Family Choice Initiatives and Updates for Improved Healthcare Services

IPA Presentation March 30, 2022

INTRODUCTION Family Choice is committed to following: Keeping providers well-informed Excellence care coordination to members Concierge services to both providers & members Phone 1: 800-611-0111 Phone 2: 818-817-1623 Fax: 818-817-5000

CHANGES, CHALLENGES, AND CRISIS COVID-19 (Delta, Omicron, Subvariant BA.2) Inflation Ukraine War (Increases in Fuel & Gas Prices)

CALOPTIMA VS. KAISER PERMANENTE Robust IT department All-inclusive services system Restricted panel of specialists and primary care physicians Cherry-pick Members

CALOPITMA RECENT PRESS RELEASE Easy Access (Same Day Authorization of Specialized Services) Same Day Processing Claims (Expansion of PCP and SPC Panel) Street Medicine Cal-Aim

FAMILY CHOICE UPDATES Family Choice Application for Restricted Knox Keene (RKK) Network Adequacy (Contract with other OC Hospitals & Expansion of Providers Panel) Additional CAP for Providers who serve members with mental health illnesses and homelessness. (Submit Encounter Data) Merit-Based Incentive Distribution

Introduction Family Choice Initiatives PCP Care Coordination Referral and Follow-up for Specialty Visits AGENDA

OVERVIEW: FAMILY CHOICE INITIATIVES Family Choice has undertaken several initiatives in response to the CalOptima rates cuts: o Reducing PCP cap o Ensuring VSP is paying for routine eye exams, especially diabetic screening o Scrutinizing use of ancillary services PT repeatedly and routinely asks your office to request thousands of dollars of services o Eliminating routine approval of high acuity codes 99204, 99205, 99215, 99245 and 99255 these will require your office to submit notes o Specialty/ancillary self-referral will require medical justification that demonstrates care cannot be delivered by the member s PCP o Increasing HEDIS payments and patient satisfaction o Improving RAF scores through improved documentation

OVERVIEW: FAMILY CHOICE INITIATIVES Eliminating routine approval of high acuity codes 99204, 99205, 99215, 99245 and 99255 these will require PCP office to submit notes 99204: a comprehensive examination; medical decision making of moderate complexity. Counseling and/ or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.

OVERVIEW: FAMILY CHOICE INITIATIVES Fraud, Waste and Abuse: Fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get money.Waste is when someone overuses health services carelessly. And abuse happens when best medical practices aren't followed, leading to expenses and treatments that aren't needed.

OVERVIEW: FAMILY CHOICE INITIATIVES Neutral/cost-based budgeting: One strategy for controlling specialty/ancillary costs is to set a target for the specialty and adjust the fee schedule as utilization varies Fee schedule x utilization = total cost Another strategy is to narrow the network and capitate the specialty One of these strategies needs to be adopted if high volume/high cost specialties Ophthalmology, Cardiology and PT continue to grow at unsustainable rates

PCP CARE COORDINATION PCP care coordination is the backbone of managed care and the strength of FCMG s continued success Reduces readmissions Avoids duplication of services Eliminates unnecessary ED utilization Enhances HEDIS scores Ensures care is comprehensive and effective Improves patient satisfaction PCP engagement tracked through submission of encounter data

PCP CARE COORDINATION To ensure care coordination is taking place, FCHN allows 2 specialty visits per authorization and 12 ancillary Units (97110--3 hours of PT) Additional requests for services should involve a PCP visit Specialists need to submit notes back to the PCP with directions for follow up or additional services required

REFERRAL AND FOLLOW UP FOR SPECIALTY VISITS Direct referral to network specialists was always intended to cover two visits Expectation that PCPs will re-engage at that point with specialty guidance PCPs routinely being asked to authorization 4-6 specialty visits PCPs are expected to more closely monitor their members

Please fill out the evaluation form and return it to Family Choice within 30 days to receive the meeting stipend. EVALUATION FORM

Q&A SESSION