Michigan Osteopathic Association Conference

November 6, 2015

Provider Consultants

Ben RussSandy Stimson

Objectives -

• Physician Group Incentive Program (PGIP)• Provider Servicing Blue Cross• Clinical Edits – BCN and Blue Cross• Provider Enrollment • eviCore • GeoBlue• Panel Discussion

The Physician Group Incentive Program and Creating a High Performance System:

Aligning the Payment Model

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2005 ‘10

Patient-Centered Medical Home (PCMH)

Provider-Delivered Care Mgt. (PDCM)

‘09‘07 ‘08‘06 ‘11 ‘12 ‘13 ‘14

Value Partnerships ProgramCatalyzing Statewide Health System Transformation in Partnership with Providers

Patient-Centered Medical Home – Neighbor (PCMH-N) & Organized Systems of Care (OSC)

Physician Group Incentive Program (PGIP)

‘15

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Expansion of Hospital Collaborative Quality Initiatives (CQI)

High Intensity Care Model

Physician Group Incentive Program/ Patient Centered Medical Home (PGIP/PCMH)

PGIP began in early 2005- 46 participating physician organizations (POs)- 19,000+ participating practitioners

• Over 5,800 PCPs and over 13,500 specialists

- PGIP participating physicians in 81 of 83 counties- Over 68% of network PCPs & over 51% network specialists participating in

PGIP- PGIP-participating practitioners provide care to 2+ million commercial

members- 87% of our commercial PPO population is cared for by practitioners

engaged in PGIP

PCMH began in 2008- Today over 4,000 PCPs in over 1,550 practice units- Approximately 2 out of every 3 PGIP-participating PCPs are PCMH

designated and are receiving a fee differential for practice transformation

- PCMH-designated practices in 78 MI counties5

What is a Patient Centered Medical Home?

• Personal physician • Physician-directed

medical practice• Whole-person

orientation• Coordinated &

integrated care• Quality & safety• Enhanced access• Payment reform

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Patient Centered

Medical HomeAdults (18-64)

8.7%Lower rate of high-

tech radiology usage

10.9%Lower rate of low-

tech radiology usage

12.6%Lower rate of primary

care-sensitive emergency department

visits

26%Lower rate of

ambulatory care- sensitive inpatient

discharges10.9%Lower rate of emergency

department visits

PCMH-Designated Practices Compared to Non-PCMH Designated Practices

HCV Data Analytics, Blue Cross Blue Shield of Michigan, PCMH 2015 Designation7

Blue Cross Strategy to Align Professional Payment with Performance Measured at Population Level

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Two separate payments:1. Payments to Physician Organizations (POs) - PO payments emphasize

capabilities for information sharing, integrated registries, performance measurement, Patient Centered Medical Home/Neighborhood facilitation, and population measures related to cost and HEDIS quality performance

2. Potential payments to PGIP-participating physicians – through tiering of professional fees via (1) PCMH designation for PCPs and (2) specialist fee uplifts for specialists. • In 2011, Blue Cross began tiering some specialist fees, based on

nomination by POs, population-based performance measurement and/or participation in specific improvement programs. Tiering fees based on population level performance is the primary method for rewarding professional providers

How is a Specialist Eligible for Tiered Fees/Fee Uplifts?

A specialist must: • Be a member of a PGIP PO for at least a year• Have a signed Primary Care-Specialist agreement with the

member PO • Be nominated by the member PO• Be nominated by and have a signed agreement with another

PO, if a significant proportion of the specialist’s patients are attributed to a PO other than the member PO

• All MDs/DOs (except anesthesiologists) and chiropractors and fully licensed psychologists are eligible

• Anesthesiologists will be eligible in 2016

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What Metrics Are Used to Rank Practices?

• Blue Cross has developed specialty specific cost, quality, utilization and/or efficiency quality metrics for 11 specialty types– Allergy, Cardiology, Emergency Medicine, Endocrinology,

Gastroenterology, Nephrology, Neurology, OB/GYN, Oncology, Orthopedics, Otolaryngology, Pulmonology

• For the other specialty types, Blue Cross uses a per member per month (PMPM) cost metric

• In 2016, Blue Cross will introduce a composite quality metric for all specialty types

• With only a few exceptions, metrics are calculated at the population level

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Specialist Fee Uplifts: Key Points

• Fee uplifts are the primary method for rewarding specialists• The fee uplift program rewards specialists who actively

collaborate with PCPs and their PO leadership to:– Create improved systems and care processes– Implement evidence-based care – Promote efficient and effective care

• The measures BCBSM uses to select which specialists receive fee uplifts are population-based and reward specialists who serve patient populations with higher overall performance

• Eligibility for fee uplifts is determined on an annual basis with an effective date of February

• Fee uplift are applied only to PPO/Traditional Commercial claims

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How Can Specialists Succeed in PGIP?• Actively engage with their PO(s). Learn and meet PO’s criteria for

specialist nomination

• Actively work to support PO in its work of creating a high performance system of care. Work with other clinicians to improve communication, share information, and improve process of care. Examples:

– ED use of imaging services– Improve performance on “Choosing Wisely” recommendations– Complex care patient whose doctors “aren’t talking to each other”

• Understand areas of population management strengths and weaknesses and help PO carry out its role more effectively

• POs can support specialist engagement in population management by holding meetings of PCPs and specialists to foster conversations about how to improve efficiency and quality. Potential topics include duplicative testing, and what practitioners experience “downstream” as potentially either unnecessary, uncoordinated, or of limited value

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Blue Cross PCMH patients also report higher-quality care, more preventive care and reduced costs.

Improved outcomes from PCMH practices

relative to non-designated practices

Savings associated with the

Blue Cross PCMH model

Blue CrossProvider Servicing

2015 Initiatives & Updates

Call Center Servicing Efficiencies:

• New phone systems with improved technologies installed over the last 9 months

• Greater capabilities to service all providers across the state

• Ability to easily route, expand and segment how calls are answered

• All like lines of business across the entire state can support each other when call volumes fluctuate

Written Inquiry Reductions. Resolving your issues: Do I call or do I write?

We’re committed to resolving your inquiries as quickly as possible and making it

easy for you to do business with us.

Did you know that many of your inquiries can be handled more quickly and

efficiently by calling Provider Servicing rather than by writing to us?  

• In 2014, Provider Relations and Servicing handled more than 1.3 million phone inquiries and more than 100,000 written inquiries

• On average, we answered each phone call within 90 seconds• On average, each phone call lasted 11 minutes• On average, our response time for written inquiries was more than 21 days

When Should I Write to Provider Servicing?

To improve your overall service experience, beginning Nov. 1, 2015,

we will only process the written inquiries that can’t be handled on a

telephone call:

• Pre-authorizations (See June 2012 Record article on requesting medical reviews)

• Ten or more claims regarding the same issue, including refund requests

When Should I Call Provider Servicing?

Provider service representatives will determine how to best resolve your issue.

If the issue requires further investigation the representative will assist you with

steps for getting your inquiry reviewed and resolved.

• Assistance with benefit and eligibility questions that can’t be answered

via self service tools• Any rejection needing clarification (e.g., duplicates, benefits,

precertification, BlueCard, provider affiliations)• Claims processed after Medicare has paid or rejected• Quantity billed inquiries• In or out-of-network payments• Requests for refunds and additional payments• COB claim inquiries • Payment discrepancies

Resolving Your Issues: Self-Service Tools

• Web-DENIS — Provides information on medical policy, fees, claims and benefits, Clear Claim Connection

• Provider Automated Response System — PARS offers information on eligibility, benefits, deductibles and cost share by voice response, fax and email - 800-344-8525.

• Provider manuals — There are customized provider manuals for each provider type. To learn how to use them more effectively, see the March Record article, part of our “Training Tips and Opportunities” series.

• Training and online resources — There are a variety of learning opportunities and online resources designed to give you the information you need. For an overview, see the May Record article, part of our “Training Tips and Opportunities” series

Clinical Editing:What BCN Providers

Need to Know

Deciding whether to appeal a denial

• When you receive a clinical editing denial — when the final page of the BCN Remittance Advice shows a denial associated with an EX (explanation) code — first do the following:

1. Read the language associated with the EX code and make sure you understand what it says.

2. Note: EX codes begin with either a lower-case “a” or “d” an upper-case “B,” “N” or “Q.” EX codes are not always about clinical editing denials; sometimes they communicate about other ways in which the claim was handled.

3. Verify the EX code and locate it on the EX Codes: Recommendations Regarding Appeal or Resubmission document.

Deciding whether to appeal a denial (continued)

3. Determine whether you should appeal the denial or resubmit the claim.

Note: The recommendations on the EX Codes: Recommendations Regarding Appeal or Resubmission document are just that — recommendations. You need to decide for yourself on the best course of action.

Deciding whether to appeal a denial (continued)

• If you decide to resubmit the claim, do the following:

Deciding whether to appeal a denial (continued)

• If you decide to appeal the denial:– There’s only one level of appeal. If you submit the appeal

late or with incomplete information, you will not have another opportunity to appeal. So, carefully read the instructions for submitting an appeal and follow them exactly.

– You can find the instructions on the Clinical Editing Appeal Form.

– BCN must receive the appeal request no later than the 180th calendar day after the original adjudication date of the claim. If the appeal is not received within that time frame, it will be denied with EX code BHP (sent after filing limit of 180 days). You will not have another opportunity to appeal.

Resources related to BCN clinical editing

• The documents referred to in this presentation are located on BCN’s web-DENIS Billing page.

• To access those documents:

1. visit bcbsm.com/providers.

2. Log in to Provider Secured Services.

3. Click web-DENIS.

4. Click BCN Provider Publications and Resources.

5. Click Billing.

6. Click on the hyperlink to the document or form you need.

Resources related to BCN clinical editing

Resources related to BCN clinical editing

Resources related to BCN clinical editing• One of those documents, titled Appealing a Clinical Editing

Denial, provides a handy summary of the process of appealing:

Preparing and submitting an appeal

• If you decide to appeal, here are the steps to take:

STEP 1: Access the Clinical Editing Appeal Form.

Preparing and submitting an appeal (continued)

• If you decide to appeal, here are the steps to take:

STEP 2: Enter information into every pertinent field (1 through 15) in the Clinical Editing Appeal Form. Be sure to complete all the required fields. (The required fields are marked with an asterisk.)

STEP 3: Gather supporting documentation of the kind listed in field 16 on the form.

Preparing and submitting an appeal (continued)

• If you decide to appeal, here are the steps to take:

STEP 4: Submit the completed appeal form and the supporting documentation as indicated on the form. Keep copies in case any questions come up.

Checking the status of an appeal• To check the status of an appeal you’ve submitted,

call BCN Provider Inquiry:

– If there is no record of an appeal and it’s been at least 30 days since you’ve submitted it, Provider Inquiry will advise you to resubmit the appeal using the address or fax number on the Clinical Editing Appeal Form.

– If the status of the appeal is shown as pending, Provider Inquiry will advise you to wait for the resolution, as an appeal may take up to 60 business days to process. (Response time may be longer when many appeals are being handled.)

– If a determination has been made on the appeal, Provider Inquiry will inform you of the determination.

Clinical editing: What Blue Cross providers

need to know

ClaimsXten (Clear Claim Connection)

• McKesson’s ClaimsXtenTM system:

o Help with the constant changes in national rules and coding guidelines

o Add coding guidelines that were not available in the McKesson’s ClaimCheckTM system (previous system)

o Assist with consistent payment through:

Modifier-to-procedure validation

Modifier 59

Professional and technical component

Missing Modifier 26

Add-on code without base codeSee a complete listing in The Record, August 2011, page 7.

ClaimsXten (Clear Claim Connection) continued

• With ClaimsXten, procedure codes eligible to be used by a technical surgical assistant (80, 82 and AS) can be verified in C3.

• Continue to use Benefit Explainer to identify required modifiers.

• The change was effective Sept. 12, 2012.

• See The Record:

March 2011, page 2

May 2011, page 4

August 2011, page 7

February 2012, page 2

September 2012, page 11

ClaimsXten (Clear Claim Connection) continued

ClaimsXten (Clear Claim Connection) continued

ClaimsXten (Clear Claim Connection) continued

Provider Enrollment

Guidelines to help make the credentialing process go faster:• Reattest every 120 days and keep your CAQH information

current.• Maintain your current board specialty and certification status on

CAQH.• Be careful when choosing your primary specialty on CAQH

because your primary specialty choice:– Determines whether you’re designated as a primary care physician or

specialist for managed care networks– May affect the way claims are processed and paid– Will be shown in our online provider directories

• Give CAQH your current malpractice insurance face sheet.• Ask your malpractice insurance carrier to submit your liability

insurance information on time. Send the Professional Liability Verification Form (PDF) and the Authorization for Release of Information Form (PDF) to your current insurance carriers. Please note that the Professional Liability Verification form needs to be completed by your carrier and faxed to the number on the form.

Guidelines to help make the credentialing process go faster: (continued)

• If you’re practicing exclusively in an inpatient hospital setting, be sure to update CAQH with that information. It’s used to determine if full credentialing is needed.

• If you’re a new graduate, wait until 60 days before you finish your training to submit your application.

• If you’re relocating from out of state, you can submit your application 30 days before your start date.

• Be sure you’ve signed and included all your enrollment signature documents before you fax them.

Self-Service Tool• Did you know Blue Cross Blue Shield of Michigan and Blue Care Network

have a Provider Enrollment and Change Self-Service online application?• It makes it easier for professional group administrators to update group

information and enroll new practitioners within their groups.

– Easy — The self-service application is more streamlined and electronic, making it easier to keep your group records up to date.

– Fast — Your enrollment and change requests are processed quickly, with some transactions completed within minutes.

– Secure — Your data remains secure since the practice group determines its users and their access levels, and the application provides an audit trail for every transaction.

– Accurate — You control the data entered for enrollment and change requests. You’ll be able to check your group information and the status of your enrollment and change requests online anytime with a few mouse clicks.

– Green — The need to print and fax forms is greatly reduced, which saves money and is more environmentally friendly.

What transactions can you do on line?

Register for Self-service tool

• Register now so you can experience the benefits of online enrollment and change processing. The self-service application is available within 10 days of submitting your registration request.Registration steps:

– All users must have access to BCBSM Provider Secured Services. If you do not have this access, you must first register for Provider Secured Services.

– Your group then completes Addendum G to select a practice administrator and designate users and the level of access for

each user.

eviCore healthcare:

Expanded reviews October 1, 2015

What has changed October 1, 2015?

• eviCore healthcare (formerly CareCore National) handles prior authorization requests for high-tech radiology procedures.

• Effective October 1, 2015, eviCore handles prior authorization requests for:

– Additional radiology procedures

– Select cardiology procedures

– Select radiation therapy procedures

What changed October 1, 2015? (continued)

• Examples of procedures reviewed effective Oct. 1:

• The lists shown here are not all-inclusive. The full list of codes is on the Radiology Management Program* page at ereferrals.bcbsm.com.

* Starting in late September, the name of this page will be “Procedures Managed by eviCore for BCN.”

eviCore Q & A• QUES: Who do these requirements apply to?

– BCN HMOSM (commercial) and BCN AdvantageSM members

– Select non-emergent outpatient services performed in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices (not in emergency, observation or inpatient settings)

• QUES: How do I request prior authorization?

– Preferred method: online at www.evicore.com. Click Visit CareCore National, at upper right.

– By phone at 1-855-774-1317 (In fact, always call when requests are clinically urgent.) Hours are 7 a.m. to 7 p.m., E.S.T., Monday through Friday.

– By fax at 1-800-540-2406

eviCore Q & A

• QUES: If a primary care physician refers a patient to a specialist, who determines that the patient needs a study that requires prior authorization? Who needs to request prior authorization?

The practitioner who orders the study should request prior authorization. In this case, it would be the specialist (examples: orthopedic surgeon, neurologist, cardiologist, radiation therapist, oncologist, urologist, etc.).

• QUES: Is a separate authorization request required for each procedure code or treatment plan?

In general, yes.

eviCore Q & A

• QUES: What information must be submitted when requesting prior authorization?

Note: When requesting approval for PET scans, certain CTs and breast MRIs, you may need to submit clinical notes.

Go to www.evicore.com, click Visit CareCore National and click eviCore Solutions.

You can access worksheets with specific questions for each type of request. You’ll also find eviCore’s criteria there.

See the next three slides for examples of what you’ll find there.

Name of member’s plan Working diagnosis Patient’s name, birth date, ID number Signs / symptoms Ordering physician’s name, NPI, address, phone, fax Test results Facility’s name, phone, fax Relevant medications Requested tests (procedure code number or description)

www.evicore.com, for Radiology Tools

• Click Radiology and click Radiology Tools and Criteria.

www.evicore.com, for Cardiology Tools

• Click Cardiology and click Cardiology Tools and Criteria.

www.evicore.com, for Radiation Therapy Tools

• Click Radiation Therapy and click Radiation Therapy Tools and Criteria.

eviCore Q & A

• QUES: What about changing a request already approved by eviCore?

– You can call to indicate the need to modify the request. Be ready to submit the pertinent clinical information for review.

Note: For radiology and cardiology requests, you must call with two days of the date the service was provided. Radiation therapy requests can be modified anytime.

– If the change involves expanding or upgrading services and the change is approved, a new authorization number will be issued. Changes that are similar to the original request may be approved within the same authorization.

eviCore Q & A

• QUES: How will the referring or rendering provider know that a prior authorization request was completed?

Providers can check online at www.evicore.com or call eviCore Customer Service. Also, typically, cases will show in BCN’s e-referral system in 1-2 days.

• QUES: What information is available online?

– Prior authorization number or case number

– Status of request

– Procedure code and name

– Site name and location

– Prior authorization date / expiration date / DOSs

eviCore Q & A• QUES: How long are authorization approvals valid?

– Generally, prior authorizations are valid for 45 calendar days from the date of the approval.

– For radiation therapy, authorizations can be valid for at least six weeks or up to six months, depending on the number of fractions (treatment sessions) that are approved / covered.

• QUES: What’s the appeal process for requests that are not approved? Submit all appeals to eviCore. Then —

– For BCN commercial, eviCore handles first- and second-level provider appeals.

– BCN Advantage appeals initially go through eviCore, but BCN makes the final determination.

eviCore Q & A

• QUES: What additional resources are available that have information about these requirements?

– Articles in BCN Provider News

– Web-DENIS messages

– One excellent place to go for information is ereferrals.bcbsm.com. Click Radiology Management.

Note: Starting in late September, you’ll click eviCore-Managed Procedures, because we’ll have changed the name of the page.

See the next three slides for examples of the information you can find there.

ereferrals.bcbsm.com > Radiology Management

Starting in late September, you’ll click eviCore-Managed Procedures.

Starting in late September, the name of this page will change to “Procedures Managed by eviCore for BCN.” The headings and content of the page will be updated as well, to reflect that eviCore will manage more than just radiology procedures.

ereferrals.bcbsm.com > Radiology Management

Starting in late September, you’ll click eviCore-Managed Procedures.

Starting in late September, the name of this page will change to “Procedures Managed by eviCore for BCN.” The headings and content of the page will be updated as well, to reflect that eviCore will manage more than just radiology procedures.

ereferrals.bcbsm.com > Radiology Management

• Also, remember to visit www.evicore.com to access worksheets with questions specific to each request type and also criteria.

Starting in late September, you’ll click eviCore-Managed Procedures.

GeoBlue®

What is GeoBlue?

• GeoBlue is the largest health care provider network in the world for international health insurance customers.

• GeoBlue is the global health insurance product offered in the U.S. under the Blue Cross Blue Shield brand as part of the Blue Cross Blue Shield Association.

• GeoBlue provides Blue Cross Coverage for more than 3,000 internationally based General Motors members.

• GeoBlue members are enrolled in Blue Cross Blue Shield and have full access to the BlueCard® provider network.

GeoBlue ID card

• When GeoBlue members seek care in the U.S., they present the GeoBlue ID card.

• The GeoBlue ID card meets all BlueCard specifications.

GeoBlue health care benefits / processes

• To verify eligibility for GeoBlue health care benefits:

– Call GeoBlue Customer Service at 1-855-282-3517.

– Use the online Blue Exchange BlueCard system.

• All BlueCard processes apply for GeoBlue coverage and claims.

Verifying GeoBlue dental benefits

• Members with a GeoBlue ID card also have BlueDental® coverage.

• To verify eligibility for GeoBlue dental benefits:

– Use web-DENIS online.

– Call the Provider Automated Response System (PARS).

• Submit claims through the regular dental claims process.

Questions?

Panel Discussion