August 29, 2019, 03:20 pm Sheri Porter – In direct response to a resolution adopted by the Academy's 2018 Congress of Delegates, the AAFP Board of Directors has approved a new policy that addresses the inability of some health plans to accept supplemental data from physicians who are participating in value-based contracts.
The issue revolves around payers and billing software vendors who accept only a limited number of codes on claims, as well as patients who seek medical care services outside of the physician practice that may not be submitted to the payer.
That means physicians have to fill in the gaps with supplemental data they retrieve from other pieces of a patient's medical record.
David Howlett, M.D., of Windsor, Conn., authored the 2018 COD resolution. In a recent interview with AAFP News, he said if insurance companies want to base physician payment on performance, then the data behind it must be accurate.
"Often, claims-based data is not correct, but some contracts do not allow for validation of the data," he explained.
"For example, if the insurer says that their data show our practice only performed 50% of the colonoscopies that patients needed, but our internal data shows that we did 80% -- the payer will only use their numbers and not the actual data from our charts.
"That seems a bit unfair," said Howlett.
The policy, titled Payer Acceptance of Supplemental Data, notes that physicians rely on the accuracy of the claims they submit to payers -- and then on the data reported back from those health plans -- because those details determine whether a physician is eligible for shared savings and other kinds of value-based payments.
To accurately assess a physician's performance, health plans and their intermediaries must be able to accept all of the data submitted, says the AAFP policy.
"The consequences of a health plan's inability to accept and record data may result in physicians not receiving payment otherwise earned under a value-based contract," the policy continues.
In addition to the new policy on this issue, the AAFP also crafted model guidance and a chart showing which of the top five payers with whom the AAFP has working relationships accept supplemental data for commercial or Medicare Advantage plans. That chart will be updated as necessary.
Currently, two of the payers accept supplemental data for both commercial and Medicare Advantage, and the other three have made some progress toward resolving these issues.