.2........Full Service Family Practice Incentive Program.....................................................6-7

Chronic Care Practice Enhancement Incentive (Pilot Project) ..................................... 6-7 Structured Collaborative Participation Incentive ........................................................... 6-7 Family Physician Obstetrical Care Incentive ................................................................ 6-8

6.3.3........Rural Health Programs ..........................................................................................6-8

6.4. Health Information for Patients ..........................................................................................6-9 6.4.1........BC HealthGuide Handbook....................................................................................6-9 6.4.2........BC HealthGuide OnLine ........................................................................................6-9 6.4.3........BC HealthFiles.......................................................................................................6-9 6.4.4........BC NurseLine ........................................................................................................6-9 6.4.5........Chronic Disease and Your Health: Information for Patients...................................6-9


Section Contents SECTION 6 – RESOURCES


SECTION 6 – RESOURCES Enhancing PHCO Service

6. Resources

6.1. Enhancing PHCO Service

As described in this section, a variety of information resources, programs and initiatives are available to PHCOs who wish to enhance or expand the services they offer. Current health resources, programs and initiatives can help patients to use self-care strategies and assist PHCOs in attracting and retaining patients.

The Ministry of Health Services also provides health information and resources for patients. These are designed to promote health literacy and to support British Columbians in making better health decisions and staying healthy.


Information Resources for PHCOs SECTION 6 – RESOURCES

6.2. Information Resources for PHCOs

6.2.1. Primary Health Care Branch Web Site

The Primary Health Care Branch Web site provides a wealth of information on primary health care renewal for PHCOs, stakeholders and patients. Visit the site regularly to obtain both general and specific information on primary health care and to download any primary health care forms you may require.

Visit the Web site at www.healthservices.gov.bc.ca/phc.

6.2.2. Primary Health Care Compendium

The Primary Health Care Compendium describes innovative primary health care activities, programs and projects currently underway across British Columbia. It is a resource for learning about successes, best practices, challenges, works in progress, and opportunities for partnerships and collaboration. It also documents research projects and the activities of primary health care programs in BC health authorities. Each submission to the compendium includes a point-of-contact for those wanting to learn more about the specific initiative discussed.

This ongoing project will expand and change as new material is added and in response to comments by users.

To view this document, visit the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/phc_materials.html.

To contribute, to update information, or to provide comments on the compendium, please contact:

Megan Loeb Primary Health Care Branch Ministry of Health Services Telephone: (250) 952-2405 E-mail: [email protected].

6.2.3. Electronic Medical Summaries (e-MS) Initiative

The Electronic Medical Summaries (e-MS) Initiative, sponsored by the Ministry of Health Services and funded under BC’s Primary Health Care Transition Fund (PHCTF), is being developed in consultation with the health authorities.

This initiative will enable primary health care providers and other health professionals to exchange patient information electronically. The e-MS will become one of the key components of the BC Electronic Health Record Strategy.


www.healthservices.gov.bc.ca/phc

www.healthservices.gov.bc.ca/phc/phc_materials.html

SECTION 6 – RESOURCES Information Resources for PHCOs

The goal of the e-MS project is to provide physicians in BC with a more efficient, effective and reliable way to share data, supporting continuity of care among a team of care providers and practices.

Information or data in an e-MS will include health concerns, allergies, tests, treatment and medical procedures. Over time, electronic medical summaries may be expanded to include links to other diagnostic information.

The Vancouver Island Health Authority (VIHA) is leading the project and will act as the pilot site. Key partners include the BC Ministry of Health Services, the BC Medical Association (BCMA), and the Provincial Health Services Authority (PHSA). In addition, at least one other primary health care environment in a BC health authority will pilot the e-MS Project in the four-year PHCTF funding time frame, ending on March 31, 2006.

For more information on this project, visit the healthnetBC Web site at http://healthnet.hnet.bc.ca/initiatives.html.

6.2.4. Medical Practice Access to PharmaNet

PharmaNet is BC PharmaCare’s province-wide secure computer network linking all pharmacies to a central set of data systems. These systems provide data and services to support drug dispensing, drug monitoring and claims processing.

By allowing BC health care providers controlled computer access to their patient’s medication profiles, PharmaNet protects British Columbian patients from potentially dangerous medication interactions and duplications. It also helps to limit prescription fraud and drug abuse.

Medical practice access to PharmaNet allows authorized medical practitioners to request and receive up-to-date records of the medications dispensed to a patient in any pharmacy in the province. It also allows authorized medical practitioners to update patient medication histories.

For more information, or to register for this service, visit the healthnetBC Web site at http://healthnet.hnet.bc.ca/catalogu/products/medpract.html.

6.2.5. Medical Practice Access to Medical Laboratory Reports

Two companies in British Columbia currently offer access, 24 hours a day, 7 days a week, to medical laboratory reports from British Columbia’s largest medical laboratory firms.

For more information, visit the company Web sites:

• MediNet—www.medi.net

• PathNet—www.pathnet.ca


http://healthnet.hnet.bc.ca/initiatives.html

http://healthnet.hnet.bc.ca/catalogu/products/medpract.html

www.medi.net

www.pathnet.ca

Complementary Initiatives SECTION 6 – RESOURCES

6.3. Complementary Initiatives

6.3.1. Chronic Disease Management

Chronic disease management (CDM) is a systematic approach to improving health care for people with chronic disease. Health care can be delivered more effectively and efficiently if patients with chronic diseases take an active role in their own care and providers are supported with the necessary resources and expertise to assist patients in managing their illness more effectively.

Chronic Disease Management (CDM) Toolkit for Practitioners

The CDM Toolkit is an expansion of the Ministry of Health Service’s Secure Web Site for Practitioners where BC physicians can access a list of their patients with chronic conditions (such as congestive heart failure, diabetes, asthma and hypertension) and reports on the extent to which the care provided is consistent with BC Clinical Guidelines.

The CDM Toolkit, made possible through funding from Health Canada’s Primary Health Care Transition Fund, was developed and tested in collaboration with BC family physicians to ensure that it meets the chronic care management needs of BC practitioners. It can be easily incorporated into day-to-day practice management.

The CDM Toolkit enables practitioners to:

• Electronically access BC Clinical Guidelines (developed through the MSP/BCMA Guidelines and Protocols Advisory Committee).

• Electronically complete patient flow sheets.

• Share patient flow sheets with colleagues in their practice or practice network, or with consultants via secure Internet data transfer.

• Generate the following clinical and administrative reports based on the patient flow sheet data:

• Patient Profile Reports that compile all the chronic care information for a patient into a single record that can be printed and maintained in the patient’s chart. Aggregation of information across different chronic diseases enables easy access to patient co-morbidity information.

• Practice Profiles that provide a breakdown of a practice’s population of patients with a particular chronic disease.

• Recall Reports that list patients who should be scheduled for their next office visit and the specific test or procedure that is due according to evidence-based clinical guideline recommendations.

• Run Charts that show changes in a practice’s clinical processes and in patient health outcomes over a specific period of time.


SECTION 6 – RESOURCES Complementary Initiatives

• Patient Education Reports that provide patients with valuable information on their particular chronic disease and their progress over time on a number of disease relevant values (e.g., A1C levels, blood pressure).

• Data Extremes Reports that enable practitioners to easily identify patients who fall below the practice average on a number of disease relevant clinical process and health outcome measures.

PHCOs who use electronic medical records (EMRs), will also be able to automatically transfer patient chronic care information from their EMRs to the CDM Toolkit.

PHCO physicians are pre-registered for access to the CDM Secure Web Site for Practitioners and can use the same user ID and password to access the Toolkit.

For more information on Chronic Disease Management, visit the CDM Web site for Practitioners at www.healthservices.gov.bc.ca/cdm/practitioners/index.html.

6.3.2. Full Service Family Practice Incentive Program

The Ministry of Health Services, the British Columbia Medical Association and the Society of General Practitioners of BC have worked in partnership to develop the Full Service Family Practice Incentive Program.

This program is funded through a $20 million allocation set aside for general practice services under the Subsidiary Agreement for General Practitioners, November 2002. It offers BC's general practitioners the opportunity to participate in any of the following three initiatives for improving patient access to comprehensive health care.

For more information on the three initiatives, visit the Ministry of Health Services Web site at www.healthservices.gov.bc.ca/cdm/practitioners/fullservice.html.

Chronic Care Practice Enhancement Incentive (Pilot Project)

This $16.5 million incentive, being run as a two-year pilot, is aimed at supporting high quality management of congestive heart failure and diabetes. Physicians receive an annual payment of $75 per patient if the patient’s clinical management is consistent with the recommendations in the BC Clinical Practice Guidelines.

Structured Collaborative Participation Incentive

A “structured collaborative” is a team of health care providers participating in a program which includes:

• interactive education on effective chronic care interventions; and

• support for the implementation of interventions into practice through coordinated coaching, networking, and support.

The program emphasizes improvement in the quality of chronic care through a team-based approach. Teams are usually physician-led and may involve any number


www.healthservices.gov.bc.ca/cdm/practitioners/index.html

http://www.healthservices.gov.bc.ca/cdm/practitioners/fullservice.html

Complementary Initiatives SECTION 6 – RESOURCES

of health care professionals such as specialists, nurses, medical office assistants and other health care professionals. These health care professionals make a commitment to bring about office and clinical practice changes specifically designed to result in measurable improvements in the quality of care they deliver to patients with chronic illness.

$1.5 million has been allocated to support physicians who participate in a structured collaborative or in quality improvement learning sessions.

Family Physician Obstetrical Care Incentive

Obstetrical care by general practitioners is a vital service. To encourage and support low-moderate volume delivery practice, $2 million has been allocated. General practitioners receive a 50% bonus on the current value of the fee-for-service delivery payment, for a maximum of 25 deliveries per calendar year.

6.3.3. Rural Health Programs

Rural Health, part of the Alternative Incentive Program, oversees a number of key programs for physicians. It co-manages physician programs under the 2001 Subsidiary Agreement for Physicians in Rural Practice and is responsible for implementing the province’s Rural Health Initiative and Rural Specialist Locum Program.

For more information, visit the Ministry of Health Services’ Rural Health Web site at www.healthservices.gov.bc.ca/rural.


www.healthservices.gov.bc.ca/rural

SECTION 6 – RESOURCES Health Information for Patients

6.4. Health Information for Patients

6.4.1. BC HealthGuide Handbook

The BC HealthGuide Handbook provides information on more than 190 common health topics, tests, procedures and other resources available to BC residents. A French BC HealthGuide Handbook is also available.

A companion guide, the BC First Nations Health Handbook, provides information on unique health services plus advice for health professionals serving First Nations.

For more information on the Handbooks, visit www.bchealthguide.org.

6.4.2. BC HealthGuide OnLine

The BC HealthGuide OnLine provides more than 35,000 medically reviewed pages on over 3,000 health topics and conditions.

Access the BC HealthGuide OnLine at www.bchealthguide.org.

6.4.3. BC HealthFiles

The BC HealthFiles are a series of one-page fact sheets on health and safety topics such as common illnesses, environmental health concerns, problems with pests, and health and safety tips. They are regularly updated with the latest BC health advice.

For more information, visit www.bchealthguide.org.

6.4.4. BC NurseLine

BC NurseLine offers free health information and advice to the public through a toll-free telephone line. Staffed by registered nurses, the line is open 24 hours a day, 7 days a week. The separate telephone service is also available for those who are deaf or hard of hearing, and translation services are available in 130 languages.

For more information, visit www.bchealthguide.org.

6.4.5. Chronic Disease and Your Health: Information for Patients

This Ministry of Health Services Web site provides patients with information on managing chronic diseases such as asthma, congestive heart failure, diabetes and hypertension. The information provided encourages patients to become actively involved in their own care and to understand their condition well enough to take some responsibility for its management.

The site also provides in-depth information on the Chronic Disease Self-Management Program, funded under the Smart Fund by the Vancouver Coastal Health Authority.


www.bchealthguide.org




Health Information for Patients SECTION 6 – RESOURCES

The program looks at how a chronic illness affects a person's daily life and recognizes the need for people with chronic illness to deal with common issues such as pain management and stress on a daily basis.

For more information, visit the Web site at www.healthservices.gov.bc.ca/cdm/patients.


www.healthservices.gov.bc.ca/cdm/patients

APPENDIX A – Local Health Areas

APPENDIX A – Local Health Areas Map 1 - British Columbia

1 Fernie 2 Cranbrook 3 Kimberley 4 Windermere 18 Golden 25 100 Mile House 26 North Thompson 27 Cariboo - Chilcotin 28 Quesnel 29 Lillooet 30 South Cariboo 32 Hope 33 Chilliwack 39 Vancouver Aggregate 46 Sunshine Coast

47 Powell River 48 Howe Sound 49 Bella Coola Valley 50 Queen Charlotte 51 Snow Country 52 Prince Rupert 53 Upper Skeena 54 Smithers 55 Burns Lake 56 Nechako 57 Prince George 59 Peace River South 60 Peace River North 65 Cowichan 69 Qualicum

71 Courtenay 72 Campbell River 75 Mission 76 Agassiz - Harrison 80 Kitimat 81 Fort Nelson 83 Central Coast 84 Vancouver Island West 85 Vancouver Island North 87 Stikine 88 Terrace 92 Nisga'a 94 Telegraph Creek

Refer to page A-2 for detailed maps of Southern Vancouver Island, Vancouver, Lower Mainland and Southern Interior.

Primary Health Care Organizations: Operations Manual A - 1 Version 1.0 – October 2004

APPENDIX A – Local Health Areas

Map 2 – Southern Vancouver Island

Map 4 - Vancouver

Map 3 – Lower Mainland

Map 5 – Southern Interior

61 Greater Victoria 62 Sooke 63 Saanich 64 Gulf Islands

65 65 Cowichan 66 Lake Cowichan 67 Ladysmith 68 Nanaimo 70 Alberni 161 City Centre 162 Downtown Eastside 163 North East 164 West Side 165 Midtown 166 South Vancouver 34 Abbotsford 35 Langley 37 Delta 38 Richmond 40 New Westminster 41 Burnaby 42 Maple Ridge 43 Coquitlam 44 North Vancouver 45 West Vancouver-Bowen Island 75 Mission 201 Surrey 202 Surrey/White Rock 5 Creston 17 Princeton 6 Kootenay Lake 19 Revelstoke 7 Nelson 20 Salmon Arm 9 Castlegar 21 Armstrong - Spallumcheen 10 Arrow Lakes 22 Vernon 11 Trail 23 Central Okanagan 12 Grand Forks 24 Kamloops 13 Kettle Valley 31 Merritt 14 Southern Okanagan 77 Summerland 15 Penticton 78 Enderby 16 Keremeos

A - 2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

APPENDIX B – Information Required for Site Analysis


Primary Health Care Organizations: Operations Manual B - 1 Version 1.0 – October 2004


B - 2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004


Primary Health Care Organizations: Operations Manual B - 3 Version 1.0 – October 2004

APPENDIX B – Information Required for Site Analysis APPENDIX B – Information Required for Site Analysis



APPENDIX C – PHCO Site Analysis Report


Total Patients ReviewedExemptions Patients

DiedAlready Registered PATIENT RATIOSTotal Excluded 0 % of TPP %TLA

0 0

Lives Out of Area0 0

<= %50 at PCO Last 3 Not at PCOLast 2 Out of Catchment

0 0

Last 2 at PCO>50% at PCO

0 0

Gross ACG Amountless:Estimated Deducted Outflow

$0.00

Net ACG Amount $0.00plus:MSP FFS Incomeplus:ICBC, WCB, etc.

$0.00$0.00

Project No:

Total Possible Patients:

Total Lives In Area:

Health Authority:

Section 1

NOTE

.0% n/a

.0% 0.0%

.0% 0.0%

.0% 0.0%

PA = Patient Analysis, IA = Income Analysis

Catchment Area - LHAs (catchment area of practice in bold)

Practitioners/Payees

Primary Health Care - Site Analysis Review Outcome

Clinic Name:

Report Date: Service Period:

Patient Analysis

Section 2

Section 3

Section 4Total Not Registered:

$0.00$0.00

Total Patients to Register:

Blended Funding Model Fee-for-ServiceIncome Analysis

Net ACG Amount:

Total Estimated Income: $0.00Variance: Estimated BFM less Estimated FFS:

FFS Value of Equivalent Service:

PA1

PA2

PA3

PA4

PA5

PA6

PA8

IA1IA2

IA3IA4

IA5

IA6IA7

IA8

PA7

PA9

PA10

PA11

IA3

Primary Health Care Organizations: Operations Manual C - 1 Version 1.0 – October 2004


This report identifies the patients who would initially be considered for registration in the PHCO/CHC practice, and the estimated annual income that would be generated under the ACG funding model for the practice as a whole. It is based on three years of fee-for-service claims for those physicians considered part of the practice.

CATCHMENT AREA

The geographic area (by Local Health Area - LHA) for determining outflows, e.g., core services to registered patients from other general practitioners. (See www.chspr.ubc.ca/Research/healthatlas/newboundaries.pdf for more information.)

PRACTITIONERS/PAYEES

The names and practitioner/payee numbers of the physicians considered part of the practice.

INCOME ANALYSIS

PA1. The name used to identify the practice for reference purposes.

PA2. Total Patients Reviewed - number of patients that have been served by the physicians in the last three years.

PA3. The number of patients who have died or who are already registered with another PHCO.

PA4. Total Excluded – the sum of all patients from PA3.

PA5. Total Possible Patients – number of patients considered for registration.

PA6. Lives out of Area - patients not considered eligible to be registered because they don’t live in the catchment area.

PA7. Total Lives in Area - the number of the patients reviewed (from PA5.) who live in the catchment area.

PA8. Three categories for excluding patients from initial register according to their service access pattern.

PA9. Total Not Registered – total number of patients excluded from registration based on PA8.

PA10. Patients who meet these criteria are eligible for registration according to the registration rules (two categories).

PA11. Total Patients to Register – initial estimate of patients on which to base the register. ACG income and estimated outflows are based on these patients.

INCOME ANALYSIS

IA1. The estimated Gross ACG Amount for the registered patients in the reporting period = registered patients X daily ACG mean X number of days registered.

IA2. The Estimated Deducted Outflow for core services received within the catchment area outside the practice by registered patients.

IA3. Estimated Net ACG Income for the year is calculated as estimated Gross ACG Income less estimated Deducted Outflow Amount.

IA4. The equivalent fee-for-service value of core services for the registered patients

IA5. Amount of FFS Income for non-core services to registered patients and for all insured services to non-registered patients.

IA6. The practice’s third party payments provided to registered patients in the reporting period e.g. WCB/ICBC.

IA7. The Actual Total Fee-for-service Income for the practice (all identified practitioners) during the reporting period – based on all services to all patients.

IA8. Variance: Estimated BFM less Estimated FFS gives an estimate of the difference in income between the two funding methods.

C - 2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

APPENDIX D – Outflow Reduction Strategies

APPENDIX D – Outflow Reduction Strategies

The following strategies can help to reduce the volume of service outflows from your PHCO:

• Encourage your registered patients to make every attempt to visit your PHCO when they require medical care (except emergencies).

• Let your patients know that you are penalized financially whenever they seek primary health care services from another practice in your catchment area.

• Try to determine why a patient is choosing to seek medical care elsewhere. It may be in the best interest of your PHCO and the patient for them to receive the bulk of their care elsewhere.

• Invite patient feedback by providing a forum for their input (for example, a suggestion box or short surveys).

• Emphasize the benefits that continuity of care provides to taxpayers, patients and health care providers. The benefits include:

• Faster, more accurate diagnosis due to familiarity with patient history;

• Less duplication of both services and tests;

• Decreased risk of potentially dangerous prescription drug combinations; and

• More efficient referrals.

• Advise your patients that, if you are unavailable for some reason, it is in their best interest to seek care from another provider within your PHCO whenever possible. This ensures continuity of care.

• Invite patients to make greater use of alternate care providers for preventive care, weight loss, nutrition, smoking cessation, etc.

• Create an information booklet or package describing how your PHCO is organized. Include information such as the types of health care providers working in your PHCO, the available services and office hours, and who patients can contact if their family doctor is unavailable.

Primary Health Care Organizations: Operations Manual D - 1 Version 1.0 – October 2004

APPENDIX D – Outflow Reduction Strategies APPENDIX D – Outflow Reduction Strategies

D - 2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

D - 2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

APPENDIX E – Patient Registration Reports


Primary Health Care Organizations: Operations Manual E - 1 Version 1.0 – October 2004


Complete Registration History

RPT02 COMPLETE REGISTRATION HISTORY XXXXX YOUR PHCO PAYEE NUMBER AND NAMEREPORT DATE: 2004-02-12

LAST NAME FIRST NAME SECOND NAME PHN

BIRTH DATE SEX PRAC# ADDRESS LINE 1 ADDRESS LINE 2 ADDRESS LINE 3 ADDRESS LINE 4 CITY PROV

POSTAL CODE EFF DATE

CANCEL DATE

ADMIN CODE

CANCEL REASON

REG REASON

SURNAME13 FIRST13 MIDDLE13 9XXXXXXX13 19130103 M 1313 1313 THIRTEENTH STEET BOX 13 THIRTEEN CITY BC V1M3M1 19991001 99991231 0SURNAME14 FIRST14 MIDDLE14 9XXXXXXX14 19140104 F 1414 1414 FOURTEENTH ROAD FOURTEEN TOWN BC V1N4N1 20020901 20031031 0 QSURNAME15 FIRST15 MIDDLE15 9XXXXXXX15 19150105 M 1515 1515 FIFTEENTH LANE FIFTEEN VILLE BC V1O5O1 20001001 99991231 0 2SURNAME16 FIRST16 MIDDLE16 9XXXXXXX16 19160106 F 1616 1616 SIXTEENTH AVENUE SIXTEEN CITY BC V1P6P1 19991001 99991231 0SURNAME17 FIRST17 MIDDLE17 9XXXXXXX17 19170107 M 1717 1717 SEVENTEENTH ROAD SEVENTEEN CITY BC V1Q7Q1 19991001 99991231 0SURNAME18 FIRST18 MIDDLE18 9XXXXXXX18 19180108 F 1818 1818 EIGHTEENTH STREET EIGHTEEN VILLE BC V1R8R1 19991001 99991231 0See PHC Help Files for additional details https://healthregistry.moh.hnet.bc.ca

Current Registrations

RPT01 CURRENT REGISTRATIONS

XXXXX YOUR PHCO PAYEE NUMBER AND NAME

REPORT DATE: 2004-02-12

LAST NAME FIRST NAME SECOND NAME PHN BIRTH DATE SEX PRAC# ADDRESS LINE 1 ADDRESS LINE 2 ADDRESS LINE 3 ADDRESS LINE 4 CITY PROV


CANCEL DATE

ADMIN CODE

SURNAME19 FIRST19 MIDDLE19 9XXXXXXX19 19191009 M 1919 1919 NINETEENTH STREET NINETEENTH TOWN BC V1S9S1 19991001 99991231 0

SURNAME20 FIRST20 MIDDLE20 9XXXXXXX20 19200202 F 2020 2020 TWENTIETH ROAD TWENTY VILLE BC V2T0T2 20001001 99991231 0

SURNAME21 FIRST21 MIDDLE21 9XXXXXXX21 19210201 M 2121 2121 TWENTY-FIRST AVENUE TWENTY-ONE TOWN BC V2U1U2 19991001 99991231 0

SURNAME22 FIRST22 MIDDLE22 9XXXXXXX22 19220202 F 2222 2222 TWENTY-SECOND ROAD TWENTY-TWO CITY BC V2VSV2 19991001 99991231 0

SURNAME23 FIRST23 MIDDLE23 9XXXXXXX23 19230203 M 2323 2323 TWENTY-THIRD STEET TWENTY-THREE VILLE BC V2W3W2 19991001 99991231 0

SURNAME24 FIRST24 MIDDLE24 9XXXXXXX24 19240204 F 2424 24234 TWENTY-FOURTH STREET TWENTY-FOUR TOWN BC V2X4X2 19991001 99991231 0

See PHC Help Files for additional details

https://healthregistry.moh.hnet.bc.ca



Pending Registrations/De-Registrations

RPT03 PENDING REGISTRATIONS



LAST NAME FIRST NAME SECOND NAME PHN



CANCEL DATE

ADMIN CODE

PEND ACTION

ACTION REASON

OVERRIDE CODE

SURNAME7 FIRST7 MIDDLE7 9XXXXXXXX7 19070707 M 7777 7777 SEVENTH ROAD SEVEN CITY BC V7A7A7 19991001 99991231 0 D D

SURNAME8 FIRST8 MIDDLE8 9XXXXXXXX8 19080808 F 8888 8888 EIGHT STREET EIGHT TOWN BC V8A8A8 20030301 99991231 0 D D

SURNAME9 FIRST9 MIDDLE9 9XXXXXXXX9 19090909 M 9999 9999 NINTH AVENUE NINE TOWN BC V9A9A9 19991001 99991231 0 D B

SURNAME10 FIRST10 MIDDLE10 9XXXXXXX10 19101010 F 1010 1010 TENTH PLACE TEN CITY BC V1A0A1 19991001 99991231 0 D D

SURNAME11 FIRST11 MIDDLE11 9XXXXXXX11 19111111 M 1111 1111 ELEVENTH CLOSE ELEVEN VILLE BC V1A1A1 19991001 99991231 0 D A0

SURNAME12 FIRST12 MIDDLE12 9XXXXXXX12 19121212 F 1212 1212 TWELFTH LANE TWELVE TOWN BC V1A2A1 19991001 99991231 0 D D



Recently Applied Registration Changes (Audit Log File)

RPT04 RECENT APPLIED REGISTRATION CHANGES



LAST NAME FIRST NAME

SECOND NAME PHN



CANCEL DATE

ADMIN CODE

CANCEL REASON

REG REASON

SURNAME1 FIRST1 MIDDLE1 9XXXXXXXX1 19010101 M 1111 100 FIRST STREET BOX 1000 STATION A ONETOWN BC V1A1A1 20000101 99991231 0

SURNAME2 FIRST2 MIDDLE2 9XXXXXXXX2 19020202 F 200 SECOND ROAD TWO CITY BC V2B2B2 20000202 99991231 0

SURNAME3 FIRST3 MIDDLE3 9XXXXXXXX3 19030303 M 3333 300 THIRD CRESCENT APARTMENT 33 THREE VILLE BC V3C3C3 20000303 99991231 0

SURNAME4 FIRST4 MIDDLE4 9XXXXXXXX4 19040404 F 400 FOURTH AVENUE FOUR VILLAGE BC V4D4D4 20000404 99991231 0

SURNAME5 FIRST5 MIDDLE5 9XXXXXXXX5 19050505 M 5555 500 FIFTH LANE FIVE CITY BC V5E5E5 20000505 99991231 0

SURNAME6 FIRST6 MIDDLE6 9XXXXXXXX6 19060606 F 6666 600 SIXTH BOULEVARD SIX HOMETOWN BC V6F6F6 20000606 99991231 0




APPENDIX F – Quarterly/Annual Payment Reports


Sample Quarterly Adjustment Reports

Primary Health Care Organizations: Operations Manual F - 1 Version 1.0 – October 2004


F - 2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004


Sample Quarterly Financial Reports


APPENDIX F – Quarterly/Annual Payment Reports APPENDIX F – Quarterly/Annual Payment Reports




Sample Quarterly Patient Registration Reports



Sample Quarterly Service Outflow Reports



Sample Quarterly Service Utilization Reports




Sample Year End Report


GLOSSARY ACG

GLOSSARY

ACG Refer to “Adjusted Clinical Group.”

ACG income The ACG income for a patient is calculated as the number of days a patient is registered with the PHCO multiplied by the patient’s ACG Daily Rate.

Adjusted Clinical Group (ACG) A series of mutually exclusive health status categories defined by morbidity (as indicated by ICD-9 Codes), age and gender as derived from the Johns Hopkins University Adjusted Clinical Groups Case-Mix System.

Adjusted Clinical Group (ACG) Daily Rate

The daily rate applied to each patient within a specific age group of an Adjusted Clinical Group. The ACG Daily Rate for each registered patient is used to calculate population-based funding.

Adjusted Clinical Group (ACG) Means Refer to “Adjusted Clinical Group Daily Rate” above.

Adjustment 65 The quarterly advances paid to PHCOs based on the projected ACG income for registered patients and expected service outflows.

Adjustment 67 An adjustment made on a quarterly basis that reflects actual ACG income for the quarter and actual service outflows.

Aggregated Diagnosis Group (ADG) A grouping of ICD-9 codes that are similar in terms of severity and likelihood of persistence of the health condition.

Under the Johns Hopkins ACG Case-Mix System, ICD-9 diagnostic codes are mapped to 32 Aggregated Diagnosis Groups (ADGs). A patient’s ADGs, combined with the patient’s age and gender, are used to assign the patient to an Adjusted Clinical Group (ACG).

Billing Number A number assigned to each BC physician by the Medical Services Plan. The billing number consists of a Practitioner ID and a Payment Number. The MSP Payment Number is referred to as the “Payee” number by Teleplan.

Primary Health Care Organizations: Operations Manual 1 Version 1.0 – October 2004

Blended Funding GLOSSARY

Blended Funding The combination of: population-based funding for core services to PHCO

registered patients, and fee-for-service payments for non-core services to

registered patients, and fee-for-service payments for all services to non-registered

and transient patients.

Catchment Area Usually the Local Health Area in which the PHCO is located plus any adjacent Local Health Areas from which a patient could reasonably be expected to use the PHCO as their main source of primary care. The catchment area defines the boundary for patient registrations and service outflows.

Community Health Centre (CHC) Refer to “PHCO.”

Core Services The Medical Services Plan (MSP) fee items most commonly provided by general practitioners in the delivery of comprehensive primary care. Core services to registered patients are funded by population-based funding.

The complete list of core services is available on the Primary Health Care Branch Web site at www.healthservices.gov.bc.ca/phc/infosites.html

Encounter Refer to “Patient Encounter.”

Extended Services Extended services are specifically designed to reflect the work of PHCO practitioners including, for instance, case conferencing, telephone follow-ups and patient education on a variety of topics. There are no equivalent fee-for-service items for some of these services. Extended services to registered patients are covered under population-based funding.

Fee-for-Service Claims for services to patients submitted by practitioners and paid by the Medical Services Plan in accordance with the provisions of the Medicare Protection Act and Regulations, the relevant payment schedule, and MSP claims policy and procedures.

2 Primary Health Care Organizations: Operations Manual Version 1.0 – October 2004

http://www.healthservices.gov.bc.ca/msp/legislation/mpa.html

GLOSSARY Fifty Percent Payment Rule

Fifty Percent Payment Rule If a non-registered patient lives in the PHCO catchment area: The PHCO receives 100% of the fee-for-service payment

for the first two core services provided to the patient during a half calendar year (January through June or July through December).

For any additional core service provided to the non-registered patient within the same half calendar, the PHCO receives 50% of the fee-for-service payment.

In the next half calendar year, the fee-for-service payments for the first two core services will again be paid at 100%.

Half Calendar Year The Medical Services Plan defines a half calendar year as the periods of January through June and July through December.

HNFTP Account HealthNet (Secure) File Transfer Protocol account.

HNWeb Part of the Primary Health Care Branch’s Secure Web site for Practitioners. HNWeb provides patient registration management transactions, patient register reports and audit trails.

ICD-9 Codes International Classification of Diseases, 9th Revision, diagnostic codes, consisting of three to five digits, used to code diagnoses.

Local Health Area British Columbia health boundaries consist of six health authorities (5 regions +1) and 16 health service delivery areas. The 16 health service delivery areas are further divided into 89 local health areas.

Locum A physician who temporarily stands in for another physician.

Medical Services Plan (MSP) The Medical Services Plan (MSP) insures medically required services provided by physicians and supplementary health care practitioners, laboratory services and diagnostic procedures for eligible British Columbians.

Medical Services Commission (MSC) The Medical Services Commission (MSC) manages the Medical Services Plan (MSP) on behalf of the Government of British Columbia in accordance with the Medicare Protection Act and Regulations. The MSC is a nine-member statutory body made up of three representatives from Government, three representatives from the British Columbia Medical Association (BCMA) and three members from the public jointly nominated by the BCMA and Government to represent MSP beneficiaries.


Non-Registered Patient GLOSSARY

Non-Registered Patient A patient who lives in the PHCO catchment area but who does not receive the majority of their primary care from the PHCO or is not insured by the Medical Services Plan.

Outflow Refer to “Service Outflow.”

Patient Encounter Any contact with a registered patient in which a core service, extended service, or special fee item is provided.

Patient Register The list of patients who live in the PHCO catchment, who receive the majority of their primary care services from the PHCO and who the PHCO has elected to register.

Payee Number Also known as payment number.

PHC Primary health care. PHC is the point in the health care system where short-term health issues are resolved, patients with chronic or complex health issues receive ongoing care and are linked to other services in their community, and where health promotion and education efforts are most effective.

PHCO Refer to “Primary Health Care Organization.”

PHCO Listserv The PHCO Listserv is an automated e-mail forum through which PHCOs, health authorities and the Primary Health Care Branch share information pertinent to PHCO operations and concerns.

PHN Personal Health Number (as indicated on a patient’s British Columbia CareCard) issued by the Medical Services Plan of BC that uniquely identifies each resident of the province.

Population-Based Funding Income based on the number of registered patients and their respective Adjusted Clinical Group Daily Rate. (Population-based funding is calculated as the number of days a patient is registered with the PHCO times the patient’s ACG Daily Rate less any deductions for core services the patient receives outside the PHCO but within the PHCO catchment area.)

Primary Health Care Organization (PHCO)

A primary care medical practice that receives blended funding (and may include Community Health Centres).

Primary Health Care Transition Fund (PHCTF)

A fund, set up by Health Canada, which supports and encourages primary health care renewal. PHCTF funds are distributed through health authority programs and incentives that meet the guidelines set out by Health Canada.


GLOSSARY Registered Patient

Registered Patient A patient who lives in the PHCO catchment area, who receives the majority of their core services from the PHCO and who the PHCO elects to register.

Service Outflow Service outflows occur when a registered patient receives a core service from a general practitioner outside the PHCO but within the PHCO catchment area.

Special Fee Items Five core services, identified by the ministry, for which PHCOs receive a premium for each encounter recorded. This premium is paid in addition to population-based funding for the patient.

Stability Fund The Stability Fund ensures that a PHCO never receives less than zero ACG income for a patient as a result of service outflows.

System Date The date on which the ministry receives and processes a claim. For instance, records entered late at night on the 14th may not be processed until the 15th. In this case, the 15th is the system date.

Teleplan The Ministry of Health Services billing software system administrated by the Medical Services Plan.

Virtual Register A patient register developed using the past Medical Services Plan Claims History of patients. Virtual registers may be determined for new PHCO sites that are not based on an existing practice.


Virtual Register GLOSSARY Virtual Register GLOSSARY



INDEX A

INDEX

A

ADGs........................................................................................................................................................... 2-5 Adjusted Clinical Groups (ACGs) .............................................................................................................. 2-4

assignment of ACGs ........................................................................................................................2-5, 5-9 daily rates .........................................................................................................................................2-6, 5-9 funding for patients diagnosed with HIV/AIDS ..................................................................................... 2-5 funding for patients without ACG assignments ...................................................................................... 2-5

Adjustment Code 65.................................................................................................................................... 5-4 Adjustment Code 67.................................................................................................................................... 5-4 Administrative codes ................................................................................................................................. 3-12 Aggregated Diagnosis Groups (ADGs)....................................................................................................... 2-5 Annual reconciliation reports ...................................................................................................................... 5-7 Audits, Medical Services Plan..................................................................................................................... 4-9

B

Backdating of registrations by the ministry ...................................................................................................................................... 4-12 by the PHCO......................................................................................................................................... 4-13

BC First Nations Health Handbook............................................................................................................. 6-9 BC HealthFiles ............................................................................................................................................ 6-9 BC HealthGuide .......................................................................................................................................... 6-9 BC HealthGuide OnLine ............................................................................................................................. 6-9 BC NurseLine.............................................................................................................................................. 6-9

C

Call-out services ........................................................................................................................................ 4-14 Catchment areas

definition of............................................................................................................................................. 2-9 relationship to health areas.................................................................................................................... 2-10 use in developing initial register ........................................................................................................... 2-10

Chronic Care Practice Enhancement Incentive ........................................................................................... 6-7 Chronic disease management (CDM)

information for patients........................................................................................................................... 6-9 Toolkit for Practitioners .......................................................................................................................... 6-6

Community Health Centres (CHCs)............................................................................................................ 1-3 Contacts for PHCOs

Health authorities .................................................................................................................................. 1-11 Primary Health Care Branch ................................................................................................................. 1-10 Teleplan and HNWeb ........................................................................................................................... 1-10

Conversion of claims and records ............................................................................................................. 4-11 backdating of registrations by the ministry ........................................................................................... 4-12 backdating of registrations by the PHCO.............................................................................................. 4-13

Core services, funding for ........................................................................................................................... 2-5

D

Data submission basic claim/record information required ................................................................................................. 4-5 call-out services .................................................................................................................................... 4-14 claims submission overview ................................................................................................................... 4-3


E INDEX

direct patient billing .............................................................................................................................. 4-16 encounter records .................................................................................................................................... 4-8 encounter records versus fee-for-service claims ..................................................................................... 4-3 facility identifiers .................................................................................................................................... 4-7 fee-for-service claims............................................................................................................................ 4-10 formal/informal case management ........................................................................................................ 4-23 hospitalized patients.............................................................................................................................. 4-20 ICD-9 diagnostic codes........................................................................................................................... 4-6 locums ................................................................................................................................................... 4-17 methadone treatment ............................................................................................................................. 4-22 MSP Service Verification Audits............................................................................................................ 4-9 newborns ............................................................................................................................................... 4-19 no charge referrals................................................................................................................................. 4-21 payment modes ....................................................................................................................................... 4-7 Personal Health Numbers (PHNs) .......................................................................................................... 4-5 PHCO single MSP Payee Number.......................................................................................................... 4-5 practitioner number ................................................................................................................................. 4-5 pre-natal care services........................................................................................................................... 4-18 reporting type of service ......................................................................................................................... 4-6 service location codes ............................................................................................................................. 4-7 special fee items ...................................................................................................................................... 4-8 third party billings................................................................................................................................. 4-15

De-registration overrides........................................................................................................................... 3-25 De-registration reason codes ..................................................................................................................... 3-24 Direct patient billings ................................................................................................................................ 4-16

E

Electronic Medical Summaries (e-MS) Initiative........................................................................................ 6-4 Encounter records

backdating of registrations by PHCO ................................................................................................... 4-13 backdating of registrations by the ministry ........................................................................................... 4-12 conversion to fee-for-service claims ..................................................................................................... 4-12 submitting ............................................................................................................................................... 4-8

Extended services, funding for.................................................................................................................... 2-5

F

Facility identifiers........................................................................................................................................ 4-7 Family Physician Obstetrical Care Incentive .............................................................................................. 6-8 Fee-for-service claims

conversion to encounter records ........................................................................................................... 4-11 funding for .............................................................................................................................................. 2-6 submitting ............................................................................................................................................. 4-10

Fifty Percent Payment Rule....................................................................................................................... 4-10 Formal/informal case management............................................................................................................ 4-23 Full Service Family Practice Incentive Program......................................................................................... 6-7 Funding

calculation of population-based funding................................................................................................. 2-7 core services............................................................................................................................................ 2-5 estimating funding for proposed PHCOs .............................................................................................. 2-14 extended services .................................................................................................................................... 2-5 non-insured patients ................................................................................................................................ 2-6 overview.................................................................................................................................................. 2-4 payments for PHCO services .................................................................................................................. 2-5 Site Analysis Report.............................................................................................................................. 2-14


INDEX H

H

HNWeb logging in ................................................................................................................................................ 3-4 patient registration reports

accessing reports............................................................................................................................... 3-30 Pending Registration Changes Report .............................................................................................. 3-28 PHC Complete Registration History Report..................................................................................... 3-29 PHC Current Registrations Report ................................................................................................... 3-28 Recently Applied Registration Changes Report ............................................................................... 3-30

Personal Health Number (PHN) searches ............................................................................................... 3-5 Teleplan Support Centre ......................................................................................................................... 3-7

Hospitalized patients ................................................................................................................................. 4-20

I

ICD-9 diagnostic codes ............................................................................................................................... 4-6 Information resources.................................................................................................................................. 6-4

BC First Nations Health Handbook ........................................................................................................ 6-9 BC HealthFiles........................................................................................................................................ 6-9 BC HealthGuide...................................................................................................................................... 6-9 BC HealthGuide OnLine......................................................................................................................... 6-9 BC NurseLine ......................................................................................................................................... 6-9 Chronic Disease and Your Health, information for patients ................................................................... 6-9 Chronic Disease Management Toolkit.................................................................................................... 6-6 Electronic Medical Summaries (e-MS) Initiative ................................................................................... 6-4 medical practice access to medical laboratory reports ............................................................................ 6-5 medical practice access to PharmaNet .................................................................................................... 6-5 Primary Health Care Branch Web site .................................................................................................... 6-4 Primary Health Care Compendium......................................................................................................... 6-4

Interdisciplinary teams .............................................................................................................................. 2-13

J

Johns Hopkins ACG Case Mix System....................................................................................................... 2-5

L

Laboratory reports, medical practice access................................................................................................ 6-5 Locums

deleting registration with the PHCO..................................................................................................... 2-25 submission of claims and records ......................................................................................................... 4-17

M

Medical practice access to PharmaNet ........................................................................................................ 6-5 Medical Services Plan (MSP) Service Verification Audits......................................................................... 4-9 Methadone treatment ................................................................................................................................. 4-22 Ministry of Health Services Help Desk..................................................................................................... 1-10 Monthly registration reviews..................................................................................................................... 3-21

amending Administrative Codes ........................................................................................................... 3-27 application of patient register changes by the ministry......................................................................... 3-27 HNWeb patient registration reports ...................................................................................................... 3-28 Pending Registration Changes Report .................................................................................................. 3-23 registration and de-registration reason codes........................................................................................ 3-24 reviewing proposed changes to the register .......................................................................................... 3-23 schedule................................................................................................................................................. 3-22

Primary Health Care Organizations: Policies and Procedures 3 Version 1.0 – October 2004

N INDEX

submitting override requests ................................................................................................................. 3-25 verifying the patient register ................................................................................................................. 3-28

MSP Payee Number .................................................................................................................................... 4-5

N

Newborns .................................................................................................................................................. 4-19 No charge referrals .................................................................................................................................... 4-21

O

Outflows ......................................................................................................................... See Service Outflows Override requests....................................................................................................................................... 3-25

P

Patient registers community service profiles ..................................................................................................................... 2-9 determination of initial register ............................................................................................................. 2-10 registration reviews..................................................................................See Monthly registration reviews review of initial register by PHCO and health authority....................................................................... 2-12 verification ............................................................................................................................................ 3-28 virtual registers........................................................................................................................................ 2-9

Patients assigning patients to specific practitioners............................................................................................ 3-11 de-registering ........................................................................................................................................ 3-18 de-registering using HNWeb ................................................................................................................ 3-19 de-registering using Teleplan................................................................................................................ 3-18 funding for non-insured patients ............................................................................................................. 2-6 introducing new patients to PHCO ......................................................................................................... 3-8 modifying an Administrative Code....................................................................................................... 3-14 reassigning a patient to another PHCO practitioner.............................................................................. 3-15 registering ............................................................................................................................................... 3-8 registering using HNWeb ..................................................................................................................... 3-10 registering using Teleplan....................................................................................................................... 3-9 setting an Administrative Code............................................................................................................. 3-12

Payment modes............................................................................................................................................ 4-7 Payments to PHCOs .................................................................................................................................... 5-3

ACG Daily Rate calculations .................................................................................................................. 5-9 actual service outflow calculation......................................................................................................... 5-11 Adjustment Code 65 ............................................................................................................................... 5-4 Adjustment Code 67 ............................................................................................................................... 5-4 annual reconciliation ............................................................................................................................... 5-4 annual reconciliation reports ................................................................................................................... 5-7 estimated service outflow calculations.................................................................................................. 5-10 process and schedule............................................................................................................................... 5-3 quarterly reconciliation ........................................................................................................................... 5-4 quarterly reports ...................................................................................................................................... 5-5 semi-monthly remittances ....................................................................................................................... 5-4 Stability Fund........................................................................................................................................ 5-11

Pending Registration Changes Report..............................................................................................3-23, 3-28 Personal Health Numbers (PHNs)............................................................................................................... 4-5 PharmaCare/PharmaNet access ................................................................................................................... 6-5 PHC Complete Registration History Report ............................................................................................. 3-29 PHC Current Registrations Report ............................................................................................................ 3-28


INDEX Q

PHCO administration changes in practitioners......................................................................................................................... 2-25 locums ................................................................................................................................................... 2-25 ongoing requirements............................................................................................................................ 2-25 practitioner assignments........................................................................................................................ 2-25

PHCO Listserv .......................................................................................................................................... 2-24 PHCO single MSP Payee Number .............................................................................................................. 4-5 PHCO Site Analysis .................................................................................................................................... 2-3 PHCOs................................................................................................See Primary Health Care Organizations PHCTF ............................................................................................See Primary Health Care Transition Fund PHNs ................................................................................................... See Personal Health Numbers (PHNs) Physicians

adding to the PHCO .............................................................................................................................. 2-25 deleting registration with the PHCO..................................................................................................... 2-25 modifying registration with the PHCO ................................................................................................. 2-25

Practitioner numbers.................................................................................................................................... 4-5 Practitioners

adding to the PHCO .............................................................................................................................. 2-25 deleting registration with the PHCO..................................................................................................... 2-25 modifying registration with the PHCO ................................................................................................. 2-25

Pre-natal care............................................................................................................................................. 4-18 Primary Health Care Branch

contact information ............................................................................................................................... 1-10 Primary Health Care Branch Web site ........................................................................................................ 6-4 Primary Health Care Compendium ............................................................................................................. 6-4 Primary Health Care Organizations

benefits to health care providers ............................................................................................................. 1-7 benefits to patients .................................................................................................................................. 1-6 definition of............................................................................................................................................. 1-6 overview of funding for .......................................................................................................................... 1-8

Primary health care renewal key goals ................................................................................................................................................. 1-4 models of care ......................................................................................................................................... 1-4

Primary Health Care Transition Fund (PHCTF) ......................................................................................... 1-5 Primary health care, definition of ................................................................................................................ 1-3

Q

Quarterly Reports ........................................................................................................................................ 5-5

R

Recently Applied Registration Changes Report ........................................................................................ 3-30 Registration data submission

assigning patients to specific practitioners............................................................................................ 3-11 de-registering a patient using HNWeb.................................................................................................. 3-19 de-registering a patient using Teleplan ................................................................................................. 3-18 HNWeb ................................................................................................................................................... 3-4 modifying an Administrative Code....................................................................................................... 3-14 reassigning a patient to another PHCO practitioner.............................................................................. 3-15 registering a patient using HNWeb....................................................................................................... 3-10 registering a patient using Teleplan ........................................................................................................ 3-9 registration effective dates

backdating by PHCO........................................................................................................................ 4-13 backdating by the ministry................................................................................................................ 4-12 changes by the ministry .................................................................................................................... 3-13

setting an Administrative Code............................................................................................................. 3-12

Primary Health Care Organizations: Policies and Procedures 5 Version 1.0 – October 2004

S INDEX

submitting override requests using HNWeb ......................................................................................... 3-26 submitting override requests using Teleplan......................................................................................... 3-25

Registration overrides................................................................................................................................ 3-25 Registration reason codes.......................................................................................................................... 3-24 Registration reviews .....................................................................................See Monthly registration reviews Rural Health Programs ................................................................................................................................ 6-8

S

Service location codes ................................................................................................................................. 4-7 Service outflows.......................................................................................................................................... 2-6

calculation of actual service outflows ................................................................................................... 5-11 calculation of estimated service outflows ............................................................................................. 5-10 Stability Fund........................................................................................................................................ 5-11

Site Set-up applying for Teleplan service................................................................................................................ 2-22 asigning practitioner payments to PHCO.............................................................................................. 2-21 checklist for PHCOs ............................................................................................................................. 2-19 contact information ............................................................................................................................... 2-18 designating PHCO contacts .................................................................................................................. 2-24 eligiblity requirements ............................................................................................................................ 2-8 HNWeb Secure Web Site for Practitioners........................................................................................... 2-23 MSP Practitioner Number ..................................................................................................................... 2-20 PHCO Listserv ...................................................................................................................................... 2-24 Single MSP Payee (Payment) Number ................................................................................................. 2-21 Teleplan software compliance............................................................................................................... 2-22 transfer of payments to single bank account ......................................................................................... 2-22

Special fee items.......................................................................................................................................... 4-8 Stability Fund ............................................................................................................................................ 5-11 Structured Collaborative Participation Incentive ........................................................................................ 6-7

T

Teleplan Support Centre.....................................................................................................................1-10, 3-7 Third party billings.................................................................................................................................... 4-15 Third party services ..................................................................................................................................... 2-6

Y

Year end .................................................................................See Payments to PHCOs: annual reconciliation


Primary Health Care Renewal In Bc

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