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Managing patient attribution panels worth the time and effort :

January 8, 2020

Editor’s note:This is the first of two articles looking at how pediatricians should maintain accurate patient attribution and its impact on a practice’s value-based payment. 

About half of general pediatricians are involved in a value-based payment model, according to a recent AAP Periodic Survey of Fellows ( Models include bonus payments for performance in addition to fee for service; capitation (per member per month payments) for sick care, well care, chronic care or all three (with “bill-aboves” for certain procedures); and per patient per month payment for care coordination services with varying levels of payment based on the patient case mix and severity (i.e., risk-adjusted payment).

Common to all advanced payment models is having a defined group of patients who are attributed to the practice (or provider). This attribution panel serves as the denominator for all other measurements and payment. When this list is incorrect, it dilutes the efforts of all parties involved:

  • Payers are not assuring highest value care can be delivered because they are not communicating accurate, actionable information to the provider.
  • Practice time and resources are wasted when working from inaccurate lists. For example, you may not know you are being held responsible for some patients and have no contact information for them.
  • Patients are not receiving outreach for important services from their medical home.

Practices can do the following to manage their attribution panel.

Routinely manage active patient lists.

This requires people, processes and technology. First, you must understand how to indicate in your electronic health record (EHR) or practice management system (PMS) which patients are active. Practices should have a process to maintain active patient lists, which includes ongoing, regular maintenance.

Key considerations for both primary care pediatricians and specialists include:

  • Do you routinely transition teens/young adults to an adult provider when they graduate from high school or college or turn 21?
  • Do you ensure patients who leave your practice (e.g., transition to adult provider, move out of area) are appropriately transferred and mark in your system as transferred?
  • Do you periodically (e.g., semi-annually) run a report to identify all patients not seen in your office in the last two or three years and attempt to engage them or inactivate them?

Obtain attributed patient roster lists from major payers at least quarterly.

Most payers will tell you their methods for attributing patients to you are proprietary and will not share their methodology. However, they should be willing to share their list/panel roster with you.

One exception is health maintenance organization (HMO) plans, which include most of the Medicaid managed care products. HMOs require their patients to choose a primary care physician (PCP); those patients are automatically on your panel roster.

Have a procedure to reconcile your list with the payer list.

You should have the ability to run a report from your EHR or PMS based on active patients by payer. When comparing the payer attributed patient list with your list, you will find three groups of patients:

  1. Patients both parties agree should be attributed to your practice or national provider identifier (your medical home).
  2. Patients the payer attributes to your medical home, but you don’t know them, have been unsuccessful in outreach or have them associated with a different payer. This group may include those never seen by any provider during the time period but that were auto-assigned to you by the managed care organization (MCO), or the family chose you as their PCP but never sought care. They also may be parents to whom you administered a flu vaccine but never got care elsewhere or a visitor you saw once.
  1. Patients you care for in your medical home but the payer has not attributed to your practice.

Aligning your medical home list with your payer’s list of members you are graded/paid on is essential to proving your value and improving your payer partnership. If possible, check patient panel assignment before each visit when you verify a patient’s coverage.

Alert the MCO regarding inappropriately attributed patients. Ask all payers to provide their process for moving patients on/off your attributed panel.

As part of contracting (or re-negotiating a contract) with a payer, practices should define a mutually agreeable way of reconciling attributed patient panels. For example, if a practice attempts to contact a family three times in three different ways and cannot make a connection, the patient should be removed from the practice panel. Similarly, adult patients who are erroneously attributed to a pediatric practice should be removed upon request.

For the MCO to agree to a process, there has to be mutual benefits. Practices should work with the payer to engage patients who should be receiving care and use family contact information the payer can provide. This work must be ongoing.

Drs. Kressly, Barabell and Schonfeld are members of the AAP Payer Advocacy Advisory Committee.

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