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Quality Counts
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Blue Care Network of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
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J A N U A R Y – F E B R U A R Y 2 0 1 3
Inside this issue…
n Blue Care Network focuses on group contracting for specialists ............... Page 2
n New incentive program coming in 2013 for Medicare Advantage primary care physicians ................ Page 7
n From the medical director ............Page 14
n Arthroscopy of the knee requires clinical review effective March 1, 2013 .............Page 38
n Lumbar spine surgery requires clinical review effective March 1, 2013 ...... Page 38
Ann Arbor pediatrician makes strep testing part of practice’s culturePhysicians are paying closer attention to the inappropriate use of antibiotics, and some have established strict office procedures that must be followed before prescribing these drugs.
Liberty Pediatrics in Ann Arbor requires strep testing for children who have symptoms of pharyngitis. “We all feel that it’s important to not give an antibiotic,” Andrew Seiler, M.D., said of himself and his two partners. “When we started working together it was one of the questions we asked each other,” he said. The practice has been seeing patients for 11 years.
The doctors discuss the risks of antibiotics and make the topic part of its monthly staff meetings. Even though they have eliminated offering a prescription for antibiotics by phone, “I still think it’s important to talk about it and keep our doctors feeling like it’s worthwhile,” says Dr. Seiler. The policy is consistent throughout the office, including after‑hours staff.
The doctors do a rapid strep test when children complain of symptoms. The rapid strep is followed up by a culture, which takes a few days for results. No antibiotics are prescribed until the culture comes back because the rapid strep can show a false negative, Dr. Seiler explains.
Patients are also used to the idea that antibiotics are never prescribed over the phone. The doctors first bring up the topic with parents at the initial meeting so they are aware of the practice’s rules.
Please see Strep testing, continued on Page 2
Andrew Seiler, M.D. and six-year old Theron Brooker-Nolan
Appropriate testing for children with pharyngitisThe percentage of children 2 to 18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.
HEDIS Measure
BCN Provider News User Guide PDF
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network operations
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Blue Care Network focuses on group contracting for specialistsBlue Care Network has changed its approach to contracting with specialist providers. Rather than contract individually, BCN contracts at the group practice level for BCN Commercial, BCN Advantage HMO‑POSSM and Blue Cross Complete. There are several reasons for the change in contracting philosophy, including:
1. To improve the provider’s ease of doing business with BCN. As new specialists join a contracted group, once credentialed, they are considered participating in BCN networks under that group relationship and can begin to see BCN members. This occurs automatically from submission of the group change/enrollment form and no additional forms or paperwork is necessary.
2. To support how health care providers practice. The majority of specialists work together in practice groups, operating and billing under a group tax ID and group type II National Provider Identifier, or NPI. Contracting at the group level supports this.
3. To improve the matching of tax ID and NPI information on claims with authorizations to ensure timely and accurate claims payment.
4. To reduce the number of contracts that need to be signed or processed by individual physicians.
The questions and answers in the PDF below will help you navigate through the enrollment/contracting process.
EditorCindy Palese [email protected]
Provider CommunicationsCatherine Vera‑Burgos, Manager
Elizabeth Donoghue ColvinJennifer FryMaryann O’Shea
Market Communications Publications Cathy Rauckis
Contributors: Tina Boortz; Terri Brady; Laura Cornish; Emily DuVall; Patti Earl‑Cole; Jeniene Edwards; Mary Ellison; Brenda McCarthy; Thomas Michalski; Martha Ratke; Pamela Reinert; Dani Sokoloski; Michelle Smith; Jill Torok; Marge Worth
BCBSM and BCN maintain BCBSM.com, hcbo.com and theunadvertisedbrand.com. The Blues do not control any other websites referenced in this publication or endorse their general content.
References to “Blue Care Network” and “BCN” in this publication refer to all Blue Care Network of Michigan, Blue Care of Michigan, Inc., BCN Services Company and Blue Cross Complete of Michigan products, except where noted otherwise. Clinical information in this issue is consistent with BCN Clinical Practice Guidelines and applies to the care of BCN and BCN subsidiary/affiliate corporation members regardless of product. More information is available in the BCN Provider Manual on web‑DENIS. Specific benefit information is available on web‑DENIS, CAREN or by calling Provider Inquiry.
No portion of this publication may be copied without the express written permission of Blue Care Network of Michigan, except that BCN-participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCN.
Most of the time children with pharyngitis don’t need the antibiotic, explains Dr. Seiler. Right from the time the parents’ first call the office, they can discuss symptoms with a nurse and can be persuaded to wait the extra day or two until the culture comes back.
“People often feel like they want to do something to help the child’s symptoms,” says Dr. Seiler. “So we teach them how to care for children with colds without giving
them a prescription and it makes the parents feel better too.”
To keep same‑day appointment slots open for sick children, Dr. Seiler and the other two doctors at the practice schedule fewer checkups during the winter. “It gives us the opportunity to spend more time with our patients,” Dr. Seiler says.
Strep testing, continued from Page 1
Frequently asked questions about specialist group contracting PDF
Andrew Seiler, M.D.
HEDIS® is a registered trademark of the National Committee for Quality Assurance.
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network operations
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Reminder: Women’s preventive care takes effect for most members in January
Women’s preventive services with no member cost-sharing
Type of Service Frequency Benefit change for BCN Well‑woman visits Annually Already covered; no changes Counseling for sexually transmitted infections
Annually Already covered; no changes
Counseling and screening for human immune‑deficiency virus, or HIV
Annually Already covered; no changes
Counseling and screening for interpersonal and domestic violence
Annually Already covered; no changes
Screening for gestational diabetes for pregnant women
2 screenings during course of pregnancy
Already covered; no changes
Human papillomavirus, or HPV, testing
1 test every 3 years for women ages 30 and above
Already covered; no changes
Breastfeeding counseling, support and supplies
1 breast pump following birth, replaced according to durable medical equipment guidelines and limited to no more frequent than one every 24 months.
Lactation counseling and support already covered; Breastfeeding supplies coverage to include purchase of an electric nonhospital grade breast pump from Northwood, BCN’s durable medical equipment provider
Contraceptive methods and counseling
As prescribed Patient education and counseling, sterilization procedures and all Food and Drug Administration‑approved generic contraceptive methods except for over‑the‑counter items for all women with reproductive capacity
A document that shows the health reform procedure codes with no member cost‑sharing is available on web‑DENIS. Go to BCN Provider Publications and Resources and click on Health Reform.
Group health plans sponsored by certain religious employers may be exempt from the requirement to cover contraceptive services if they meet certain criteria. In addition, nonprofit employer groups that, based on their religious beliefs, do not currently cover contraceptive services may be able to delay the implementation of this benefit until their first plan year on or after Aug. 1, 2013. The exemption or delay for these groups only applies to the contraceptive methods and counseling portion of the provision (including female sterilization), not other preventive services.
Check member benefits and eligibility at each visit.
For more information on women’s preventive health and contraceptive coverage, please see the article in the July-Aug. 2012 issue.
In compliance with the Patient Protection and Affordable Care Act, Blue Care Network will cover additional preventive services for women without cost sharing (no copays, deductibles or coinsurance to members) when services are provided by network providers. The federal mandate went into effect Aug. 1, 2012 for some members but will become effective for most members in January 2013.
Grandfathered groups and retiree opt‑out groups are exempt from the mandate. BCN groups not included in the mandate are BCN Advantage HMO‑POSSM (except BCN Advantage with commercial Rx rider), Blue Cross Complete, BCN 65 non‑group, and MyBlue MedigapSM.
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network operations
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Providers do not need to give referrals to Blue Care Network members enrolled in the Blue Elect PlusSM product. Members covered by this product select a primary care physician and may choose to self‑refer to any in‑network or out‑of network Michigan provider. Members have the lowest out‑of‑pocket costs when their care is provided by their primary care physician or by another provider in the BCN network.
If a member self‑refers to a provider outside the BCN network, but within Michigan, the member is responsible for a higher deductible and coinsurance and for any amount charged by the nonparticipating provider that exceeds the BCN‑approved amount.
Members may also see any primary care physician in BCN’s network, but will pay a specialist copayment when seeing a PCP who is not affiliated with the primary care physician they select.
The member’s provider information card gives an overview of the billing and care management requirements for participating and nonparticipating providers. Providers should place a copy of both the member’s ID card and the provider information card in the member’s file. You can access the provider information card on the web‑DENIS BCN Products page.
Tips:• BCN requires benefit or clinical review in advance,
regardless of network affiliation.
• Check member benefits on web‑DENIS under Subscriber Info.
• Check clinical review requirements on web‑DENIS in BCN Provider Publications and Resources on the Care Management and Referrals page or on our e‑referral website at ereferrals.bcbsm.com by clicking on Clinical Review & Criteria Charts.
If you have questions, call BCN Provider Inquiry: 1‑800‑255‑1690
Care Management requirementsThe requirements for plan notification and benefit and clinical review apply whether services are performed by in‑network or out‑of‑network providers. Please refer to the Blue Care Network Referral and Clinical Review program for guidance.
In addition, the following requirements may apply:
• If a specific service is not available from an in‑network provider and the member wishes to see an out‑of‑network provider, the provider must request clinical review and receive approval from BCN Care Management for the member to receive the in‑network benefit.
• If a member wishes to see an out‑of‑network provider for a service that normally requires clinical review, the out‑of‑network provider must contact Care Management to obtain clinical review prior to obtaining the service.
• Clinical review is required for members to see a neurosurgeon or orthopedic surgeon as part of the Spine Care Referral Program.
Plan notification or clinical review is also required for the following services:
• Maternity: up to 48 hours following routine delivery or 96 hours following C‑section
• Chiropractic services
• Spine Care Referral Program — Clinical review is required for all members for the initial visit to a spine care specialist and for office visits and procedures.
Reminder: Members in Blue Elect Plus plan do not need referrals
BlueElect InfoCard PDF
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BCN offices will be closed on Jan. 1 (New Year’s Day) and Jan. 21 (Martin Luther King Day). When BCN offices are closed, call the BCN After‑Hours Care Manager Hot Line at 1‑800‑851‑3904 and listen to the prompts for help with:
• Determining alternatives to inpatient admissions and triage to alternative care settings
• Arranging for emergent home health care, home infusion services and in‑home pain control
• Arranging for durable medical equipment
• Emergency discharge planning coordination and authorization
• Expediting appeals of utilization management decisions
• Notifying BCN of Blue Cross Complete urgent and emergency inpatient admissions if both demographic and clinical information are available
We will not authorize admissions without clinical information. Do not use this number to notify BCN of an admission for commercial or BCN Advantage HMO‑POSSM members. Admission notification for these members can be done by e‑referral, fax or phone the next business day.
As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member’s medical condition and coordinate care before admitting the member.
BCN offices closed for holidays
Providers encouraged to keep CAQH information current for credentialing and enrollmentBlue Care Network has changed our enrollment and credentialing systems to be consistent with the Council for Affordable Quality Healthcare database. Please be aware that it’s important to keep your information updated on CAQH, which serves as our official application and is used to update our systems.
If you have any questions about CAQH or the credentialing process, refer to the CAQH website or call your provider representative.
Blue Care Network website merged with BCBSMMiBCN.com has merged with bcbsm.com, providing a unified website for all Blues products. The redesigned site is easier to use and has a lot more information available in one place. Beginning in December, any visits to MiBCN.com have been redirected to bcbsm.com. If you have trouble finding what you are looking for, try using the search option or contact your provider representative for assistance.
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Blue Advantage RewardsSM is the new name for the Healthy Advantage Rewards program. BCN Advantage HMO‑POSSM and BCN Advantage HMOSM members will receive a different coupon book for each screening recommendation they meet in 2013.
We’ve made some important changes to the program this year. We’ve eliminated incentives for pneumonia vaccine and smoking cessation. In addition, BCN Advantage will no longer pay physicians for completing the physician assessment form. Instead, we’re introducing an incentive program that rewards primary care physicians for closing diagnosis code gaps. (See article on Page 7 for details.)
Members will be rewarded for the following:• Member health evaluation• Glaucoma test• Retinal eye exam – New for 2013• Diabetes testing – New for 2013• Cholesterol screening• Mammogram• Colorectal cancer screening – New for 2013• Flu vaccine
The member health evaluation encourages members to visit their primary care physician at least annually for the following wellness services:• Creation of a personal prevention or treatment plan,
including needed tests, vaccines or screenings• Blood pressure check• Body mass index assessment• Review of medications, including over‑the‑counter
medicines, vitamins and supplements• Discuss safety concerns, such as preventing falls
The member must attest that he or she has had the health evaluation and discussed the topics to receive a coupon book.
Diabetes testing includes the following:• LDL‑C• HbA1c• Macroalbumin or microalbumin urine test• If the member is on an ACE or ARB medication, the
date the prescription was filled and the number of days supply must be included on the screening form.
Colorectal screening includes one of the following tests, as determined by the physician:• Fecal occult blood test• Flexible sigmoidoscopy• Colonoscopy
To qualify for the rewards, the evaluation and screenings must take place between Jan. 1 and Dec. 31, 2013. Attestation for the member evaluation and forms for the screenings must be postmarked by or faxed to BCN by Jan. 12, 2014.
BCN Advantage members will be receiving a new member health assessment, the Blues Medicare Advantage Health Assessment, in the mail. We are asking providers to remind patients to bring those assessments to their wellness visit. The form can be completed by the member or by the member and doctor together at the annual wellness visit as required by the Centers for Medicare & Medicaid Services. (The Blues Medicare Advantage Health Assessment form is not related to any of the rewards in the new Blue Advantage Rewards program. See article on Page 9 for details.)
BCN offers Blue Advantage Rewards program for 2013
BCN will accept 2012 physician assessment through early JanuaryProviders need to enter the physician assessment information for 2012 dates of service into Heath e‑BlueSM by Jan. 4, 2013 to get paid for completing the form.
If you’re mailing or faxing the form, completed forms must be signed by the provider and postmarked or faxed to us by Jan. 13, 2013.
Completing the forms by the deadline will ensure members receive their incentives for 2012.
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Blue Cross Blue Shield of Michigan and Blue Care Network are pleased to announce a new primary care physician Medicare Advantage Diagnosis Gap Closure incentive program in 2013. The new incentive applies to Blues Medicare Advantage patients, including those with BCN Advantage HMO‑POSSM, BCN Advantage HMO FocusSM and BCBSM Medicare Plus Blue PPOSM coverage.
The new Diagnosis Gap Closure incentive program replaces reimbursement for completion of the Physician Assessment Form effective for dates of service Jan. 1, 2013, or later.
Here’s how it worksThe Diagnosis Gap Closure incentive rewards physicians for having annual face‑to‑face visits with Blues Medicare Advantage patients during which diagnoses are evaluated, documented and coded according to standards set by the Centers for Medicare & Medicaid Services. Physicians will receive a financial incentive for closing diagnosis code gaps identified by the Blues.
Primary care physicians will be able to view a report of their Medicare Advantage patients who have diagnosis code gaps on Health e‑BlueSM in the first quarter of 2013. The new Diagnosis Evaluation Form on Health e‑Blue will list Blues Medicare Advantage patients who are suspected of having a condition based on pharmacy claims, medical claims, other supplemental data sources or prior year diagnoses, but the diagnosis has not been submitted to the Blues yet in the current year on a claim, through Health e‑Blue, on an electronic medical record or a paper version of the Diagnosis Evaluation Form.
A suspected or historic condition that has not been accurately documented and coded in the current year is considered a “gap”. Medicare Advantage patients with one or more gaps will be identified on the primary care physician’s Health e‑Blue Diagnosis Evaluation Form. The report will be refreshed monthly so physicians can track their progress in closing these identified diagnosis code gaps. The Blues will pay physicians $100 for each Medicare Advantage member with one or more gaps identified between January and October 10, 2013, for whom all gaps are closed during a face‑to‑face encounter by Dec. 31, 2013, and reported to the Blues by Jan. 31, 2014 following CMS guidelines.
An identified gap can only be closed following a face‑to‑face visit with the patient in 2013 during which the diagnosis is documented in the patient’s medical record following CMS guidelines. Then the gap must be closed through one of the following methods:
• Confirming the diagnosis code ‑ By submitting a claim with the diagnosis code ‑ Through Health e‑Blue ‑ By submitting a paper Diagnosis Evaluation Form* ‑ Through an EMR interface (available after May 2013)
• Notifying the Blues that the patient does not have the suspected condition ‑ Through Health e‑Blue ‑ By submitting a paper Diagnosis Evaluation Form* ‑ Sending a delete record on an EMR file (available after
May 2013)
*The new paper Diagnosis Evaluation Form will be available in January on web‑DENIS in BCN Provider Publications and Resources on both the BCN Advantage and Forms pages.
New Medicare Advantage Diagnosis Gap Closure incentive program for primary care physicians for 2013 replaces Physician Assessment Form reimbursement
Please see Diagnosis gap closure, continued on Page 8
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Diagnosis gap closure, continued from Page 7
Gaps that are closed by InovalonTM, formerly MedAssurant, will not result in an incentive payment.
As you conduct face‑to‑face annual wellness visits with Blues Medicare Advantage patients, make sure you address every chronic condition or past diagnosis that is still relevant to the patient. Then document this in the patient’s medical record following coding guidelines and include all of the diagnoses in your claim submission.
More information about this new incentive program will be mailed to Blues Medicare Advantage primary care physicians in early 2013. If you do not have access to Health e‑Blue, sign up today on bcbsm.com/provider. If you have questions, please contact your BCN provider representative.
As you conduct face-to-face annual
wellness visits with Blues Medicare
Advantage patients, make sure you
address every chronic or previously
diagnosed condition that is still
relevant to the patient including
transplant or amputation status.
Then document this in the patient’s
medical record following coding
guidelines and include all of the
diagnoses in your claim submission.
Learn more about documentation, coding and closing gapsThe Blues have staff available who can provide training to physicians and their office staff on proper documentation and coding guidelines and the importance of closing gaps for Medicare Advantage patients. Please contact your BCN provider representative for more information.
If you would like a Blues speaker to address a large provider group on this topic, please contact Laurie Latvis at [email protected].
TIP TIP
The new Diagnosis Gap Closure incentive program replaces reimbursement for completion
of the Physician Assessment Form effective for dates of service Jan. 1, 2013, or later.
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Blue Care Network will continue to offer a member health assessment form that providers can use for BCN Advantage HMO‑POSSM and BCN Advantage HMOSM members during their annual wellness visits. A member health assessment completed by the patient is required as part of an annual wellness visit for Medicare Advantage members, according to the Patient Protection and Affordable Care Act and the Centers for Medicare & Medicaid Services.
The new form, called the Blues Medicare Advantage Health Assessment, has been updated with new questions focused on senior health. Beginning in January 2013, the same member health assessment form will be mailed to Blue Cross Blue Shield of Michigan and Blue Care Network Medicare Advantage members, including BCN AdvantageSM and BCBSM Medicare Plus Blue PPOSM members.
The results of the member health assessment need to be available during the wellness visit so the physician can consider this information when creating a care plan for patients.
If your patients have completed the Blues Medicare Advantage Health Assessment and returned it to our vendor for processing, their responses will be loaded automatically into the Health e‑BlueSM website. Here’s how primary care physicians and their office staff can get the information:
1. Go to bcbsm.com/provider, log in to Provider Secured Services and click on BCN Health e-Blue.
2. Click on Panel – Health Assessment
3. From the Product Line dropdown box, select Medicare.
4. Click the Advance Patient Search check box. Enter the last name or first name or the 11‑digit member contract number.
5. Click Search Records
6. Click on Contract Mbr Num to see the patient’s complete health assessment report. Only the questions that the member answered will be displayed.
7. Click Print to place a copy in the member’s medical record for review during the annual wellness visit.
Members will receive a response letter from BCN or BCBSM outlining topics they should discuss with their physicians.
Providers can download an assessment form from BCN for patients who haven’t completed one before their annual wellness visit. The form and instruction sheet is available on web‑DENIS in BCN Provider Publications and Resources by clicking on BCN Advantage and scrolling down to Member forms. The member or physician must fax or mail the completed assessment to Scantron, our vendor, so the responses can be loaded into Health e‑Blue.
Providers should also remind patients to bring a copy of their member health assessment or the response letter to their annual wellness visit.
New member health assessment form encouraged for well visits
Steps for including a member health assessment in the annual wellness visit1. When scheduling the annual wellness visit,
remind the patient to bring a copy of the member health assessment or Blues response letter to the appointment.
2. Before the appointment, check Health e‑Blue to see if recent health assessment results are available.a. If available, print these out and include them in
the member record for review during the annual wellness visit.
b. If not available, locate the blank Blues Medicare Advantage Health Assessment on web‑DENIS. It is available on BCN Provider Publications and Resources. Click on BCN Advantage and look under Member forms. Type the patient’s information at the top, print a copy and place it in the member’s file for completion and review at the annual wellness visit.
3. If the form is completed at the annual wellness visit, fax a copy to the number on the form so results can be posted to Health e‑Blue.
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What you need to know about Medicaid and Medicare fraud, waste and abuse
BCN Advantage has new transportation vendorBCN Advantage HMO‑POSSM, BCN Advantage HMOSM and Blue Cross Complete have contracted with a new transportation vendor, Medical Transportation Management. The transportation benefit offers up to 12 round‑trip doctor visits annually for members who have the following BCN AdvantageSM coverage options: Classic, Prestige, Elements and Focus.
This change should result in improved service and patient satisfaction.
The phone number has not changed. Call 1‑888‑803‑4950 to arrange transportation for your BCN Advantage patients.
@HOMeSupport coming in 2013BCN Advantage HMO‑POSSM members will be eligible for a new pilot program called @HOMeSupport, to begin in the first quarter of 2013.
Blue Care Network is contracting with Hospice of Michigan to offer the pilot program in certain areas of the state. The program is for members with advanced illness who may benefit from additional assistance to manage their health. In addition to one‑on‑one interaction with BCN AdvantageSM members identified for the program, Hospice of Michigan staff will collaborate with members’ primary care physicians to close gaps in care.
Watch for a web‑DENIS message in late January announcing the implementation date. More information will be available in the March‑April 2013 BCN Provider News.
Medicaid and Medicare pay doctors, hospitals, pharmacies, clinics and other health care providers to take care of children and adults who need help getting medical care. Sometimes, providers and patients misuse Medicaid and Medicare resources, leaving less money to help people who need care. This misuse is called fraud, waste and abuse.
See full article on Page 12.
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BCN Advantage HMO‑POSSM received high scores on its Consumer Assessment of Healthcare Providers and Systems® member surveys. The plan received four or five stars in 11 measurements. The CAHPS® scores contributed to BCN Advantage’s 4.5‑star rating for 2013 from the Centers for Medicare & Medicaid Services Star program. (See BCN Provider News, Nov.‑Dec. 2012, Page 1.)
BCN AdvantageSM ranked first among 10 plans in getting needed prescription drugs. The plan ranked third in getting needed care, rating of specialist, and getting information from plan about prescription coverage and cost. BCN Advantage ranked fourth on the customer service composite and care coordination composites.
“The scores show that the things we are doing are well received by our members,” said Patti Earl‑Cole, manager of Medicare programs at Blue Care Network. Some of those efforts include an outreach program, where we call members to let them know what their benefits are and the concierge program. The concierge program provides individualized telephone assistance to help members understand their benefits and coverage and remind them about preventive care and gaps in care that exist. (See Concierge pilot begins for BCN Advantage members, May‑June 2012, Page 11.)
“In addition, we make sure we send our members something at least every month. In November, we sent a calendar to all BCN Advantage members. In January, members will receive a reminder of when they got their flu shot. Those kinds of things are really making a difference in how our members feel about our plan,” said Earl‑Cole.
BCN Advantage also shares survey results with providers in medical director meetings to try to improve member satisfaction rates with their physicians.
Blue Care Network continuously works to improve our scores and will be looking at several opportunities to improve member satisfaction in 2013.
BCN Advantage CAHPS® star ratings StarsGetting needed care 5Getting appointments and care quickly 4Customer service 4Getting needed prescription drugs 5Getting information from plan about prescription drugs
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Coordination of care 4Overall rating of health care quality 4Overall rating of health plan 4Overall rating of prescription drug plan 4Flu vaccination 4Pneumonia vaccination 4
BCN Advantage members give the plan high scores1
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Medicaid and Medicare pay doctors, hospitals, pharmacies, clinics and other health care providers to take care of children and adults who need help getting medical care. Sometimes, providers and patients misuse Medicaid and Medicare resources, leaving less money to help people who need care. This misuse is called fraud, waste and abuse.
Definition of fraudFraud occurs when someone intentionally deceives or misrepresents the truth, knowing that it could result in some unauthorized benefit to himself or herself or some other individual.
Fraud schemes range from those committed by individuals acting alone to broad‑based activities by institutions or groups of individuals. Sometimes these activities employ sophisticated telemarketing and other promotional techniques to lure consumers into serving as the unwitting tools in the schemes. Seldom do these schemes target only one insurer or the public or private sector exclusively. Most are simultaneously defrauding several private and public sector victims, including Medicare and Medicaid.
Michigan Medicaid health care fraud is defined in 42 CFR 455.2, as an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under applicable federal or state law.
Medicare health care fraud is defined in Title 18, United States Code (U.S.C.) § 1347, as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.
Definition of abuseAbuse occurs when provider practices are inconsistent with sound business or medical practices, resulting in an unnecessary cost to the Medicaid and Medicare programs.
Abusive practices involve payment for services that are not medically necessary or that fail to meet professionally recognized standards for health care.
Differences between fraud and abuseFraud is distinguished from abuse in that there is clear evidence that the fraudulent acts were committed knowingly and intentionally. Abusive billing practices, on the other hand, may not be intentional or it may be impossible to show that intent existed. Although these types of practices may initially be classified as abusive, they may develop into fraud if there is evidence that the provider was intentionally conducting an abusive practice.
Definition of wasteWaste involves payment or billing for items or services when there was no intent to deceive or misrepresent, but the outcome of poor or inefficient billing or treatment methods causes unnecessary costs.
Minimizing fraud, waste and abuse means the federal government can provide more care to more people and make the Medicaid and Medicare programs even stronger. Together, all of us can work to find, report and investigate fraud, waste and abuse.
Fraud, waste and abuse preventionSee our policy and applicable laws on web‑DENIS under BCN Provider Publications and Resources. Click on Policies and Information and then Detection and Prevention of Fraud, Waste and Abuse Policy. Information on fraud, waste and abuse can also be found in the BCN Provider Manual.
Blue Cross Complete providers and members can report fraud and abuse to the anti‑fraud hotline for Blue Cross Blue Shield of Michigan at 1‑855‑232‑7640 or contact the Office of Health Services Inspector General at 1‑855‑MI‑FRAUD (1‑855‑643‑7283)
BCN Advantage HMO‑POSSM and BCN Advantage HMOSM providers and members can report fraud and abuse to the anti‑fraud hotline for Blue Cross Blue Shield of Michigan at 1‑888‑650‑8136.
What you need to know about Medicaid and Medicare fraud, waste and abuse
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MDCH offers online training for blood lead screeningTo help reach federal and state goals of eliminating lead poisoning, the Michigan Department of Community Health offers professional development training for nurses, physicians and other health care providers.
This program is designed to:
• Enhance professional awareness of the problem of lead poisoning
• Increase blood lead testing rates for young children
• Eliminate or manage lead sources
• Increase communication among stakeholders about resolving this environmental health problem
Visit training.mihealth.org for more information or to register for the course. The course is approved for two American Medical Association PRA Category 1 credits for physicians, and two continuing education credits for nurses.
The MDCH Childhood Lead Poisoning Prevention Program also offers in‑office education. This includes information on lead poisoning prevention and blood lead testing. For more information contact the MDCH CLPPP or call 517‑335‑8885.
MDCH requires that all children receive a blood lead test at 12 months and 24 months. Michigan Medicaid policy requires that all Medicaid enrolled children be blood lead tested at 12 and 24 months, or between 36 and 72 months if not previously tested.
The Healthcare Effectiveness Data and Information Set measure stipulates that children have at least one capillary or venous blood test for lead poisoning by age 2.
Cholesterol screening recommended for Blue Cross Complete membersAll Medicaid‑eligible children and adolescents should undergo cholesterol screening once between the ages of 9 and 11 years old and once between the ages of 17 and 21. The Michigan Department of Community Health requires providers to follow the recommendations of the American Academy of Pediatrics for all Early and Periodic Screening, Diagnosis and Treatment visits for Medicaid beneficiaries under 21.
The cholesterol screening should include non‑fasting total cholesterol and high‑density lipoprotein (HDL) testing. Children and adolescents identified as being high‑risk should be counseled on lifestyle changes in an effort to reduce the risk of developing cardiovascular disease.
Blue Cross Complete has new transportation vendorSee article on Page 10.
See reformatted Blue Cross Complete Referral and Clinical Review Program charts, Page 37.
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...from themedical director
Please see From the medical director, continued on Page 15
Strategies for improving immunization rates
Immunization rates have improved, but gaps in care continue to exist. While low income, minority, and inner city children and adults are at the greatest risk for under immunization, gaps can occur in all demographic groups. BCN Health e‑BlueSM is a great tool for identifying gaps in addition to giving you the opportunity to improve HEDIS® scores.
In this column, I want to discuss some proven
strategies for improving immunization rates in your practice:
• Recordkeeping
• Recommendations and reinforcement
• Reminder and recall to patients
• Reminder and recall to providers
• Reduction of missed opportunities
• Reduction of barriers to immunization
RecordkeepingRecords should be available at the time of the visit, easy to read, and should accurately reflect your current population and all vaccines given. Make use of the Michigan Care Improvement Registry and make every attempt to obtain immunization records.
Recommendations and reinforcement• One of the most powerful motivators for patients to
receive vaccines is the recommendation of healthcare providers. Patients do listen to their healthcare providers.
• It’s important to emphasize the need to return to complete the series.
Reminder and recall to patients• Notifying patients that immunizations are due or past
due is a very effective strategy for improving rates.
• Reminders can be verbal, written (postcard, letter, text message) or linked to a calendar event. Also, consider automating reminders as well as using your electronic medical record or patient portal if you have one.
• Implement processes that alert providers that immunizations are due (EMR alerts, flag charts, registries and administrative data).
Reduce missed opportunities• Consider implementing a “no missed opportunities”
policy in your practice. One way to do this is to educate your staff regarding the immunization schedules and encourage everyone from the front office to the back office to check the immunization status of every patient at every encounter. Consider using standing orders in your practice.
Felecia Williams, M.D., is a medical director at Blue Care Network.
By Felecia Williams, M.D.
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patient careFrom the medical director, continued from Page 14
• Be aware of common reasons for missed opportunities: ‑ Lack of simultaneous administration – The Advisory
Committee on Immunization Practices recommends giving all indicated vaccines at the same visit. Giving vaccines together produces seroconversion rates and occurrences of adverse reactions similar to those observed when the vaccines are administered separately. Simultaneous administration also eliminates the possibility that the patient will not return in a timely manner for the deferred vaccine.
‑ Unaware patient needs additional vaccines ‑ Perceived or invalid contraindications – Know
the contraindications and precautions for vaccine administration, but realize that there are very few true contraindications and precaution conditions.
‑ Inappropriate clinic polices ‑ Reimbursement deficiencies
Reduce barriers to immunization• Inconvenient clinic hours and long waiting times can be
barriers. Open access, extended hours and immunization clinic days may help eliminate these barriers.
• Unpleasant experiences and safety concerns can prevent patients from receiving immunizations. Supportive and knowledgeable healthcare providers can help alleviate fears and misconceptions.
Actively reach out to your patients to ensure that, in addition to immunizations, preventive services and wellness visits are also addressed.
Lastly, consider implementing AFIX in your practice. AFIX (Assessment, Feedback, Incentives, eXchange) is a Centers for Disease Control and Prevention outcomes‑based program designed to raise immunization coverage levels and improve standards of practices at the provider level. The program helps identify practice areas that need to be improved and provides specific, measurable strategies for improvement.
Reference: Immunization Strategies for Healthcare Practices and Providers http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/strat.pdf
HEDIS® is a registered trademark of the National Committee for Quality Assurance.
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Medical policy updatesBlue Care Network’s medical policies are posted on web‑DENIS. Go to BCN Provider Publications and Resources and click on Medical Policy Manual. Recent updates to the medical policies include:
Noncovered services• Multianalyte assays with algorithmic analysis for
the evaluation and monitoring of patients with chronic liver disease
• Near infrared spectroscopy for wound examination
Covered service• Cataract removal
surgery
January is cervical cancer awareness monthHelp your patients protect themselves against cervical cancer. Please remind your female patients age 18 and older about the benefits of routine cervical cancer screening.Blue Care Network follows these screening guidelines:
Screening WhenCervical cancer screening and Pap smear
Age 18 to 65• Every 3 years after becoming
sexually activeAge 66+• Ask your doctor
Blue Care Network also recommends chlamydia screening for all sexually active women under 24, women 25 and older (if high risk), and pregnant women.
For additional screening information, refer to the Michigan Quality Improvement Consortium adult preventive services guidelines for ages 18 to 49 and for ages 50 to 65+.
Medical Policy Updates PDF
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To support good health for our members, Blue Care Network provides Guidelines to Good Health. These guidelines are adopted from the Michigan Quality Improvement Consortium clinical guidelines recommended for healthy adults and children. MQIC updates guidelines every two years using sources from the most current medical and scientific literature. These guidelines also address some of the Healthcare Effectiveness Data and Information Set® measures covering a broad range of important health issues. These guidelines are developed as a resource to support practitioners. They are not intended to be a substitute for medical judgment.
The following preventive care guidelines will be updated in 2013:
• Adult Preventive Services Ages 50 to 65+
• Adult Preventive Services Ages 18 to 49
• Routine Preventive Services for Children and Adolescents Ages 2 to 21
• Routine Preventive Services for Infants and Children Birth to 24 Months
The following 15 clinical guidelines were updated by MQIC in 2012:• Management of uncomplicated acute bronchitis in adults• General principles for the diagnosis and management
of asthma• Management of asthma in youth 12 years and older
and adults• Prevention of pregnancy in adolescents 12 to 17 years• Primary care diagnosis and management of adults
with depression• Adolescent health risk behavior assessment• Management of asthma in children 0 to 4 years• Management of diabetes mellitus• Routine prenatal and postnatal care• Management and prevention of osteoporosis• Management of acute low back pain• Management of asthma in children 5 to 11 years• Prevention and identification of childhood overweight
and obesity• Treatment of childhood overweight and obesity• Advance care planning (new)
Preventive health guidelines updated for 2013
The National Patient Safety Foundation has designated March 3 ‑ 9 as National Patient Safety Week. Blue Care Network supports the efforts of the Patient Safety Foundation and encourages its provider community and members to get involved.
NPSF offers some tips to encourage patients to get involved in their health care. Studies show that patients who are more involved in their health care make fewer mistakes when they take their medicine or prepare for a medical procedure. Patients may also recover more quickly and are better equipped to manage a chronic health condition.
• Make your patients feel they are part of the team.
• Provide an environment where patients feel comfortable talking openly.
• Talk to patients at eye level by sitting instead of standing.
• Provide information about your patient’s care in a way that’s understandable to them.
To learn more about the efforts of the National Patient Safety Foundation visit their website.
Patient Safety Awareness Week is in March
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Service excellence is important to the successful practice. Patient satisfaction is what the patient says it is, according to Sherry Sheehan.
Sheehan stressed the importance of having a professional office environment that puts patients first and recognizes the stresses patients may be dealing with. “Patients can come in angry or scared,” she said. “They may leave your office with a life‑changing diagnosis.”
Patients evaluate service by the following factors:
• Doctor’s demonstration of concern
• Length of time the doctor spends with the patient and family
• Ability to meet emotional needs
• Staff friendliness, helpfulness and concern
To meet these service expectations, Sheehan emphasizes that it’s important to cross‑train staff as much as possible. She suggested providing additional training to front‑office staff so you don’t have to tell the patient she needs to talk to another person to answer a question. It’s more helpful if the patients can get basic answers at the front desk.
If patients have been waiting a long time to see the doctor, they get impatient. Sheehan recommends being proactive by offering to check on the patient chart to see how much longer they may need to wait. “If the doctor had an emergency that’s affecting his schedule, let patients know,” she suggests. “If a patient needs to step out to make a phone call, ask them where you can find them when it’s their turn so they’re not frustrated sitting in the waiting room.”
Sheehan also recommends establishing policies that help patients understand treatment and billing information. “Put things in writing. Don’t try to give the patient too much information verbally.”
To maintain a professional atmosphere, Sheehan said the office manager should tell staff to be aware of their surroundings. “Finish personal conversations when patients are not around. The office should be warm and friendly without it being too relaxed,” she says. “You want to be approachable, but the office should also be businesslike.”
Nonverbal cues can speak louder than words, Sheehan warned. Negative nonverbals include raising your eyebrows, sighing, folding your arms, bouncing your leg, critical expressions (frowning) and looking away from the speaker.
“Treat the patient like you would want to be treated,” says Sheehan. “Exceptional customer service, gives the patients a ‘Wow’, instead of a ‘wow…why was I treated like that?’”
What can you do to give exceptional customer service?
Tips to improve patient satisfactionBlue Care Network hosted a provider partnership open house for specialists and ancillary providers in October, which featured speakers on various topics. In a series of articles over the next few issues, we will feature highlights of a seminar by Sherry Sheehan, CPC, and practice manager at Lansing Pediatric Associates. Her seminar, titled, “Successful Strategies for Patient Satisfaction,” covered providing good service, communication with patients, and dealing with difficult patients. In this issue, we offer some of her tips for providing excellent service.
Why patients choose not to return• Registration staff was “mean”• Impersonal, curt treatment• Billing wrong; left patient confused• Staff not warm; acted annoyed and impatient• Patients treated like a burden• Poor explanations• Staff takes its “good old time”
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Blue Care Network focuses on osteoporosis preventionBlue Care Network is working to improve our overall score on Healthcare Effectiveness Data and Information Set® measures related to the management and prevention of osteoporosis.
BCN has been requesting information from physicians regarding patients who appear to meet HEDIS® criteria for bone mineral density testing. We send a fax form to the doctor requesting results of completed bone marrow density tests. BCN also encourages doctors to consider ordering a BMD test if a woman member age 67 years or older has had a recent fracture.
If a patient has a diagnosis of osteoporosis, we ask the physician to notify BCN by fax of the osteoporosis medication therapy prescribed. If you haven’t ordered medication therapy, we ask that you please consider prescribing medications in the next 30 days. This project is one example of BCN partnering with practitioners to ensure that our members receive quality care. It is also a means to improve our HEDIS® results.
The clinical guideline for the management and prevention of osteoporosis was updated in 2012. The updated information includes the following recommendations:
• Calculate FRAX® to asses fracture risk and need for BMD testing. Calculate and record result.
• If > 20 percent prediction, prescribe a drug to treat osteoporosis (for example, bisphosphonate)
• If < 20 percent prediction, obtain a BMD if not done in the past year. Recalculate FRAX with BMD result and treat as above.
• Bone mineral density testing using DXA for white women > 65 years or men and women with similar or higher fracture risk (>9 percent/10 years by FRAX). The U.S. Preventive Services Task Force recommends this service for women.
• Patient selection for pharmacological management based on risk has also been updated.
Please visit mqic.org to access these guidelines. BCN informs members that their primary care physician may recommend a different schedule or treatment based on their individual needs.
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February is American Heart Month, and Blue Care Network is reminding providers that it is important for members to be appropriately screened for conditions that can affect heart health. BCN supports the Michigan Quality Improvement Consortium guidelines, including those for screening and management of hypercholesterolemia, hypertension, overweight and obesity and tobacco control.
Heart disease is caused by the narrowing of the coronary arteries that carry blood and oxygen to the heart. The arteries become narrowed by fat and cholesterol deposits which block the flow of blood and oxygen.
Hypertension is a serious condition and, if left untreated, can lead to coronary heart disease, kidney disease and possibly stroke. About one in three adults in the United States has hypertension, which usually starts between the ages of 35 and 50. There are no symptoms or warning signs, and it can affect anyone regardless of race, age or gender.
Risk factors that cannot be controlled• Age (45 and older in men, 55 and older for women)
• Family history of early heart disease
Risk factors that can be controlled by the member with guidance from the provider• High cholesterol (high LDL or “bad” cholesterol)
• Low HDL (“good” cholesterol)
• Smoking
• High blood pressure
• Diabetes
• Obesity, overweight
• Physical inactivity
Factors that determine LDL (“bad”) cholesterol level• Heredity
• Diet
• Weight
• Physical activity and exercise
• Age and gender
• Alcohol
• Stress
Some highlights from the MQIC guidelines are noted below. For the complete guidelines, visit mqic.org.
Screening and management of hyperlipidemia (MQIC refers to as Screening and Management of Hypercholesterolemia)
• Initial screening to include fasting lipid profile (total cholesterol, LDL‑C, HDL‑C, triglycerides). Repeat every five years if normal.
• Screening of LDL‑C levels at least annually for member with a cardiac event (AMI, PTCA, CABG) or diagnosis of ischemic vascular disease with optimum LDL‑C (goal of <100mg/dl)
• Treatment based on LDL‑C, major risk factors and presence of CHD or equivalents
• Treatment goals:
‑ LDL‑C < 130 mg/dl if two or more risk factors present
‑ LDL‑C <100 mg/dl if CHD or CHD risk equivalents is present
• Educate about therapeutic lifestyle changes such as losing weight if indicated; increasing exercise to moderate activity for 30 minutes per day, most days of the week; and following a low‑fat diet.
February focus is on heart health
Please see Heart health, continued on Page 20
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Management of overweight and obesity in adults• If BMI >30 or >27 with other risk factors or conditions,
consider referral to a program that provides guidance on nutrition, physical activity and psychosocial concerns.
• Consider pharmacotherapy only for patients at increased risk because of their weight and coexisting risk factors or comorbidities.
• Consider weight loss surgery for patients with a BMI >40 or >35 with uncontrolled comorbid conditions.
Providers can encourage healthy lifestyles by reminding patients to do the following:
• Develop a healthy eating pattern: Eat foods low in saturated fat and cholesterol
• Reduce salt and sodium
• Maintain a healthy weight
• Get regular physical activity for at least 30 minutes most days of the week
• Limit alcohol
• Quit smoking
• Take blood pressure medication as prescribed
Providers can also refer members to the National Heart Lung and Blood Institute website for information about heart disease.
Heart health, continued from Page 19
Question:
Is the criteria point “Encourage PO intake or IV fluid” referring to fluid or food? Do I need a medical practitioner’s order to apply this criterion?
Answer:
The criteria point “Encourage PO intake or IV fluid” is referring to oral hydration or IV fluid administration. How much fluid the patient takes orally is dependent on the diagnosis and clinical status. While an order is not required, there should be documentation in the patient’s medical record that PO fluids are encouraged, advancing as tolerated, or adequate. If IV fluids are necessary, a medical practitioner’s order is required.
Question:
What is the definition of “IV fluid challenge”?
Answer:
McKesson uses standard medical terminology for treatments such as the “fluid challenge” criteria point. A fluid challenge is a rapid infusion of IV fluids with close monitoring of urine output to determine if the kidneys will produce urine in response to the sudden influx of IV fluids. The infusion of a usual hourly rate of IV fluids is not a fluid challenge.
Criteria cornerBlue Care Network uses McKesson’s InterQual Level of Care Criteria when conducting admission and concurrent review activities for acute care hospitals. To ensure that providers and health plans understand the application of the criteria, BCN provides clarification from McKesson on various topics.
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Behavioral health providers now have instructions available for entering the provider name and NPI information on the BCN Behavioral Health Continuing Outpatient Treatment Request Form.
The instructions come in the form of examples for various provider types. These examples are found in the document Entering behavioral health provider names and NPIs, which you can find on BCN’s e‑referral Behavioral Heath page.
To keep things as simple as possible, nine scenarios were developed, each for a provider type billing in a specific outpatient setting. Examples are shown for individual practitioners, for an outpatient psychiatric clinic, and for practitioners billing as part of a group. Together, the examples are intended to describe the general principles involved in completing the form for every provider type in every outpatient setting. They include:
• Individual practitioners
‑ MD/DO completing the form for psychotherapy (not for the initial evaluation or for medication management)
‑ Certified nurse practitioner
‑ PhD fully licensed psychologist
‑ Master’s‑level licensed social worker
• Outpatient psychiatric clinic setting
• Group setting
‑ MD/DO completing the form for psychotherapy (not for the initial evaluation or for medication management)
‑ Master’s‑level licensed social worker who is part of a group
‑ LLP or LPC who is part of a group
‑ Certified nurse practitioner or physician assistant who is part of a group
In each instance, a picture of the completed form is provided that shows which fields need to be completed and what information should be entered into those fields. We know it’s not always easy to understand how to complete this part of the form correctly, and we hope these examples will help.
For additional questions about completing this form and billing the associated services, contact the BCN provider representative who handles behavioral health services in your region. To find the contact information for that person:
• Log on to bcbsm.com/provider.
• Click on Help Center in the top navigation bar.
• Click on Contact Us.
• Click on Blue Care Network provider contacts.
• Scroll down to Provider Servicing (BCN). Select the region in which your office is located.
Instructions for completing name and NPI on the BCN Behavioral Health Continuing Outpatient Treatment Request Form available
behavioral health
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behavioral health
Since announcing how autism is covered (see Sept.-Oct. 2012 issue), Blue Care Network has changed the approval process for applied behavior analysis treatment for members who were previously diagnosed.
For the purpose of approving applied behavior analysis treatment, Blue Cross Blue Shield of Michigan and Blue Care Network will accept a diagnosis of autism spectrum disorder if that diagnosis was made by an approved autism evaluation center within three years of the date of request.
This is true even if the evaluation center had not yet been granted AAEC designation at the time of diagnosis. However, only those applied behavior analysis services rendered on or after Oct. 15, 2012, are eligible for coverage.
Some self-funded groups adding autism benefitSelf‑funded groups will be able to add an autism benefit beginning Jan. 1, 2013. Please check web‑DENIS for coverage. Go to the web‑DENIS or e‑referral Autism page for detailed information about the benefit, new contracted providers, autism evaluation centers and billing codes.
Reminder: Members already diagnosed with autism may not have to be reevaluated
Effective Jan. 1, 2013, there will be new procedure codes to define behavioral health services. As part of the transition, several codes used today will end on Dec. 31, 2012. All claims must be billed with these new codes, as applicable.
While Blue Care Network does not instruct providers how to bill, we can provide resources to help you understand the transition to these new codes. Below are a few links to professional organizations that have released information about the new codes.
Additional resources are available on the Internet.
• American Medical Association presentation
• American Psychiatric Association CPT Coding Changes for 2013
• American Academy of Child and Adolescent Psychiatry CPT & Reimbursement
For any currently issued authorization whose effective dates span into 2013, those authorizations will work with the new procedure codes. For new authorizations, please select *90791 on e‑referral.
An updated Behavioral Health Fee Schedule will be posted on web‑DENIS before Jan. 1, 2013.
* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
Behavioral health procedure code changes
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Blue Care Network plans to conduct HEDIS® chart reviews in provider offices January through April of 2013. These reviews are part of our National Committee for Quality Assurance requirements for health plan accreditation.
Please note that Inovalon™ will also be doing chart reviews for BCN Advantage HMO‑POSSM January through March, and Blue Cross will be doing chart reviews for its PPO and Medicare Advantage PPO plans during this time period as well. Our reviewers will call you to schedule appointments to minimize disruption to your office.
We need to submit complete and accurate data to NCQA for the BCN chart review. Therefore, we will be making copies of the records that are reviewed. Reviews will be minimized if physician offices have already provided data
through Health e‑BlueSM or electronic medical record feeds. In addition, if we require five records or fewer, your office has the option to fax the records to BCN. In other cases, we may be copying a large number of medical records and will supply our own paper. In future reviews, we hope to be able to scan the records to reduce copying time and costs.
These chart reviews are important to BCN’s health plan accreditation, which is a requirement for listing for BCN on the health exchange under the Affordable Care Act starting near the end of 2013. The reviews also influence our Star rating for our BCN AdvantageSM products under the Centers for Medicare & Medicaid Star program.
Thank you for your time and efforts in providing medical records for these reviews.
Blue Care Network to begin HEDIS chart reviews in January
MQIC releases new guideline to assess adolescent health risksThe Michigan Quality Improvement Consortium has a new clinical practice guideline, Adolescent Health Risk Behavior Assessment.
The guideline was developed by health care leaders and organizations in the state with a special interest in adolescent health. The risk factors for assessment have been identified by the Centers for Disease Control and Prevention as the leading causes of morbidity and mortality in adolescents.
Data confirm that adolescents aren’t being seen for routine visits or annual visits for screening health risk behaviors.
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Blue Care Network will provide you with ongoing information about our quality improvement programs and clinical practice guidelines through this newsletter and on our website at bcbsm.com. Approved clinical practice guidelines are available to all Blue Care Network primary care physicians, primary care groups and specialists. Copies of the complete guidelines are available on provider secured services. To access the guidelines:
• Log into web‑DENIS.
• Click on BCN Provider Publications and Resources.
• Click on Clinical Practice Guidelines.
The MQIC guidelines are also available on the organization’s website. BCN promotes the development and use of uniform, evidence‑based clinical practice guidelines and preventive care guidelines for practitioners. These guidelines are established by the Michigan Quality Improvement Consortium and help ensure the delivery of consistent, quality medical care to our members.
Our Quality Improvement Program encourages adherence to MQIC guidelines. We also offer interventions focusing on improving health outcomes for BCN members. Some examples include member and provider incentives, reminder mailings, telephone reminders, newsletter articles and educational materials. Ongoing monitoring of compliance with the preventive health guidelines is
conducted through medical record reviews and during quality studies.
As a part of our focus on achieving positive health outcomes, the quality improvement program addresses potential quality‑of‑care concerns such as patient safety, medical errors and serious adverse events for all products to ensure investigation, review and timely resolution of quality issues.
To ensure accessibility to care for all our members, BCN has established access and availability standards for the following types of appointments: preventive care, routine primary care, urgent care, emergency care, after‑hours access and practitioner waiting room times. Quality management coordinators monitor access throughout the year. Physicians who don’t meet access standards are given the opportunity to correct the issue. More information is available in the BCN Provider Manual. Log in to web‑DENIS, click on BCN Provider Publications and Resources, then click on Provider Manual and open the Access to Care chapter.
Members can call our BlueHealthConnection® line at 1‑800‑637‑2972 for health education and chronic condition management information. For more information about our programs or guidelines, please contact our Quality Management department at 248‑455‑3471.
Quality improvement program information available upon request
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Blue Cross and Blue Care Network measures show claims paid quickly and accuratelyBlue Cross Blue Shield of Michigan and Blue Care Network participate in the Blue Cross and Blue Shield Association Member Touchpoint Measures program, which assesses operational and service performance. The MTM program includes various timeliness goals, but focuses on quality in particular, measuring claims for financial and procedural accuracy, customer service inquiry accuracy, and enrollment member and group accuracy.
Maintaining high MTM scores is a requirement to continue using the Blue Cross Blue Shield trademark. More importantly, the scores reflect the type of service we are giving to providers, members and other customers.
Claims measures include all non‑BlueCardSM branded core health claims processed on all systems and received via all media (for example, electronic, paper, fax, and clearinghouse). This includes all claims that are outsourced, processed by a third‑party administrator or delegated to a provider or employer group.
The following chart shows our claims measures for Blue Cross and BCN for the period of January through September 2012.
Measure Blue Cross and Blue Shield Association goal
Blue Cross Blue Shield of Michigan and Blue Care Network Performance
Enrollment timeliness 99% 99.99%
Member‑level accuracy 99% 99.72%
Group‑level accuracy 99% 99.31%
Claims timeliness 98% 98.88%
Claims processing accuracy 98% 99.15%
Claims financial accuracy 99% 99.97%
Inquiry timeliness 95% 99.71%
Inquiry accuracy 99% 99.61%
First call resolution* 74% 1st half 2012 – 68%
2nd half 2012 – 62%
*First call resolution measures a plan's ability to resolve a customer's issue with a single call, determined by the customer. An Association‑approved vendor conducts the telephone survey through direct interaction with the caller within one to three days after the member calls the plan.
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When the U.S. Food and Drug Administration issues a drug recall or a drug is withdrawn from the market for safety reasons, the Blue Care Network Pharmacy department assesses the impact to members, their PCPs and the prescriber of the medication.
BCN Pharmacy then notifies members and providers of the recall and suggests the actions they should take, based on recommendations from the recalling manufacturer and the FDA.
BCN followed this procedure last fall when contaminated methylprednisolone resulted in the nationwide outbreak of meningitis. Michigan was one of the states hardest hit by the outbreak. Numerous cases of meningitis and epidural abscess and several deaths were reported statewide.
For this recall, BCN Pharmacy identified members whose medical claims revealed a dose of injectable methylprednisolone from a prescriber associated with a clinic named by the FDA. BCN Pharmacy notified both the prescriber and the member’s PCP to help them identify and notify the affected patients.
The contaminated drug was compounded by the New England Compounding Center in Massachusetts. The FDA is continuing to investigate this compounding pharmacy and its affiliated partners. The Centers for Disease Control and Prevention has worked with the institutions that received the NECC methylprednisolone product to identify and contact all patients potentially exposed to the tainted methylprednisolone injection.
The NECC has recalled all of its compounded preparations based on the FDA findings. NECC’s affiliate, Ameridose LCC, also recalled all of its compounded products based on the discovery of sloppy manufacturing practices, although no contaminated products have been identified. Neither company is currently producing any product.
Hundreds of different products are affected by the recall; most were exclusively shipped and used in institutional settings. BCN Pharmacy department will continue to monitor the situation closely.
The FDA and the CDC have set up special websites to communicate the latest information on this situation. You can access the websites below:
• The FDA site on fungal meningitis
• The CDC site on the fungal meningitis outbreak investigation
• The CDC has also set up a Clinicians Consultation Network of experts in fungal disease treatment and management to assist physicians who are treating patients associated with the current outbreak of fungal meningitis. To access the service, physicians can call 1-800-CDC-INFO (1‑800‑232‑4636).
• Regularly updated guidance documents are also available on the CDC’s outbreak‑related Clinician Guidance webpage.
BCN takes steps to notify prescribers and members affected by drug recall
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On Jan 1, 2013, Blue Care Network is implementing an exciting new program to help improve member and provider satisfaction with our commercial drug benefit.
Members who newly enroll in Blue Care Network who are taking a nonformulary drug or one that requires prior authorization or step‑therapy at BCN may qualify for a one‑time “transition fill” prescription. Under our new Transition Fill program, a 30‑day prescription can be provided for one copayment.
The dispensing pharmacist will need to enter an override code that will allow the prescription to process. A one‑time supply of up to 30‑days can then be dispensed.
Blue Care Network will then notify the member and the prescriber that a one‑time transition fill has been dispensed and that action is needed. The member will then have 30 days to work with their prescribing physician to switch to a covered drug or to request a formulary exception or prior authorization.
Members can take advantage of our new Transition Fill program within 90‑days of joining Blue Care Network. There are a few exclusions to this new program, including:
• Drugs filled at a non‑contracted pharmacy
• Drugs that are not normally covered by Blue Care Network, such as drugs for cosmetic use and drugs not approved by the Food and Drug Administration
• Certain drugs which that are frequently abused or misused
• Prescriptions that exceed BCN’s maximum quantity limits
If you receive a notice regarding a transition fill for one of our Blue Care Network members, consider prescribing a drug that does not require authorization. If this is not medically appropriate for your BCN member, please contact our BCN Pharmacy Help Desk at 1‑800‑437‑3803 to initiate a request for coverage.
Thank you for working with us as we strive to improve our service to our valued members and providers!
This program does not apply to Blue Cross Complete members. A similar program is available for our BCN Advantage HMO‑POSSM members.
New transition fill program introduced for BCN members
2013 BCBSM and BCN Formulary Quick Guide now availableFor a listing of commonly prescribed Tier 1 and Tier 2 drugs on our formulary, please refer to our 2013 BCBSM and BCN Formulary Quick Guide. It can be viewed or downloaded by clicking on the link below.
Custom Formulary Quick Guide PDF
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Feedback Please see Diabetes, continued on Page 29
The benefits of ACE inhibitors and ARBs in diabetesMore than 11 million Americans have a diagnosis of both diabetes and hypertension, comorbid conditions that strongly predispose patients to renal and cardiovascular injury.1 All patients with a diagnosis of diabetes who also have hypertension, macroalbuminuria, or are at an increased cardiovascular risk should be started on an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) therapy, unless otherwise contraindicated.2
ACE inhibitors and ARBs slow the progression of kidney damage and help control related complications in these patients.3,6 These agents are also effective for vascular protection in diabetics who are at a high risk of experiencing a cardiovascular event.3
Most adverse effects related to ACE or ARB therapy can be managed without stopping the drug:
• Although it is not uncommon to see up to a 30‑percent decrease in the glomerular filtration rate within the first four months of treatment, this initial decrease may not be clinically relevant and does not affect long‑term renal function.1,7 If hyperkalemia develops, consider discontinuing any concurrent medications that might impair potassium excretion (NSAIDs, potassium‑sparing diuretics, etc.), adding a thiazide or loop diuretic, placing the patient on a low potassium diet or adding Kayexalate®(g).4
• A cough commonly develops in patients treated with an ACE inhibitor due to the accumulation of bradykinin; switching from an ACE inhibitor to an ARB is appropriate in these patients.1
• Transient abrupt decreases in blood pressure are most likely to occur after initiation of treatment or after dose escalation. Initiating therapy with moderate doses followed by slow titration will decrease the incidence and severity of hypotension. A dose reduction of other medications that decrease blood pressure may be required.5
All ACE inhibitors (except for the tablet version of Altace®) are now available as a generic version and are available for the member’s lowest copayment. Several new generic versions of ARBs are now available.
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Diabetes, continued from Page 28
Generic versions of Cozaar®/Hyzaar®, and Teveten® are available for the member’s lowest copayment; no step‑therapy is required for these agents. Generic versions of Avapro®, Avalide® and Diovan HCT® are also available for the lowest copayment. These generic ARBs and Benicar®/Benicar HCT® require step‑therapy with generic Cozaar/Hyzaar or Teveten prior to coverage.8
The other available ARBs are nonformulary and require treatment with both a generic ARB and Benicar/Benicar HCT prior to coverage.8
Most ARBs have quantity limit restrictions to help ensure appropriate dosing (one or two doses per day, depending on the drug).
Note: Step-therapy and prior authorization requirements do not apply to BCN Advantage HMO-POSSM members.
Angiotensin II receptor blockers and combinations8
Formulary Preferred
Trade name Generic name Utilization managementAvalide (g) Irbesartan/Hydrochlorothiazide [ST]Avapro (g) Irbesartan [ST]Cozaar (g) Losartan potassiumHyzaar (g) Losartan/HydrochlorothiazideTeveten (g) Eprosartan mesylate
Formulary options
Trade name Generic name Utilization managementBenicar Olmesartan medoxomil [ST]Benicar HCT Olmesartan/Hydrochlorothiazide [ST]
[ST] = step therapy required
References:
1. Bakris GL, Williams M, Dworkin L et al. Preserving Renal Function in Adults with Hypertension and Diabetes: A Consensus Approach. American Journal of Kidney Diseases. 2000: 36(3): 646‑661.
2. PL Detail‑Document, Does My Patient with Diabetes Need an Aspirin, Statin, ACE Inhibitor, or ARB? Pharmacist’s Letter/Prescriber’s Letter. November 2012.
3. American Diabetes Association. Standards of Medical Care in Diabetes ‑ 2012. Diabetes Care. 2012; 35 [Suppl 1]: S4–S10
4. Palmer B. Angiotensin‑converting enzyme inhibitors and angiotensin receptor blockers: what to do if the serum creatinine and/or serum potassium concentration rises. Nephrology Dialysis Transplantation 2003:18(10): 1973‑75.
5. The National Kidney Foundation Kidney Disease Outcome Quality Initiative. Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease 2012
6. Lewis EJ, Hunsickler LG, Bain RP, Rohde RD. The Effect of Angiotensin Converting Enzyme Inhibition on Diabetic Nephropathy. N Engl J Med 1993; 329:1456‑62.
7. Epstein BE. Elevations in serum creatinine concentration: concerning or reassuring? Pharmacotherapy.2004:24(5):697‑702.
8. Blue Cross Blue Shield of Michigan and Blue Care Network. Custom Formulary. July 2012 Update.
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Talk with your BCN members about their drug coverage
Generic drug flyer PDF
Now is the perfect time to talk with your members about their drug therapy. Most group and individual health plans have benefit years that begin Jan. 1. As a result, this is the time of year when many patients experience changes in their prescription drug coverage. These changes can include removing a drug from the formulary or significant copayment increases that provide a decision point for members continuing on higher‑cost medications.
Please help us ensure our members get the care they need by talking with them about their drug copayments. Nearly all Blue Care Network members have a tiered pharmacy benefit. This means they pay their lowest copayment for Tier 1 (mostly generic) drugs. Tier 2 drugs require a higher copayment and Tier 3 (nonformulary) drugs are either not covered or require the highest copayment. The recent introduction of generic versions of many blockbuster medications has resulted in great cost‑savings opportunities for our members. Generic versions of Actos, Singulair®, Dovonex®, Xopenex® inhalation solution and several antipsychotics and angiotensin receptor blockers are examples.
Generic drug discount programs are another excellent way to ensure that patients receive affordable health care. However, many members do not realize the importance of always using their Blues ID card with these programs. Members will always pay the lowest amount when using their Blues ID card. This allows us to automatically detect drug interactions, therapeutic duplications and other drug therapy problems. To ensure safe and affordable drug therapy, please talk with your members about generic drug discount programs. For information about generic drug discounts, view the flyer below.
Please go to bcbsm.com/provider/pharmacy_services for additional information for BCN, BCN Advantage HMO-POSSM and Blue Cross Complete. If you have any questions, call the BCN Clinical Pharmacy Help Desk at 1‑800‑437‑3803.
For a listing of commonly prescribed Tier 1 and Tier 2 drugs on our formulary, please refer to our 2013 BCBSM and BCN Formulary Quick Guide. Additional pharmacy resources for selecting affordable and effective drug therapy, including the complete Blue Cross Blue Shield of Michigan and Blue Care Network Custom Formulary, are available online.
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Acute bronchitis ranks among the top 10 conditions that account for most ambulatory office visits. More than 90 percent of acute bronchitis cases have a nonbacterial cause. Despite this, antibiotics are prescribed 65 to 80 percent of the time.
Antibiotics are not indicated in clinical guidelines for treating adults with acute bronchitis who do not have a comorbidity or other infection for which antibiotics may be appropriate. In addition, numerous clinical trials have established that antibiotics do not improve outcomes for patients with uncomplicated acute bronchitis. Inappropriate antibiotic treatment is of clinical concern, as overuse and misuse lead to antibiotic drug resistance.
The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. When there is a low probability of pneumonia (no abnormal vital signs and normal chest exam), treatment with antibiotics is not indicated.
Antibiotics are frequently prescribed primarily to meet patient expectations. Patient satisfaction with care for acute bronchitis depends most on physician ‑ patient communication rather than on antibiotic treatment. Rather than offering a prescription medication that may be unnecessary and potentially harmful, please help us by providing education regarding the following:
1. The limited effectiveness of antibiotics in acute bronchitis
2. The potential problems associated with antibiotic drug resistance
3. A contingency plan if symptoms worsen
4. The benefits of specific symptomatic therapy
The Centers for Disease Control and Prevention’s Get Smart campaign targets five respiratory conditions that account for three quarters of all antibiotics prescribed by office‑based physicians. This website features brochures, posters and No Antibiotic Prescription sheets doctors can give to patients who ask for antibiotics to treat viral infections. The prescription sheet is an actual checklist for the physician to describe symptomatic relief for viral infections. Also available is a CDC web page of Q&A providing answers to commonly asked questions.
Through education and health promotion you can help your patients understand the importance of appropriate use of antibiotics.
References
1. Bronchitis (Chest Cold). [Internet]. Atlanta (GA) Centers for Disease Control and Prevention. Available from: http://www.cdc.gov/getsmart/antibiotic‑use/URI/bronchitis.html.
2. Gonzales R, Bartlett J, Besser R, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Annals of Internal Medicine 2001 Mar 20;134(6):521‑9.
3. Anderer T, Gonzales R, Metlay J. An algorithm to Improve Appropriate Antibiotic Use for Patients With Acute Bronchitis. Presented at: NCQA webinar session. 2011 Apr 26; Washington, DC.
Avoidance of antibiotic treatment in adults with acute bronchitis
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Procedure codes to report nerve conduction studies are changing effective Jan. 1, 2013. Electromyography codes were modified in the 2012 update; no changes were made to these codes for the upcoming year.
Nerve conduction studies performed and reported in 2013 are to be reported with the newly added procedure codes which are *95907‑95913, replacing *95903‑95905. These codes allow reporting by the number of tests performed, noting that a test can be reported only once even if it is performed several times along the same nerve. Although the nomenclature has removed the specific information regarding the type of tests, each of these test types (sensory, motor with or without F wave, H‑reflex) remains a distinct, separately reportable test, when performed.
Identify the number of distinct tests performed and select the appropriate procedure code to report. For example, if
eight distinct studies were performed and documented, the appropriate code to report is *95910 as it represents seven to eight nerve conduction studies. Modifiers are not required to identify site and units above one are not required as the quantity is noted in the code.
If an EMG is performed along with the NCS, report the appropriate add‑on code, *95885‑95887, as evidenced by the documentation and diagnosis.
Note: For dates of service in 2012, even for claims submitted in 2013, report the NCS with the 2012 codes, *95903‑95905. If an EMG is performed at the same time, also report the appropriate add‑on code, *95885‑95887, as evidenced by the documentation and diagnosis.
* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
New codes for nerve conduction studies and electromyography
Blue Care Network fixes system error causing incorrect QNF editsBlue Care Network fixed a system error that caused some of our facility partners to receive incorrect edits an adjusted claim (QNF). The system error was corrected in early October 2012.
Blue Care Network has been working diligently to obtain reports to ensure that all providers are paid correctly. One report was already run and processed, but we did identify that many providers were missed on that report. A second report was run in mid‑November. All identified providers should be reimbursed by the time this article is published.
If you believe you’re one of the providers affected and haven’t yet been reimbursed, please notify your BCN provider representative. Some of the edits are valid and will require an appeal. Your representative will be able to assist you.
Blue Cross and Blue Care Network measures show claims paid quickly and accuratelyMeasures for the period through September 2012 show that Blue Cross and Blue Care Network met or exceeded goals for timely and accurate claims payment. See article on Page 25.
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Clinical editing Q&AThe proper reporting of clinical services is challenging because of the significant volume and complexity of codes, modifiers and combinations that are used to define correct coding. Following are frequently asked questions that BCN receives about clinical editing.
Q: How do I know if my denial is a clinical edit?A: Clinical edits are identified on the remittance advice by EX codes beginning
with the letters N, QN, QO or QP. They will be three digit characters such as N01, N91, QN1, QOP, QPC, etc.
Q: What if I disagree with a clinical edit?A: Clinical edits can be appealed, though not all may require an appeal. It’s
important to look at the reason for the edit. If the edit can be resubmitted as a status or corrected claim (for example, correct a modifier or diagnosis), then an appeal may not be required.
When an appeal is required, it is important to follow the clinical editing appeal process. An appeal must be submitted with a completed clinical editing appeal form and contain the necessary clinical information to support the appeal. The documentation for each case may vary and may include office medical records, operative notes, radiology reports, combinations of several documents and so on.
Q: Must appeals be typed?A: No, but it does help. Many times handwritten appeals are not legible. The
clearer and more legible the information, the more timely and accurately your appeal will be processed.
Q: How long do I have to submit an appeal?A: Appeals will be accepted through 180 days of the original clinical editing
denial. If you continued to submit the claim and received multiple denials, it may work against you. We will go back to the original time the clinical editing denial was received. If the timeframe was exceeded, we will notify you.
Q: How do I find out more information about the appeal process?
A: Information on clinical editing, including the appeal process is published in the Provider Manual located on web‑DENIS within BCN Provider Publications and Resources.
Clinical editing billing tipsIn most issues, we publish clinical editing billing tips. This helps ensure that your claims are promptly and properly adjudicated and that Blue Care Network receives reporting of the performed procedure. To view the full content of any of the tips, click on the PDF below.
Billing tips for this issue include:
• Reporting multi‑line claims
• Reporting add‑on codes
• Use of modifiers 58, 78 and 79
• Anesthesia and E&M services
Clinical editing billing tips PDF
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billing bulletin
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As part of our hospital outpatient pricing strategy, Blue Care Network is changing the way we reimburse outpatient hospital services, effective on or after Apr. 1, 2013. The following hospital services will be affected.
• DME/P&O services
• ER and trauma services
• IVT‑chemotherapy services
• Observation services
• Treatment room services
• Recovery room and labor room services
• Pharmacy and medical/surgical supplies
• Dialysis services
• Ambulance services
• Hospital outpatient rehabilitative services
• Other therapeutic services
Please refer to the Nov.-Dec. 2012 issue for guidance on how these services should be billed when provided in the hospital outpatient location of service. We will require billers to report appropriate services using CPT and HCPCS codes for each date of service.
Blue Care Network hospital outpatient pricing strategy effective April 2013
Clear Claim Connection — not a tool for BCNFrequently Blue Care Network will receive screen prints from a product used by Blue Cross Blue Shield of Michigan, Clear Claim Connection™, when clinical edits are received. This is a tool used by BCBSM, not BCN, and accordingly does not reflect BCN’s system configuration. As a result, certain code combinations that show payable or nonpayable for BCBSM may not be the same for BCN.
If you have questions on a specific claim or claims payment issue, please contact your BCN provider representative or BCN provider inquiry.
Blood transfusion codes to be reimbursed at HCPCS levelAs part of our Hospital Outpatient Pricing Strategy which goes into effect Apr. 1, 2013, blood transfusion services (revenue codes 0390 and 0391) will no longer be reimbursed as part of the surgical fee.
Starting in April, please report these revenue codes along with the appropriate HCPCS codes for blood transfusion services. Reimbursement will be a fee at the HCPCS level.
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Feedback Please see Landmark, continued on Page 36
referral roundup
On Dec. 1, 2012, LandmarkTM Healthcare, Inc., began using a collection of new treatment plan forms for outpatient physical and occupational therapy authorization requests.
The new treatment plans were developed in response to therapist requests for forms tailored to specific conditions. By developing these forms, Landmark was able to shorten the standard Therapy Treatment Plan, which Landmark expects will be the form most commonly used. The standard Therapy Treatment Plan, together with the condition‑specific plans, replaced the Physical Therapy and Occupational Therapy Treatment Plan forms that were phased out beginning Nov. 30, 2012.
The new forms are:
• Therapy Treatment Plan (standard)
• Hand Therapy Treatment Plan
• Lymphedema Management Treatment Plan
• Neuro (Adults & Peds) Rehabilitation Treatment Plan
• Vestibular Rehabilitation Treatment Plan
• Supplemental Joint Form
New treatment plan forms available onlineThe new treatment plan forms, which are submitted to Landmark as part of a request to authorize therapy, can be submitted online or can be printed and faxed to Landmark. To access the new treatment plan forms, go to LMhealthcare.com, log in to Landmark Connect and visit the Administrative Resources page.
When submitting your treatment request electronically, the applicable form will be automatically selected for you based on the primary diagnosis you enter at the beginning of the form. If you fax your authorization requests, you will select the form that best fits each patient’s condition.
Tips for changing to the new treatment plans• If you fax your authorization requests, you should
have started using the new treatment plans on Dec. 1, 2012. Landmark allowed a 15‑day transition period during which both the old and the new forms were accepted. Any of the replaced Physical Therapy or Occupational Therapy Treatment Plan forms received after Dec. 15, 2012, will be returned to the requesting therapist to complete using the correct new form.
• You should have completed and submitted any saved e‑Forms by Nov. 30, 2012. The replaced Physical Therapy and Occupational Therapy Treatment Plan e-Forms were not available as of Dec. 1, 2012. Any partially completed e‑Forms will need to be restarted on one of the new treatment plans.
• When a patient requires additional care within an existing time period approved by Landmark (called the “Approved Time Period”), complete and submit a new treatment plan. If the start date of this treatment plan is within an existing Approved Time Period, Landmark requires additional documentation that describes the patient’s progress since the previously submitted treatment plan.
‑ If you submit the new treatment plan electronically, you will be prompted to complete additional fields to provide the clinical peer reviewers with this documentation.
‑ If you submit the new treatment plan via fax, you will likely receive back a request for information that will include a supplementary form that you must complete to document the patient’s progress since the previously submitted treatment plan.
Note: In all these instances, any additional visits will be authorized within the existing Approved Time Period. Any visits after that will require a separate treatment plan.
New Landmark treatment plan forms now in use1
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referral roundup
More information available on e-referralMany resources on therapy management are available on BCN’s e‑referral website at ereferrals.bcbsm.com by clicking on the Outpatient Physical, Occupational and Speech Therapy Management Program Web page. These resources include the following documents:
• Landmark Treatment Plan Forms
• Tips about Landmark Authorizations for BCN Members
• Suggestions for the Efficient Utilization of Therapy Services
• Tips for improving treatment efficiency
Writing the prescription for therapyWhen referring a member for physical, occupational or speech therapy, either write the prescription for “evaluate and treat” or list a range of visits, such as one to three visits per week for four weeks, or four to eight visits in a month.
More information available at Landmark ConnectIn the coming weeks, Landmark will publish a new Utilization Management Guide, Frequently Asked Questions and more help tools.
Landmark Healthcare Inc. oversees outpatient physical, occupational and speech therapy services for BCN members delivered by independent physical therapists, outpatient therapy providers and physician practices. Landmark Healthcare is an independent company that does not provide Blue Cross or Blue Shield products or services. Landmark is solely responsible for the products or services it provides.
Landmark, continued from Page 35
Writing the prescription in this way allows the treating therapist to work with the member to establish a treatment plan based on both medical necessity and the member’s anticipated response to treatment over a period of time. The treatment plan will include the proposed frequency and duration necessary to reach the expected outcomes.
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The 2013 BCN and Blue Cross Complete Referral and Clinical Review programs have been reformatted in response to suggestions by providers. The revised programs will be available on the e‑referral Clinical Review & Criteria Charts page by Jan. 1, 2013.
The content of the programs was not changed, but the format was revised for greater clarity. This is what’s changed:
• In both programs, the “Plan notification and clinical/benefit review requirements” information is separated from the “Exceptions to the referral requirement” section. This is intended to reduce confusion that was caused by presenting these two types of information together in the same table.
• In both programs, the footnotes have been integrated into the table. No more searching for footnotes on another page.
• In both programs, vendor contact information was added.
• In the Blue Cross Complete program, some entries were reworded to reflect the additional providers now serving Blue Cross Complete members.
We thank the providers who suggested ways in which the Referral and Clinical Review programs could be made clearer. We look forward to you trying out the reformatted programs and welcome any additional suggestions for their improvement. You may contact your BCN provider representative or send comments to [email protected]
The Referral and Clinical Review programs are published on January 1 of each year and are updated with Blue Dot changes throughout the year. See About Blue Dot Changes to the Referral and Clinical Review Programs for additional information.
To get a sneak preview of the reformatted programs before January 1, click on the PDF links below:
BCN and Blue Cross Complete clinical programs reformatted for clarity
Reminder: Members in Blue Elect Plus plan do not need referralsProviders do not need to give referrals to Blue Care Network members enrolled in the Blue Elect PlusSM product. Members covered by this product select a primary care physician and may choose to self‑refer to any in‑network or out‑of network Michigan provider. Members have the lowest out‑of‑pocket costs when their care is provided by their primary care physician or by another provider in the BCN network.
2013 BCN Referral and Clinical Review Program PDF
2013 Blue Cross Complete Referral and Clinical Review Program PDF
For important information about clinical review requirements, see full article on Page 4.
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referral roundup
Lumbar spine surgery requires clinical review effective March 1, 2013Effective March 1, 2013, clinical review will be required for lumbar spine surgery for Blue Care Network adult members.
This program applies to Blue Care Network commercial (including self‑funded groups,) BCN Advantage HMO‑POSSM and BCN Advantage HMOSM members.
The CPT codes that apply are *22207, *22533, *22558, *22612, *22630, *62287, *63005, *63012, *63017, *63030, *63042, *63047 and *63056.
Providers may submit requests for clinical review for these procedures to BCN electronically. Users will be prompted to complete an appropriateness questionnaire for clinical review consideration. If the criteria are met, the request will be automatically approved. If the criteria are not met, the request will require further clinical review. Health care providers may also contact BCN’s Care Management department at 1‑800‑392‑2512 to request clinical review.
A sample of the appropriateness questionnaires will be made available on ereferrals.bcbsm.com at a later date. Look on the Clinical Review and Criteria Charts page under Medical necessity criteria / benefit review requirements.
* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
Arthroscopy of the knee requires clinical review effective March 1, 2013Effective March 1, 2013, clinical review will be required for arthroscopy of the knee for Blue Care Network adult members.
This program applies to Blue Care Network commercial (including self‑funded groups,) BCN Advantage HMO‑POSSM and BCN Advantage HMOSM members.
The CPT codes that apply are *27332, *27333, *27425, *29870, *29873, *29874, *29875, *29876, *29877, *29879, *29880, *29881 *29882, *29883, *29885, *29886, and *29887 *G0289.
Providers may submit requests for clinical review for these procedures to BCN electronically. Users will be prompted to complete an appropriateness questionnaire for clinical review consideration. If the criteria are met, the request will be automatically approved. If the criteria are not met, the request will require further clinical review. Health care providers may also contact BCN’s Care Management department at 1‑800‑392‑2512 to request clinical review.
A sample of the appropriateness questionnaires will be made available on ereferrals.bcbsm.com at a later date. Check the Clinical Review and Criteria Charts page under Medical necessity criteria / benefit review requirements.
* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
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BCN AdvantageBCN offers Blue Advantage Rewards program for 2013 . . . . . . Page 6
New Medicare Advantage Diagnosis Gap Closure incentive program for primary care physicians for 2013 replaces Physician Assessment Form reimbursement . . . . . . . . . . . . . . . . . Page 7
New member health assessment form encouraged for well visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 9
What you need to know about Medicaid and Medicare fraud, waste and abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 10
@HOMeSupport coming in 2013 . . . . . . . . . . . . . . . . . . . . . . . . Page 10
BCN Advantage has new transportation vendor . . . . . . . . . . . Page 10
BCN Advantage members give the plan high scores . . . . . . . . Page 11
Behavioral HealthInstructions for completing name and NPI on the BCN Behavioral Health Continuing Outpatient Treatment Request Form available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 21
Reminder: Members already diagnosed with autism may not have to be reevaluated . . . . . . . . . . . . . . . . . . . . . . . . . Page 22
Behavioral health procedure code changes . . . . . . . . . . . . . . . Page 22
Billing BulletinNew codes for nerve conduction studies and electromyography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 32
Blue Care fixes system error causing incorrect QNF edits . . . Page 32
Blue Cross and Blue Care Network measures show claims paid quickly and accurately . . . . . . . . . . . . . . . . . . . . . . . Page 32
Clinical editing Q&A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 33
Clinical editing billing tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 33
Blue Care Network hospital outpatient pricing strategy effective April 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 34
Blood transfusion codes to be reimbursed at HCPCS level . . . Page 34
Clear Claim Connection — not a tool for BCN . . . . . . . . . . . . . . Page 34
Blue Cross CompleteWhat you need to know about Medicaid and Medicare fraud, waste and abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 12
MDCH offers online training for blood lead screening . . . . . . Page 13
Cholesterol screening recommended for Blue Cross Complete members . . . . . . . . . . . . . . . . . . . . . . . . . Page 13
Network OperationsBlue Care Network focuses on group contracting for specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 2
Reminder: Women’s preventive care takes effect for most members in January . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 3
Reminder: Members in Blue Elect Plus plan do not need referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 4
BCN offices closed for holidays . . . . . . . . . . . . . . . . . . . . . . . . . . Page 5
Blue Care Network website merged with BCBSM . . . . . . . . . . . Page 5
Providers encouraged to keep CAQH information current for credentialing and enrollment . . . . . . . . . . . . . . . . . . . . . . . . . Page 5
Patient CareFrom the medical director: Strategies for improving immunization rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 14
January is cervical cancer awareness month . . . . . . . . . . . . . . Page 15
Medical policy updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 15
Preventive health guidelines updated for 2013 . . . . . . . . . . . . . Page 16
Patient Safety Awareness Week is in March . . . . . . . . . . . . . . . Page 16
Tips to improve patient satisfaction . . . . . . . . . . . . . . . . . . . . . . Page 17
Blue Care Network focuses on osteoporosis prevention . . . . Page 18
February focus is on heart health . . . . . . . . . . . . . . . . . . . . . . . . Page 19
Criteria corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 20
Pharmacy NewsBCN takes steps to notify prescribers and members affected by drug recall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 26
New transition fill program introduced for BCN members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 27
2013 BCBSM and BCN Formulary Quick Guide now available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 27
The benefits of ACE inhibitors and ARBs in diabetes . . . . . . . Page 28
Talk with your BCN members about their drug coverage . . . . Page 30
Avoidance of antibiotic treatment in adults with acute bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 31
Quality CountsBest Practices: Ann Arbor pediatrician makes strep testing part of practice’s culture . . . . . . . . . . . . . . . . . . . . . . . . . . Page 1
Blue Care Network to begin HEDIS chart reviews in January . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 23
MQIC releases new guideline to assess adolescent health risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 23
Quality improvement program information available upon request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 24
Blue Cross and Blue Care Network measures show claims paid quickly and accurately . . . . . . . . . . . . . . . . . . . . . . . Page 25
Referral RoundupNew Landmark treatment plan forms now in use . . . . . . . . . . Page 35
Writing the prescription for therapy . . . . . . . . . . . . . . . . . . . . . . Page 36
BCN and Blue Cross Complete clinical programs reformatted for clarity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 37
Reminder: Members in Blue Elect Plus plan do not need referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 37
Arthroscoopy of the knee requires clinical review effective March 1, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 38
Lumbar spine surgery requires clinical review effective March 1, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 38
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Patient Care
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Quality Counts
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Referral Roundup
Index
Cover Story
FeedbackWP 12050 JAN 13 R011310
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