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Introducing the Enhanced Provider Pay-for-Performance Program

At Highmark Wholecare, we value the important role practitioners play in serving our members. We support recognizing and rewarding performance for those practices committed to providing quality healthcare that is accessible and efficient. Therefore, working collaboratively with an advisory work group of network primary care practitioners, (MD, DO, NP, OB/GYN, and DDS) Highmark Wholecare would like to welcome you to the enhanced Practitioner Excellence Program. This program supports Highmark Wholecare’s mission to improve the health and wellness of the individuals and the communities we serve by providing access to integrated, superior health care.

Program Overview

  • Providers must opt-in to the program (either/both the Highmark Wholecare Practitioner Excellence (HWPE) Program and the Maternity Quality Program) to be eligible for payments.
  • Providers must meet the minimum membership requirements noted in the Who Is Eligible for the Program section below.
  • Each measure within the HWPE requires the entity to have a minimum of 10 members in the denominator to qualify to be scored. The measures within the Maternity Quality Program have a minimum requirement of 20 deliveries within the measure year.
  • Following the completion of the 2023 HWPE Program, eligible providers will receive one payment. Payment will be made by June 30, 2024, to allow for final claims runout and data analysis.
  • Payments can be earned through benchmarks and/or a percentage point improvement over the prior year’s performance. Additional percentage point improvement dollars can be earned through Health Equity Measures, for year-over-year improvement for black members within specific measures.

Who is Eligible for the Program?

2023 Medicaid Program:

  • Minimum panel size requirements are a combined membership of 500 for both Medicare and Medicaid lines of business at the entity level.
  • Primary Care Physician: Family Practice, Internal Medicine, Pediatricians, Certified Registered Nurse Practitioner, Physician Assistants, Obstetrician.
  • Dentists (no minimum panel size required).


2023 Medicare Program:

  • Minimum panel size requirements are as follows
    – 100 Medicare members at the entity level OR 500 combined Medicare/Medicaid members at the entity level (membership is through assignment).
    – Federally Qualified Health Centers (FQHCs) are automatically eligible.
  • Primary Care Physician: Family Practice, Internal Medicine, Pediatricians, Certified Registered Nurse Practitioner, Physician Assistants.

Presentation
Highmark Wholecare Practitioner Excellence (HWPE) Incentive Program Guide

If you have any questions about the Practitioner Excellence pay-for-performance program, please contact your Highmark Wholecare Clinical Transformation Consultant or your Provider Account Liaison.

Last updated on 4/26/2023 10:45:17 AM

 

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Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.