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 is often 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 cost, quality and outcomes. We created a continuum of programs to encourage primary care physicians in their development of population health management capability and focus. As a PCP develops these capabilities, there is additional opportunity to advance down the continuum along the “path-to-risk” or full accountability.

Humana’s Provider Quality Rewards Program supports providers along the Continuum of Care. Our Rewards Program meets the provider practices where they are in their current practice model to help them move across our value-based programs.

Star Rewards Program

Humana’s Star Rewards Program is an integral part of Humana’s Accountable 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 Information Set (HEDIS®) measures. The 2014 Star Rewards program provides incentives to providers who meet two-thirds of six HEDIS metrics. Providers who meet these metrics receive an annual reward payment. Participating Humana PCPs automatically receive an invitation to participate in our Star Rewards program.

Model Practice Program

The next level on the continuum is our model practice program. Physicians earn incentives for each HEDIS measure they achieve. Additionally, providers can also earn incentives for achieving specific clinical initiative targets. Providers will receive reward payments for achievements in the model practice program on a quarterly basis and are also eligible for shared savings opportunities. In 2014, we added patient experience as a focus area. An additional annual bonus will be given to provider practices that attain an 80 percent patient experience rating on the Humana patient experience survey. Participating PCPs with 250 or more members are eligible to participate in Humana’s Model Practice Program. This is a Humana-contracted program.

Medical Home Program

The next level is the medical home program. This program is offered to practices that are either patient-centered medical home (PCMH) certified or in the certification process. These practices have made progress addressing some of the requirements necessary to transform their practice in order 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 the practice. Medical home program participants should meet the same reward measures as model practice; however, this program offers a care coordination fee 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 certified or are in the process of becoming certified may be eligible to participate in Humana’s medical home program. This is a Humana-contracted program.

About Humana’s Rewards Program

Humana began the fifth year of its Provider Quality Rewards Program in 2014. In 2013, Humana made a total of $60 million in pay-for-value reward payments to participating provider practices.


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