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Everyone needs a Roger.

Roger Percy, a certified registered nurse practitioner at Butler Health System (BHS) Primary Care, Nallathambi Medical Associates, decided there had to be a better way to handle the Unconfirmed Diagnosis Code (UDC) program forms Highmark sends to the practice's office periodically.

Highmark launched the program in 2015 to work proactively with primary care practices so Highmark Medicare Advantage members’ chronic conditions are addressed annually and to improve the quality and continuity of care.

Butler Health System (BHS) Primary Care, Nallathambi Medical Associates

Office locations: Butler and Cabot, Butler County
Services: Complete primary care services
Staff: 3 PCPs, 1 PA, 1 CRNP, 2 RNs, 7 CMAs, 7 clerical/medical support staff

Like some practices participating in the UDC program, Nallathambi Medical Associates experienced challenges in getting the diagnosis information to its doctors in a timely manner.

Before Roger’s initiative, the UDC forms sat on a desk. When a Highmark member came for an office visit, someone searched the stack for the member’s form. If the form was found before the end of the office visit, it was given to the doctor to review with the patient. Then the form went back in the pile for final processing.

Because of the labor-intensive process, some UDCs were going unchecked, and not all members were being evaluated annually for all of their chronic conditions. Also, the practice was missing an opportunity to earn program compensation that’s available for returning accurate, complete forms to Highmark.

People Notice a Good Thing

Initially, Roger handled the UDC forms for Dr. Nallathambi. He was so appreciative of Roger’s time and efforts that the other doctors in the practice noticed and asked Roger to handle the UDC forms for their patients as well.

So Roger created a new process.

The practice manager, Tammi Chamberlain, reviews the next day's patient appointments with the UDC forms on hand. When she finds a match, she makes a copy of the UDC form and passes it on to Roger.

He researches the diagnosis information in the patient’s electronic medical record (EMR), updating any diagnosis with clinical and lab results. He then adjusts the problem list to include any suspected, but unconfirmed, diagnoses.

He adds the information to the assessment portion of the patient’s record, so the doctor has quick and easy access to the summary. This new process saves more time for the doctor and improves the quality of care the patient receives. Chamberlain says, “It makes it so much easier for the doctors, and we have a more accurate health record, including test results.”

Since there is more information on the form now than in prior years, the initial prep work with the patient’s electronic medical record does take time. “But, putting this information in front of physicians is worth the effort, especially when it translates into better patient care,” said Lisa Percy, quality manager.

For example, the forms note patients with a persistent diagnosis, but Highmark also alerts PCPs about patients with a suspected diagnosis. These are based on claims data like lab results, radiology information, pharmacology data, and other clinical data that may indicate a patient has a specific undiagnosed condition.

By entering the data in the patient’s health records and adding a note to alert the doctor of the UDC information, practice staff enable the doctor to address the chronic conditions, persistent or suspected, with the patient.

And, at Nallathambi Medical Associates, these efforts are indeed bearing fruit.

Hard Work Pays Off — for Patients and the Practice

In 2017, the practice evaluated and responded to more than 1,400 unconfirmed diagnoses. Of that number, more than 1,100 diagnoses were either confirmed or resolved, providing for better patient care.

Lisa Percy recalls that one of the doctors, after reviewing a condition from the UDC form with the patient, called a specialist who diagnosed the patient. This conversation gave the doctor a more complete picture of the patient’s overall health, allowing for better clinical decisions. 

Under Nallathambi Medical Associates' old process, out of 10 UDC forms the practice submitted, about three or four were not eligible for program compensation. Now, out of hundreds submitted to Highmark, only one or two are returned. That's a tremendous time savings because forms don’t have to be corrected, reprocessed, and resubmitted.

Percy and the doctors consider the new process to be a success. “It's not hard. It does take a little bit of time, but if you have someone prep the medical records, it's definitely worthwhile," she said.

Through Highmark's UDC program, providers can earn:

  • $125 per member form if they return less than 60 percent complete and accurate
  • $150 per member form if they return between 60 and 74.99 percent complete and accurate
  • $165 per member form if they return 75 percent or more complete and accurate

"The incentive is important to every office financially. It's easy money, really. And, we're saving a lot of time by not having to go back and do the forms again like we did under our old process,” Percy said.

Tips for Success

The practice offered these tips for success in the UDC program:

  • Check the UDC member roster against the daily patient schedule.
  • Prepare ahead of time — front-loading the UDC information into the patient’s medical record.
  • Flag the information so the doctor sees it during the patient visit.
  • Attend all the UDC webinars and rely on other training resources.

What Is the UDC program?

  • A proactive, clinically based effort between Highmark and providers to put persistent or suspected diagnoses in front of the doctor before the patient’s visit; these diagnoses may be pertinent for annual evaluation or treatment during the patient’s office visit
  • Includes previously reported and/or suspected diagnoses that may not have been reported to Highmark in the current year
  • Designed to improve continuity, quality, and timely coordination of care and to capture the complete and accurate health status of Highmark members

Keeping up with the Program

To increase the effectiveness of the UDC efforts, Percy participates in all program webinars and other Highmark training resources. She said that helps her to stay on top of quality initiatives and also works toward improving the practice's CMS Stars ratings and HEDIS® scores.

Chamberlain also appreciates Highmark's UDC program for those reasons.

“More important than the financial incentives we earn is that the UDC program helps us to provide the best patient care," she said. "It alerts us to possible unconfirmed diagnoses and gives us an opportunity to address those concerns with our patients.”

For more information about the UDC Program, visit Highmark's online Provider Resource Center via NaviNet®. Click on Education/Manuals and then Risk Adjustment Programs. The 2018 UDC Program materials will display and include slide presentations and webinars for PCPs and specialists, a program manual, and program instructions. 

Note: The best practices and interventions are presented for your consideration only. The best practices and interventions are not required by Highmark but may be appropriate for your practice. You may find that other practices and interventions are more suitable. Please note that the successful implementation of any practice or intervention depends upon many factors and variables. Therefore, Highmark makes no representation with respect to the described practices and interventions.