As fall approaches, I'd like to focus on the leading cause of death in U.S. hospitals – sepsis. My mother nearly died from sepsis in 2019; she had septic shock and required ICU care. While my mother required critical care, I've heard of other patients who were discharged in under 24 hours without antibiotics. These vastly different clinical circumstances spurred me to research and spread awareness about sepsis.

Sepsis can develop when the body’s normal reaction to fight an infection goes awry and can quickly become life threatening. Each year, 1.5 million Americans are diagnosed with sepsis, with a 30% mortality rate.

What can you do:
Sepsis can be difficult to diagnose and treat, and the current screening tools for sepsis aren’t diagnostic. Because of this, our medical team noticed discrepancies regarding sepsis diagnoses, chart coding and inpatient length of stay (LOS). By looking at the full clinical picture when diagnosing and initiating treatment, you can help address these discrepancies to offer the best recognition, coding and care possible.

Elements to consider:

• Our data reveals sepsis and septic shock have been coded for LOS of less than three days. Given the severity, we anticipate inpatient LOS to be more than three days.
• Patients should receive education on how to recognize the signs and symptoms of sepsis, so they don’t wait until they “feel bad” to seek medical attention.
• Upon discharge, patients must finish their antibiotic regimen to avoid antibiotic resistance. If they’re feeling better, this does not mean they can stop the antibiotic or keep them for the next time they feel sick.

At Priority Health, we work with providers like you to ensure our members receive the quality care they need to be safe and healthy, at all levels. Together we create visible value through health care innovation. This is especially relevant with sepsis, for our patients and our community.

Please feel free to share your questions or comments using this form.

Best wishes,
Richard Vienne, DO

Providers only have one appeal right per Priority Health claim. Use the steps below to solve claim issues before submitting an appeal:

1. Check the status of your claim: In prism, you’ll find the most up-to-date billing information, claim status and tools to help you get answers
2. Submit an informal claim review: Get answers to general questions on the claim including details about the claims process, ambulatory payment classifications edits (APC), billing and more.
3. Review your appeal submissions carefully: All submitted appeals are treated as official. Make sure any third-party billing companies using prism on your behalf know this.
   
   • If we receive an incorrect appeal or one submitted by mistake, we'll still treat it as an appeal, comment back and close the inquiry. There won't be another opportunity to appeal that claim.

Together, we can close your patients’ gaps in care. From preventative screenings to managing chronic conditions, we’re here to support you. Get information on our latest Medicare & Medicaid quality information, provider tools and member benefits.

We appreciate your partnership as we work to provide the right care, at the right time, in the right place and at the right cost. We’re continually evolving our incentive programs to help us achieve these goals and to recognize the hard work you do to keep our members healthy.   

Below you’ll find key incentive program updates and deadlines for the third quarter of 2022.  

PCP Incentive Program (PIP)

PIP manual
We’ve updated our 2022 PIP manual. To download the latest version:

1. Log into your prism account
2. Click Provider Incentive Programs
3. Click PCP Incentive Program
4. Click the 2022 PCP Incentive Program Manual link to download the PDF

2021 Quality Awards
Drumroll… We’ll be announcing our 2021 Quality Awards winners very soon. Which practice groups are the best of the best in Michigan? Stay tuned to priorityhealth.com and our social media channels.

Behavioral Health Collaborative Care (BHCC) meeting
Attend our next BHCC meeting:

When: September 15 at noon
Where: Virtual (registration link below)

Join us to share best practices, discuss collaborative care case studies and talk about implementation barriers. Attendance is highly encouraged for at least one behavioral health care manager representing your practice.

Register online

Provider Roster App (PRA)

Download * our updated 2022 PRA Manual, which details:  

• Our expansion of the PRA tool to support data management for ACNs with Global Risk Arrangements 
• The quarterly attestation cycle calendar for 2022, with the fourth opening
  September 5
• How attestation is now required for both PIP and GRS settlement payments 

ACN requirement

An accountable care network’s (ACN's) larger membership base and expanded resource availability serve as the gateway for the provider community to participate in and receive an incentive payment for our value-based programs.

Beginning Jan. 1, 2023, to participate in and be eligible for incentive payments through our value-based programs, providers must be aligned with a qualified ACN.

Visit our website * to learn more about: 

• How we define an ACN
• What eligibility standards we have for our ACNs
• What are the ongoing responsibilities of our ACNs
• ACNs which are currently open to independent providers

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See the latest news posted to our website from April to June:

AUTHORIZATION NEWS

• Ensuring accurate Elective Inpatient Admission authorization reviews
• GuidingCare upgrade, 2022 InterQual criteria update coming this August

BILLING & PAYMENT

• New clinical edits coming Sept. 15, 2022
• New clinical edits implemented in June 2022
• New billing guidance for follow-up colorectal cancer screenings
• New clinical edits for professional and facility claims
• New clinical edit and medical policy for pain management
• New virtual care billing requirement for FQHCs and RHCs
• Reporting other insurance on Medicaid claims for vision, NEMT and MIHP providers
• Change to referring/ordering/attending editing for Medicaid claims
• Appeal vs claim inquiry: Steps for faster claim resolution

INCENTIVE PROGRAMS

• Aligning APCD data with value-based programs has never been easier
• New HEDIS® provider guide available
• HealthbyChoice incentive payments in April

PHARMACY

• Authorization required for select filgrastim drugs starting Aug. 1
• Site of service restrictions for oncology infusions
• July 2022 formulary changes
• Specialty drug savings program

PLANS & BENEFITS

• Age limits removed for ASD coverage

PRIORITY HEALTH NEWS

• Behavioral Health licensure expansion