GMP Network prides itself on being a physician-led network that drives better patient outcomes, more holistic care practices, and multidisciplinary collaboration throughout the region. The Provider Delivered Care Management (PDCM) model is one of the many ways GMP Network seeks to empower its partner physicians to align their patient care philosophies with accountability and compliance.

 

What is PDCM Validation?

PDCM, which is part of Blue Cross Blue Shield of Michigan’s Patient-Centered Medical Home (PCMH) program, involves the creation of personalized patient care plans developed by a multidisciplinary care team and tailored to each patient. This approach allows for more comprehensive, whole-person treatment and care plans as opposed to standardized one-size-fits-all approaches to care that often fail to meet patients’ diverse health and wellness needs and ultimately create service gaps in care.

 

PDCM validation requires practices to undergo confirmation by payers, oversight bodies, or internal audit teams to ensure that PDCM-billed services align with the program’s quality standards and documentation requirements. This process helps minimize the risk of incorrect billing, lack of physician accountability, and misalignment with program values, while also helping practices remain in compliance with the program.

 

While practices may experience an array of PDCM validation processes, most often this undertaking involves a few key steps:

 

• Pre-verification preparation involves the practice gathering outreach lists, care plans, case notes, and other forms of documentation to ensure that PDCM patients are fully qualified for the program and that there’s a clear workflow in place regarding which staff members consult on program patients. The validating entity then typically selects a sample of patients for the verification process and requires full patient chart documentation and data.

 

•After sample patients have been selected, verifiers then perform a full chart and documentation review to compare billed service codes with actual activities documented, checking for both consistency and completeness in all documentation, patient consent forms, and insurance coverage.

 

• Through this comprehensive review, validation entities will consistently be checking for program compliance and noting any discrepancies or potential gaps in care. Auditors may, in turn, publish a report outlining remediation or corrective actions that a practice must undertake to ensure compliance with the PDCM program, such as repaying improperly billed amounts.

 

• After a practice has undergone the validation process and performed any necessary remediation, continuing internal reviews are ideal for ensuring quality assurance and keeping in compliance with the guidelines of the PDCM program, including continuing to refine practices when care gaps are identified.

 

GMP Network believes in the power of collaborative, value-based care models that improve patient outcomes and increase efficiency within physician practices. A comprehensive validation process doesn’t just ensure compliance; it also enhances physicians’ ability to provide high-quality, patient-centered care — a cornerstone of GMP Network’s physician support philosophy.