New Primary Care Provider Auto-Assignment Policy for 2024
Beginning Jan. 1, 2024, members in all HMO products will no longer be automatically assigned to your practice, or remain attributed to you, unless they choose you as their primary care provider (“PCP”) or if a claim shows they have been cared for by a PCP in your practice in the last two years.
The previous policy, effective Jan. 1, 2023, allowed for PCPs to keep commercial and Medicare auto-assigned members regardless of whether the provider saw these members.
Medicaid members were previously automatically assigned select provider groups. To be consistent with state policy, Medicaid members will now be automatically assigned to provider groups based on demographic and location needs beginning in 2024.
Members for all lines of business will be attributed to your panel as of the date they chose you as their PCP. These members will remain paneled to your practice regardless of the utilization reporting process outlined below since they actively chose you as their PCP of record. For those members who did not actively chose you as their PCP, the following process applies:
- EmblemHealth will run a monthly claims utilization report for members in all lines of business with no assigned PCP to check for preventive visits, other evaluation and management (E&M) PCP visits, lab services referred by PCP, and prescriptions written by a PCP. If they have utilization with any of your PCPs, EmblemHealth will assign that member to your group as of the first of the month.
- A quarterly claims utilization report will be run by EmblemHealth to check utilization for all members currently assigned to PCPs for all lines of business. If members continue to use PCPs in your practice, then they will remain with your group. If, however, your members have been cared for by a different PCP, they will be assigned to that PCP starting on the date of that PCP visit. In the event a member does not have utilization with any PCP, in your group or otherwise, they will no longer be attributed to your practice.
- Capitation payments will be impacted by these changes, and recoupments and additional payments may be initiated, as applicable.
By implementing this new PCP assignment process, we aim to support proactive patient engagement and foster of good provider-patient relationships.
Assisting members with their PCP selection in this manner helps to facilitate any possible clinical care coordination, should it be necessary, and helps empower the member to achieve better overall wellness. We believe this change will help connect our members to the quality health care you provide and enable insights that accurately reflect the members whose care you manage.
JP 64134 12/2023