Transcript QCPI Welcome Orientation - Quality Care Providers, Inc.

QCPI Orientation
2014
Quality Care Providers, Inc.
3350 Peachtree Road NE
Suite 1180
Atlanta, GA 30326
Phone: (678) 553-4600
Fax:
(678) 553-4601
Email: [email protected]
Confidential Property of Quality Care Providers, Inc.
QCPI Welcome Orientation
1.
2.
Managed Care Products through QCPI’s Network
HMO Requirements
 Primary Care Selection
 Timeliness of Filing
 LabCorp, National Reference Laboratory for BCBSGA
 Precertification Requirements
 Formulary
 Practice Age Restrictions
 Accessibility / Call Coverage
3.
4.
5.
6.
7.
8.
9.
Credentialing
Reimbursement / Clinical Quality Integration Process
Incentive Programs
Network Manuals
Electronic Connectivity
BCBSGA Claims Issue Escalation Process
Resources
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Slide 2
BCBSGA Managed Care Products
• Membership growth continues to be in the Blue
Open Access HMO/POS Products
– Commercial
– State Health Benefit Plan
– Exchange Products
• PCPs are encouraged to use efficient technology
resources
– Availity: ICR and Patient Care Summary
– MMH+
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Slide 3
Managed Care Products through QCPI
• QCPI is the primary care network for the following BCBSGA
products:
– Gatekeeper Products:
• BlueChoice Healthcare Plan, (HMO) product (a PCP
designation is required)
• BlueChoice Option, (POS) product (a PCP designation is
required)
– Open Access Products:
• Blue Open Access HMO
• Blue Open Access POS
• Exchange Products through Pathway Networks
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Slide 4
Managed Care Products through QCPI
• Identifying HMO/POS Products
Network Name
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Slide 5
SHBP Member ID card
Network in Georgia: this is
the reimbursement you
can expect
PPO “suitcase” for traveling benefits
6
HMO Requirements
•
Primary Care Physician Selection: For BlueChoice Healthcare Plan
(HMO) and BlueChoice Option (POS) the PCP’s name is on the
patient’s card. For Blue Open Access HMO/POS (including SHBP and
Exchange plans), no PCP designation is required.
•
Timeliness of Filing: Claims filed (with or without preauthorization)
after ninety (90) days from the date of the service will be denied for
delay in timeliness of filing.
•
LabCorp: LabCorp is the exclusive national reference laboratory for all
BCBSGA patients. All laboratory studies must be referred to LabCorp
(or to an HMO contracted specialty or genetic laboratory provider)
except those that have been approved as in-office laboratory
procedure codes.
•
Precertification Requirements: View at www.bcbsga.com
•
Formulary: View at www.bcbsga.com
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Slide 7
HMO Requirements… cont’d
•
Practice Age Range Restrictions:
- Internists 15 years and up
- Family Practitioners ages 0-99
- Pediatricians ages 0-20 (a Pediatrician is not to see an
adult patient age 21 yrs or older)
•
Office Hours: 20 hours of patient contact per week, 4 days a
week
•
Accessibility / Call Coverage: 24 hours, 7 days a week;
covering PCP must be a QCPI In-Network PCP (who treats the
same age group)
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Slide 8
Credentialing
• Attained degree of Medical Doctor (MD) or Doctor of Osteopathy (DO)
• Completed 3 years post-graduate training in internal medicine, family
practice or pediatrics
• Board certified within specialty or board certified within 5 years of
completion of post-graduate training
* Recertification is required to maintain network participation
• Valid, unrestricted medical license, active DEA number without limitations
• Professional liability insurance coverage $1M/$3M
• Use of CAQH online credentialing is required
• 120 days to complete the credentialing process for new physicians
• Recredentialing is required every 3 years
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Slide 9
QCPI Reimbursement –Section 5 of the QCPI Manual
• QCPI generally provides (30) days written notice of any reimbursement
change; however only (10) days notice is required under QCPI
Agreement
• Gatekeeper Products:
― PCPs are reimbursed either on a fee-for-service or capitation basis
pursuant to QCPI’s Clinical Quality Integration Process
• Open Access Products:
― PCPs are reimbursed on a fee-for-service basis pursuant to QCPI’s
Clinical Quality Integration Process
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Slide 10
Reimbursement / Clinical Quality Integration
• Clinical Quality Integration - a process which aligns a physician
group’s quality of care with its financial reimbursement for
BCBSGA/BCBSHP’s managed care products.
• Physician groups (including solo practitioners), after comparison to its
peers, will be reviewed annually to receive a higher level of
reimbursement, a lower level of reimbursement, or to remain on the
same fee schedule.
• Physician groups which generate an insufficient amount of data to
allow for a meaningful analysis will NOT be affected.
• The measures used to evaluate reimbursement are available on the
QCPI website, and are communicated annually to network physicians.
• The Physician Quality Report and notice of any fee schedule changes
are mailed out annually.
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Slide 11
Quality and Incentive Programs
•
QCPI’s physician quality programs are designed to reward
physicians who are able to effectively combine high quality
preventive care with efficient use of resources.
1. Recognize & Reward Programs (R&R): Targeted preventive
metrics to recognize quality. Those QCPI PCP’s who provide
documented, measurable preventive care to their patients are
given incentives (subject to the availability of funds) for meeting
quality benchmarks. These programs require active participation
through QCPI’s Rewards website.
2. Physician Quality Report: Our annual program provides each
eligible PCP with a Physician Quality Report.
•
All of the measures for the above programs are available on the
QCPI website.
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Slide 12
QCPI PCP Network Manual / Contract
• Product Participation: Each PCP participates in the Gatekeeper
Products and the Open Access Products.
• Patients: Each PCP should accept new patients who seek to select
the PCP as his/her PCP if the PCP is accepting new patients for any
other health benefit plan which encourages patients to use a
network of health care providers.
• Panel Closing Policy: A PCP may close his/her patient panel to
patients for the Gatekeeper Products and the Open Access Products
according to Section 8.1 of the QCPI Network Manual.
• Patient Move Policy ( See Section 8.3): If you change practices, but
remain in the QCPI network (19 county service area) and your move
is more than 10 miles to the new practice – your patients will be reassigned to another QCPI provider. If you leave the QCPI network
but remain a BlueCross physician, your patients will be re-assigned
to another QCPI provider.
• Amendments to Manual: 30 days notice
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Slide 13
QCPI PCP Network Manual / Contract –Changes & Notification
Section 11 of the QCPI Network Manual discusses the
following:
• Changing or adding location address
• Changing Tax ID
• Adding a new physician to practice
• Departure of a physician from practice
• Termination/Resignation by physician
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Slide 14
Coordination With BCBSGA: HMO Physician Office Manual
BCBSGA has published a network manual relating to the
operations of the BCBSGA Products. The BCBSGA HMO
Physician Office Manual addresses operational matters such as:
•Contact information
•Provider Services
•Membership and Enrollment
•The Primary Care Physician
•Claims Filing
•Electronic Connectivity (EDI Services)
•Laboratory Tests (Lab Corp is required Lab)
•Utilization Management
•Preferred Drug List
•Quality Management
•Wellness Programs
NOTE: The BCBSGA HMO Physician Office Manual is incorporated by reference in
your Independent Physician Agreement with QCPI (Agreement) and therefore a
part of your entire contract
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Slide 15
Electronic Connectivity – BCBSGA
www.availity.com
• Secure multi-health plan portal with access to claims status, eligibility &
benefits, claims status, AIM Specialty Health link, online remits. A a multipayer portal that gives health care providers secure access with one sign-on
to multiple payer’s information
• Your practice’s use of Availity and Blue Cross and Blue Shield of Georgia’s
ProviderAccess portals are currently included in the Technology Use
Component of QCPI’s Clinical Quality Integration Process
• QCPI also encourages its network physicians to:
– File claims electronically with BlueCross
– Use Electronic Funds Transfer/Electronic Remittance Advice
– Use AIM Specialty Health® (AIM®) ProviderPortal https://www.providerportal.com to pre-certify all advanced imaging studies (CT
and MRI).
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Slide 16
Availity: www.availity.com
•
Self service tools like Interactive Care Reviewer (ICR) to request inpatient and outpatient
precertifications for many members covered by BCBSGa plans:
• Ability to find information on a precert previously submitted via phone, fax, ICR,
or other online tool
• Referral requests can also be submitted
• Access this functionality under Auth and Referral (on the left of Availity
website)
•
Secure Messaging for clarification on claims status
•
Patient Care Summary (formerly CareProfile):
• Consolidated (HIPAA compliant) view of patient health care services for a health
plan across providers at no cost
• 2 year summary of patient medical claims-based information
• Ability to retrieve separate summaries if patient had coverage with more than
one payer
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Slide 17
Member Medical History Plus – MMH+
• Provides access to your BCBSGA patients medical
and claims history online
• Free, up to 5 years of information, HIPAA
compliant
• Medical history includes: past diagnoses,
medications filled, lab results, procedures
performed, other providers seen and care alerts
• Access via internet URL
• Contact Sherry Vallee to sign-up
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Slide 18
BCBSGA Claims Issue / Escalation Process
•
Claims Payment Inquiry: Use Availity multi-payer Web Portal first for all claims payment
inquiries
•
If not successful, inquiries may be addressed through Customer Service (“CS”) for resolution
[phone number is listed on back of the member’s ID card]
•
Escalation: In the event that the self-service tools and CS Reps are unable to provide your office
with support, then request to speak with a CS Supervisor. A Reference No. will be provided for
you to retain in future communications- it is extremely import to keep this Reference No. for
future use
•
If no resolution is met after following these above steps, you may request the issue be entered
into an Escalation Tool and the Provider Inquiry Resolution Team (PIRT) will follow up with you
within 1 business day and follow through to completion
•
Process is designed to ensure you receive answers to claims inquiries
•
Visit BCBSGA website for more information
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Slide 19
BCBSGA Resources
•
The BCBSGA web site www.bcbsga.com provides
access to:
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General information and answers to frequently
asked questions
Medical Policies and Clinical UM Guidelines
BCBSHP HMO Physician Office Manual
Most up-to-date provider communications
Formulary information
Precertification Requirements
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Slide 20
QCPI Resources
•
www.qcpi.org provides access to:
– General information and answers to frequently asked questions
about QCPI
– Messages and notices about current incentive programs
– QCPI Primary Care Physician Network Manual
•
https://Rewards.qcpi.org provides access to:
– QCPI’s incentive and self-reporting programs
•
To access QCPI’s websites, use your login/password. Your login is
your firstname.lastname and your initial password was provided to
you in your welcome letter
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Slide 21