Massachusetts Association of Patient Account Managers Annual Insurers Day

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Massachusetts Association of Patient Account
Managers Annual Insurers Day
Blue Cross Blue Shield of Massachusetts is an
Independent Licensee of the Blue Cross and Blue
Shield Association
Paul Lareau, Provider Relations Manager Blue
Cross Blue Shield of MassachusettsMay 21, 2009
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Agenda

• Blue Cross Blue Shield of Massachusetts Vision
• Quality Affordability
• Technology
• Authorization Requirements
• Products and Coverage
• Network News
• Quality Improvement Initiatives
• Important Reminders

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From Our Promise to Transformation

• To always put our members health first.
• The services our members receive are only as good
  as the health care system that delivers them.
• To support the passionate commitment of
  caregivers, we must collaborate to create a
  health care system that provides safe, effective,
  affordable, patient-centered care for everyone in
  Massachusetts.

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Signs of a Troubled SystemOveruse, Underuse,
Misuse, and Errors
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We believe

• Quality Affordability

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Performance Pays Higher Quality, Lower
CostsPremier Quality Demonstration Project
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Our Quality Affordability Plan

• We are changing the way we pay doctors and
  hospitals by moving our provider payment system
  from one that rewards volume to one that rewards
  quality and effective care
• We are working with others to eliminate the
  overuse, underuse and misuse of health care
  services, and will organize our network around
  those providers who deliver the safest, most
  effective care
• We are empowering consumers by collaborating with
  others to build a public movement to advocate for
  the highest quality care
• We know we cant do this alone, so we are
  committing resources to community-based
  initiatives that result in better care at lower
  cost.

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BCBSMA Integrated Pay-for-Performance Programs

• Primary Care Physician
• Incentive Program
• Quality
• Efficiency
• Infrastructure

Specialist Performance Incentive Programs
Group-based Specialty-based
Improved health care quality, access,
affordability, and outcomes
Ancillary Incentive Program Skilled
Nursing Facility

• Hospital Performance Incentive Program
• Hospital Quality
• E-technology

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The Alternative Quality Contract (AQC) Model

• Unique contract model
• Physicians hospital contracted together as a
  system accountable for cost quality across
  full care continuum
• Long-term (5-years)
• Controls cost growth
• Global payment for care across the continuum,
  risk adjusted
• Annual inflation tied to CPI
• Incentive to eliminate clinically wasteful care
  (overuse)
• Improved quality, safety and outcomes
• Robust performance measure set creates
  accountability for quality, safety and outcomes
  across continuum
• Substantial financial incentives (up to 10) for
  high performance

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Our AQC Partners (as of May 2009)
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Technology
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Enhancements to BlueLinks for Providerswww.bluecr
ossma.com/provider

• Added a Medical Review Resources section under
  Manage Your Business housing McKesson InterQual
  SmartSheets? and Behavioral Health and
  Medical/Surgical Level of Care criteria
• Developed a search capability within our Medical
  Policies
• Enhanced our online training selection, adding
  new webinars, seminars and online courses in our
  Training Registration area Technology
  Solutions 2009, BlueCard, Health Care
  Administrative Solutions, Medicare Advantage
  products, ICD-9-CM Coding and Documentation and
  much more. available anytime you are!

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Tools on BlueLinks for ProvidersPaySpan Health

• Speeds access to payments receive rapid payment
  though direct deposit/Electronic Funds Transfer
  (EFT)
• Free, secure, and HIPAA-compliant online access
• Eliminates paper reports view Provider Payment
  Advisories, Provider Detail Advisories, and
  Accounts Receivables online
• Stores two years of history
• Available 24/7

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Tools on BlueLinks for ProvidersNEHENNet

• NEHEN, a collaborative, payer provider-owned
  solution for connectivity and administrative
  simplification, now offers NEHENNet a common
  website offering low-cost access to transactions
  for multiple payers

• NEHENNet supports all administrative transactions
  in standard HIPAA formats
• Today
• Eligibility verification, claim status inquiry,
  referrals, claim transfer, remittance transfer,
  and professional claim data entry
• Full support for NPI (national provider
  identifier)
• Future
• Remaining administrative transactions such as
  attachments and dental claims
• Extensions to other payer provider transaction
  exchanges

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Technology Solutions Training

• How to use NEHENNet, PaySpan Health, and direct
  claim submission via 837 claim files or
  telephonically to streamline and simplify common
  administrative processes

• Seminars

Webinars

• To register, go to www.bluecrossma.com/provider.
  Log on and select Resource CentergtTraining
  RegistrationgtCourse List. Choose Technology
  Solutions 2009.

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Authorization Requirements
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PPO Prior Authorization Notification

• Scheduled July 1, 2009 prior authorization
  changes for PPO plans are postponed
• Includes the following outpatient procedures
• Chiropractic services beyond 12 visits
• Physical and occupational therapy services beyond
  eight visits
• Most elective, non-emergency high-tech radiology
  services
• Neuropsychological testing
• Sleep studies
• Knee arthroscopies
• Hip and knee replacements
• Spine surgeries
• Hysterectomies
• Inpatient admissions for these and other
  procedures were not affected and continue to
  require prior authorization.

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Prior Authorization Surgeries and Sleep Studies

• Outpatient spine surgeries, knee arthroscopies
  and hysterectomies require authorization
• Effective March 1, 2009 for commercial HMO/POS
  products
• Outpatient hip and knee replacements and sleep
  studies require authorization
• Effective May 1, 2009 for commercial HMO/POS
  products
• All inpatient services continue to require
  authorization for all products.

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Prior AuthorizationCriteria and Tools

• Medical necessity decisions based on the
  evidence-based 2008 InterQual criteria
• Use McKessons InterQual SmartSheetsTM where
  available to submit your prior authorization
  requests
• Log on to www.bluecrossma.com/provider, select
  Manage Your Business gt Medical Review Resources gt
  McKesson InterQual Smart Sheets
• For more detail see our F.Y.I. dated January 1,
  2009.

Medicare Advantage products use CMS criteria
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Prior Authorization Neuropsychological Testing

• Required for
• HMO plan members for dates of service on and
  after May 1, 2009
• POS plan members utilizing in-network services
  for dates of service on and after May 1, 2009
• Use Neuropsychological Testing Request Form
• Log on to www.bluecrossma.com/provider, and
  select Resource CentergtFormsgtAuthorization Forms
• Or call Fax-on-Demand at 1-888-633-7654 and
  request document 875
• Requests approved within the following ranges
  based on medical necessity and testing
  complexity
• Children/Adolescents 8-12 hours
• Adults 8-10 hours

Neuropsychological testing solely for routine
diagnosis of ADHD is not regarded as medically
necessary and therefore will not be authorized.
Testing for educational or vocational purposes is
not covered.
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Radiology Quality Initiative (RQI) Update

• Based on updated analyses, BCBSMA is realigning
  the participation categories for HMO and POS
  members for a number of practice groups across
  the network
• Changes include
• Effective April 1, 2009
• Certain Registration groups are moving to
  Clinical Review
• Some Clinical Review groups are moving to
  Registration
• Effective May 1, 2009, certain Approved
  Alternative Radiology Management groups are
  moving to Clinical Review
• If your practice is affected, you will receive
  detailed information on changes to your RQI
  requirements

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Products and Coverage
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Product UpdatesTiered Network Plan Designs

• Additional tiered network plan available as of
  February 1, 2009
• Preferred Blue PPO Options v.2
• Joins existing tiered network plans
• HMO Blue Options?
• HMO Blue New England Options
• PPO Blue Options (for self-insured accounts)
• Three benefit tiers for Massachusetts PCPs and
  hospitals
• Enhanced Benefits Tier scores meet benchmarks
  for quality, lowest cost
• Standard Benefits Tier scores meet benchmarks
  for quality, moderate cost
• Basic Benefits Tier scores below benchmarks for
  quality, and/or for moderate cost

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Product Updates, continuedHospital Re-tiering

• Updated hospital tiers effective October 1, 2009,
  for Options plan designs
• Existing plan designs
• HMO Blue New England Options
• HMO Blue Options
• Network Blue New England Options
• Network Blue Options
• Blue PrecisionTM
• PPO BlueSM Options
• Preferred Blue PPO Options
• Proposed new plan designs effective October 1,
  2009
• HMO Blue Options 500 Deductible
• HMO Blue Options 1000 Deductible
• HMO Blue New England Options 500 Deductible
• HMO Blue New England Options 1000 Deductible
• Network Blue Options (customized to meet
  individual employer group needs)

Pending Division of Insurance Approval
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Product Updates, continued

• New plan designs available to individual and
  small group markets as of April 1, 2009
• HMO Blue Premier Value with Co-insuranceSM
• HMO Blue New England Premier Value with
  Co-insuranceSM
• Annual 1,000 individual / 2,500 family
  deductible
• 35 co-insurance for services such as outpatient
  day surgery, diagnostic labs, X-rays, and
  high-tech radiology
• Out-of-pocket maximum of 2,000 individual /
  4,000 family that includes all deductibles,
  co-insurance, and copayments that exceed 100.

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Observation Policy ChangeEffective November 1,
2009

• To be consistent with industry practice, BCBSMA
  Observation policy for all commercial products
  is being updated effective November 1, 2009
• Billing and Reimbursement
• BCBSMA will pay the lesser amount of the
  contracted rate for outpatient services and the
  charges for the service on the claim
• Billing inpatient admission following observation
• Related observation services occurring 1-2 days
  prior to, or on the same day, as an inpatient
  admission (same provider) must be billed on the
  inpatient claim
• We do not pay observation payments in addition to
  the normal inpatient reimbursement.
• BCBSMA will NOT reimburse for
• Observation for the normal recovery period
  following surgical day care
• Observation solely for the convenience of the
  provider, member, or members family.
• Referrals and authorizations are not required.

Excluding Medicare Advantage products.
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Network News
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Nurse Practitioners as Primary Care Providers

• Massachusetts statute requires insurers to allow
  members to select a Plan-participating nurse
  practitioner (NP) as a primary care provider and
  to include participating NPs in all paper and
  electronic provider directories
• BCBSMA has contracted with NPs for all products
  since 2001 and NPs are already listed in our
  online and paper directories
• We are working to implement a process to enable
  members to choose an NP accredited in family
  practice, adult medicine, or pediatrics as their
  primary care provider
• We are collaborating with the Massachusetts
  Coalition of Nurse Practitioners and will notify
  Plan-participating NPs and Primary Care
  Physicians as this implementation proceeds

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Adoption of All-Patient Refined-Diagnosis Related
Grouper for Inpatient Hospital Payments

• Implementing All-Patient Refined-Diagnosis
  Related Grouper (APR-DRG) for inpatient services
  for discharge dates on or after August 1, 2009
• Moves BCBSMA toward a payment methodology
  reflecting resource utilization, but that is
  revenue-neutral to hospitals
• Affects DRG-based (or per diem based) payment for
  inpatient services provided to Indemnity, PPO,
  HMO, and Medicare Advantage members
• Benefits
• Improves ability to correlate payment and
  resource utilization (i.e., costs) and more
  accurate payment for case-mix.
• Aligns payment with service level costs shifting
  from facility focus to patient-service
  characteristics.
• Enhances BCBSMAs analysis of hospital inpatient
  quality, development of new payment models, and
  payment based on performance and quality of care.
• For training log on to www.bluecrossma.com/provide
  r and select Resource CentergtTraining
  RegistrationgtCourse List. Choose APR-DRG Overview
  or APR-DRG Implementation Details.

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Quality Improvement
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Medicare Advantage Provider Quality Improvement
Program (MAPQIP)

• MAPQIP A prospective quality improvement
  program to facilitate annual collection of all
  applicable diagnoses (coded to the highest level
  of specificity) for our Medicare Advantage
  members.
• Designed to reduce the need for retrospective
  medical record audits and trigger early
  assessment for referrals to our disease
  management and case management services.
• Ensures complete and accurate reporting to CMS
• Annual Visit Form (AVF) created for providers
  to simplify the capture of comprehensive,
  accurate, and complete diagnosis codes to more
  accurately reflect Medicare Advantage member
  health status.
• As of March 1, 2009, providers complete AVF
  during annual visit and submit to BCBSMA with
  relevant medical record documentation.

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MAPQIP Process
Complete AVF along with medical record
Medicare Advantage member annual visit
Print, sign date AVF, including credentials
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Questions?
PEP-3338 5/09)