Transcript QUES - Michigan Osteopathic Association

Michigan Osteopathic Association
Conference
November 6, 2015
Provider Consultants
Ben Russ
Sandy 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
3
Value Partnerships Program
Catalyzing Statewide Health System Transformation
in Partnership with Providers
2005 ‘06
‘07
‘08
‘09
‘10
‘11
‘12
‘13
‘14
‘15
Expansion of Hospital Collaborative Quality Initiatives (CQI)
Physician Group Incentive Program (PGIP)
Patient-Centered Medical Home (PCMH)
Provider-Delivered Care Mgt. (PDCM)
Patient-Centered Medical Home –
Neighbor (PCMH-N) & Organized
Systems of Care (OSC)
High Intensity
Care Model
4
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 counties
5
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
6
PCMH-Designated Practices
Compared to Non-PCMH
Designated Practices
8.7%
Lower rate of hightech radiology usage
Patient
Centered
Medical Home
Adults (18-64)
12.6%
Lower rate of primary
care-sensitive
emergency department
visits
10.9%
26%
Lower rate of lowtech radiology usage
Lower rate of
ambulatory caresensitive inpatient
discharges
10.9%
Lower rate of
emergency
department visits
HCV Data Analytics, Blue Cross Blue Shield of Michigan, PCMH 2015 Designation
7
Blue Cross Strategy to Align Professional Payment
with Performance Measured at Population Level
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
8
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
9
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
10
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
11
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
12
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 Cross
Provider 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 code
See 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?





Name of member’s plan
Patient’s name, birth date, ID number
Ordering physician’s name, NPI, address, phone, fax
Facility’s name, phone, fax
Requested tests (procedure code number or description)




Working diagnosis
Signs / symptoms
Test results
Relevant medications
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.
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 eviCoreManaged
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, 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.
Starting in late
September, you’ll
click eviCoreManaged
Procedures.
ereferrals.bcbsm.com > Radiology Management
Starting in late September, you’ll click eviCore-Managed Procedures.
• Also, remember to visit www.evicore.com to
access worksheets with questions specific to
each request type and also criteria.
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