Your PBPM, also referred to as your monthly Primary Care Capitation (PCC) payment, includes all Primary Care Qualified Evaluation and Management (PQEM) codes as defined by Medicare (more info available here). This one pager provides additional information on common codes Primary Care Physicians bill for PQEM Services that are included in PCC for ACO REACH. Medicare will assess how much you’ve received in payments for these codes based on Q1-Q3 of the prior year, and will begin extending this amount on a monthly basis regardless of services being rendered at the start of the Performance Year. Note that any services or codes that do not live on the PQEM list will be paid on the normal Medicare fee-for-service schedule in addition to the monthly PBPM payment.
Providers will not receive a monthly payment for any patients that are not aligned, but will continue to receive a FFS payment for those patients. You can begin collecting monthly payments for any patients not assigned by obtaining a signed voluntary alignment form. Once patients are aligned, you should expect to see payments in approximately 4 weeks. Payments will include any retroactive dollars.
You can go into the Pearl Platform to view payments for your claims aligned and voluntary aligned patients:
Log onto the Pearl Platform: https://app.pearlhealth.com/login/
2. Click on the Financials tab at the top of the page.
3. Download the CSV file or PDF on the latest statement to view payments for patients.
Please note that payments for patients can vary based on whether they are considered an Age and Disabled patient or End-Stage Renal Disease patient. The article linked here provides additional information.