IPA Foundation presentation to IPAs Bankmed GP Provider Network & PHA

History Formation of IPAs – since early 1990’s Operational IPA offices with IT infrastructure Monthly CPD meetings Monthly newsletters, communications Many registered as MCOs with CMS Some products: –Capitation products (> lives) –Enhanced FFS product (> lives) –HIV Network –Disability Grant assessments –In-house Software –Reps on the road Profiling and Peer Review conducted

INVITATION November 2006 –Summit – Bankmed and IPA and GP groups –Agreed to work together to promote the GP as the Coordinator of Care –Negotiating Team formed

IPA Foundation Structure Funded by member IPAs To become the Representative Contracting Body of IPA organisations Facilitate formation of a Nationally contracted GP Network Contract with all willing general practitioners (IPA & non-IPA providers) Provide Network Management Services Perform Profiling and Peer review

Organogram ASAIPASAMCCSPNet IPA Foundation – network management Bankmed Administration Profiling Bankmed Contracted GP Network IPA Foundation Contracted GP Network

Profiling IPA Foundation National Peer Review Committee IPA Peer Review Committee Regional Peer Review Committee

Bankmed Goals Phase 1 –Formation of a DSP / PPN network –Enhanced remuneration (on Savings) –Cost containment – Profiling –Wellness Initiatives –Core option Coordination of Care Chronic disease management Phase 2 –Quality care –Preventative Care –Health Outcomes Phase 3 –Risk Sharing

Reimbursement Matrix Bankmed Reimbursement by Scheme Plan for 2009 Scheme Plans Non-Contracted Provider Bankmed Contracted Provider IPA ProviderNon-IPA Provider Core SaverNHRPLR 250R 230 TraditionalNHRPLR 250R 230 ComprehensiveNHRPLR 250R 230 Plus300% of NHRPL Completion of PHANoYes R140

Bankmed Core Saver Plan Change from Carecross (2008) to IPA Foundation for 2009 Each beneficiary to be registered with Bankmed contracted provider Consultations –Contracted and IPA affiliated – R250 –Contracted and non-IPA affiliated – R230 Chronic disease management –Share in savings achieved

Other Bankmed Scheme Plans Basic option – managed by Carecross Traditional and Comprehensive –Consultations – differential reimbursement (NHRPL/R230/R250) –Profiling –Share in savings achieved –DSP for primary care portions of PMBs Plus option –No change from current year

Bankmed GP Provider Contract (Summary) Appropriate, cost-effective, quality, ethical, accessible healthcare Maintain records & provide clinical information No balance billing Entitled to benefits as agreed between Foundation & Bankmed Submit to practice profiling Agreement for 1 year, notice period 90 days

Bankmed PHA Contract (Summary) Personal Health Assessment (PHA) –Part of Wellness Initiative –Only Contracted providers may participate –Fee of R140 per completed questionnaire paid to provider –Not paid from patients savings account –Complete PHA questionnaire online or submit by fax (cost from global fee) –Submit account to Bankmed – using unique tariff code –Follow instructions as per SOP/manual

IPA Foundation Contract (Summary) Conduct Profiling, utilisation & Peer Review Comply with minimum network requirements as may be determined Furnish all claims, data, clinical information to Foundation, as required from time to time Comply with HPCSA rules Personally responsible for treatment and well-being of patients Provide appropriate, cost effective, quality, ethical, accessible healthcare

IPA Foundation contract contd (Summary) Referrals are relevant, appropriate To sign Form of Accession (FOA) to participate in any IPAF contract with other schemes in future Endevour to maintain computer and EDI sunmission of claims – not compulsory Protect confidentiality of the patient Adhere to formulary, guidelines approved To inform IPAF of any changes to provider information

IPA Foundation contract contd (Summary) Be entitled, if provided for, to bonus, risk pools, alternative reimbursement Authorise IPAF to discuss with Funders to perfrom contract maintenance If continuosly fails Reviews, for penalty &/or termination of contract To carry medical indemnity / insurance Under no obligation to accept any contract negotiated bet IPAF and Funder – free to reject Enter into agreement in personal capapcity

Implementation Communication to providers Contracting with Providers Communication to Medical Scheme members Registration of members to providers

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