Medicare rewards program

Provider Medicare Quality Rewards Program

The traditional fee-for-service reimbursement model revolves around sick care and paying for services provided rather than focusing on outcomes and aligning incentives. The misalignment inherent in the traditional model can lead to inefficiencies in care delivery, quality and outcomes. The pay-for-value model focuses on promoting evidenced-based, high-quality care that leads to improved care coordination, lower health care costs and better outcomes. The focus on the three areas of cost, quality and outcome often is referred to as the “triple aim.” Humana’s support of value-based reimbursement is the foundation on which we developed our Accountable Care Continuum.

We offer financial rewards for improvements in quality, outcomes and cost. We created a continuum of programs to encourage primary care physicians (PCPs) in their development of population health management capability and focus. As a PCP develops these capabilities, there is additional opportunity to advance across the continuum along the path to value or full accountability.

Humana’s Provider Quality Rewards Program supports physicians along the value-based-care continuum. Our rewards program meets practices where they are in their current practice models to help them move across our value-based programs.

Star Rewards Program

Humana's Star Rewards Program is an integral part of Humana's value-based-care continuum. As the first level of our pay-for-value programs, the Star Rewards Program focuses on achievements for specific National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) measures. The Star Rewards Program provides an annual reward payment to physicians who meet four of five HEDIS metrics. Humana-contracted primary care physicians may participate in Humana's Star Rewards Program unless contracted for Humana’s Model Practice, Medical Home or Shared Savings programs. Physicians contracted in full-value arrangements as of Dec. 31, 2016, are not eligible for Star Rewards.

Participating PCPs serving 250 or more Humana members are eligible to participate in Humana's Model Practice and Medical Home programs.

Model Practice Program

The next level on the continuum is our Model Practice Program. Physicians earn incentives for each HEDIS measure they achieve. Additionally, physicians can earn incentives for achieving specific clinical initiative targets. They receive reward payments for achievements on a quarterly basis and are eligible for shared savings opportunities. Physician practices that see at least 75 percent of their patients two or more times a year will receive an additional annual bonus. This is a program for Humana-contracted physicians.

Medical Home Program

The next level of Humana's rewards programs is the Medical Home Program. This program is offered to practices that are recognized as a patient-centered medical home (PCMH) or are in the process of obtaining recognition. These practices have made progress in addressing some of the requirements necessary to become successful population health managers. For example, PCMH program participants have implemented electronic medical records and likely use electronic prescribing systems. Additionally, they have made other infrastructure changes, including the use of a care coordinator in their practices.

Medical Home Program participants have the same reward measures as a model practice. However, the medical home program offers a care coordination payment to address the cost of infrastructure development and PCMH certification. To remain eligible for the care coordination fee, practices must meet the reward measures on a quarterly basis. Participating PCPs with 250 or more members who are medical home-recognized or are in the process of becoming recognized may be eligible to participate in Humana’s Medical Home Program. This is a program for Humana-contracted physicians.

About Humana’s Rewards Program

Humana began its Provider Quality Rewards Program in 2012. Approximately 4,465 physician groups received payments from Humana in recognition of improved outcomes for Humana’s Medicare members achieved during 2015. Those payments totaled more than $93.6 million.


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