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Pay for Performance Program

Date: 03/29/22

Ambetter is proud to announce our 2022 Pay-for-Performance (P4P) program. The program is designed to enhance quality of care through a focus on preventive and screening services while promoting engagement with our members. Based on program performance, PCPs are eligible to earn additional compensation to what you are paid through your Participating Provider Agreement. The P4P program is upside only and involves no risk. Providers are automatically enrolled in this incentive program.  

There are 10 measures included in the program. Each measure has its own incentive payment once the PCP reaches the target score.  PCPs who achieve Target 1 receive 75% of the payment incentive amount. PCPs who achieve Target 2 receive a full 100% payment of the incentive amount. 

 

2022 Measure List

Measure Incentive

Target 1

Target 2 

Antidepressant Medication Management (AMM):

Effective Acute Phase Treatment

$25

72.74%

76.05%

Antidepressant Medication Management (AMM):

Effective Continuation Phase Treatment

$25

72.74%

76.05%

Appropriate Treatment for Children with Pharyngitis (CWP)

$25

76.83%

80.95%

Asthma Medication Ratio (AMR)

$25

75.00%

90.00%

Cervical Cancer Screening (CCS)

$25

64.97%

71.47%

Chlamydia Screening in Women (CHL): Ages 16-20

$25

52.96%

58.95%

Chlamydia Screening in Women (CHL): Ages 21-24

$25

52.96%

58.95%

Comprehensive Diabetes Care- Eye Exam (CDC-DRE)

$25

52.80%

59.45%

Monitoring for Warfarin (INR)

$25

75.00%

90.00%

Proportion of Days Covered (PDC)- Diabetes All Classes

$25

80.23%

83.13%



 

 

 

 

 

 

 

 

 

 

 

Quality Bonus Instructions

  1. The measurement period is Jan. 1 to Dec. 31, 2022. Ambetter must receive all claims/encounters by Jan. 31, 2023.
  2.  Schedule and conduct an exam with the eligible member using the Healthcare Effectiveness Data and Information Set (HEDIS®) reports (available on the secure provider portal under Provider Analytics) as guides to close care gaps and update diagnoses.
  3. Prescribe appropriate medications to your members and encourage them to fill their prescriptions that align with best prace.
  4. Upon completion of the examination, document care and diagnosis in the patient’s medical record and submit the claim/encounter containing all relevant ICD-10, CPT and/or CPT II codes.

 

Payment Timeline

 

There will be three payouts made. At this time, payments should be expected after Q2/ Q3 /Q4 with a  final reconciliation around mid-2023, each report netting any prior payouts against the total earned.

Additional Information

More about the P4P Program:

  • Each measure is evaluated if there is at least one (1) qualifing event in the denominator. Providers can qualify and receive an incentive payment for one, multiple, or all of the measures.
  • Target 1 is set at the QRS 4-Star target and Target 2 is set at the QRS 5-Star target.
  • Gap closure rates/scores are accumulated based upon member assigned PCP. The assigned PCP receives credit for gaps closed.
  • Monthly performance reports and care gaps will be placed on the secure provider portal under the Provider Analytics option.
  • P4P math for target payouts
    • (Incentive Amount) x (Number Compliant) x (75% for reaching Target 1 or 100% for reaching Target 2).
  • No bonus is earned if the minimum target is not achieved.
  • The Provider Analytics tool on your provider portal can help you view your membership and access HEDIS® reports as guides to close care gaps and earn incentives for this program. You can access Provider Analytics through your provider portal at: https://provider.azcompletehealth.com/.

Important Contact Information
If you have questions about our P4P Program, please contact your
Provider Quality Liaison or email the Provider Outreach Team: QIProviderOutreach@azcompletehealth.com