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BlueCross BlueShield of Tennessee, Inc. an Independent Licensee of the BlueCross BlueShield Association
BlueCare Tennessee
Promoting Quality Care
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Our Goal Make the Lives of Our Members Better
Coordinate the total physical, mental and long-term care support and services needs to Make the Lives of Our Members Better
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Provider Support Key to Success
Working together to deliver quality care You are the most influential element of your patients’ health care experience
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Promoting Quality Care Program Standards
Quality Program Standards • Accreditation agencies • Federal guidelines • Mandates by State of Tennessee and Bureau of TennCare
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Promoting Quality Care Clinical Data Exchange
Clinical Data Exchange • Securely share clinical data with BlueCross • Supports collaboration • Helps reduce burden of office staff Learn more about Clinical Data Exchange during our breakout session on Quality
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Promoting Quality Care Prenatal/Postpartum Care
$10 Bonus Each Claim Category II Codes 500F or 503F submitted with specific patient information Applies to BlueCare, TennCareSelect and CoverKids
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Promoting Quality Care
Quality Programs
• General health and wellness • Women’s health • Child and adolescent health • Senior health • Coordinated behavioral and primary health services for
TennCare members through Tennessee Health Link
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TennCare Kids (EPSDT)
71%
Early Periodic Screening, Diagnosis and Treatment Program
EPSDT • Comprehensive health and developmental history • Comprehensive unclothed physical exam • Appropriate immunizations • Laboratory tests • Health education
In 2015, EPSDT screening rates dropped to an average of 71% across all age groups. We can do better!
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TennCare Kids (EPSDT)
We Need Your Help!!!
Schedule Appointments and Provide
Reminders for your Members
Partner with us to conduct Outreach
Events
Document all components of the exam in the
patient’s medical record
Bill appropriately to maximize your reimbursement
There are “missed opportunities” to capitalize on:
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TennCare Kids (EPSDT) Missed Opportunities
Children with special needs require TennCare Kids services too
When a patient presents with symptoms such as an ear infection and is due for a well-child exam, then both codes may be billed using the modifier 25 added to the office visit code.
Sports physicals do not take the place of a annual TennCare Kids exam, so please provide both
Members who have other insurance
The Tennessee Chapter of the American Academy of Pediatrics offers an extensive EPSDT and Coding Program. Please visit the website at www.tnaap.org for additional information.
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TennCare Kids (EPSDT) Training and Coding Resources
New CoverKids Provider Network
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CoverKids Provider Network Same Patients, Same Providers – New Network
A new network is big news and usually means big changes Almost everything will stay the same for providers What stays the same:
• Reimbursement fees • Member benefits • Patients
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CoverKids Provider Network Same Patients, Same Providers – New Network
TennCareSelect Member
CoverKids Member
Dr. Kimble TennCareSelect
Provider
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Before Two populations: • TennCareSelect Members • CoverKids Members One provider network: TennCareSelect
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CoverKids Provider Network Same Patients, Same Providers – New Network
TennCareSelect Member
CoverKids Member
Dr. Kimble TennCareSelect
Provider
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Dr. Kimble CoverKids Provider
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Now Two populations • TennCareSelect Members • CoverKids Members Two provider networks with same providers: • TennCareSelect • CoverKids
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CoverKids Provider Network Same Patients, Same Providers – New Network
Only Major Change: Member ID Cards
ECF CHOICES Program
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Employment & Community First (ECF) CHOICES Providing Help & Hope
Tennessee is first in the nation to launch this type of program for people with intellectual and developmental disabilities Population
• People with intellectual and other developmental disabilities not currently receiving services
Program Services • Support for individuals and families • Help to achieve employment,
independent living and community goals Change lives and bring hope to individuals and their families in a way they have never known before
Claims Reminders
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Claims Reminders Administrative Notes
NICU Care Claims Accepted Only from NICU-Level Facilities Babies with life-threatening conditions born at standard birthing facilities • Stabilize baby, then transfer to a NICU facility • Code claim for stabilizing the baby for transfer, not for NICU care
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Claims Reminders Administrative Notes
Changes at Your Practice? Let us know ASAP if you have changes to: • Address • Phone Number • Office Hours • Other Key Information
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Claims Reminders Administrative Notes
Billing TennCare Enrollees • Only collect applicable TennCare Copay • Even if they have a third-party payer • Even if third-party pays in full for service Note: Your office must bill the third-party payer before billing TennCare
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Claims Reminders Administrative Notes
Non-Covered Services • Providers MUST inform TennCare enrollees that they are
responsible for any charges not covered by TennCare BEFORE performing the service
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Claims Reminders Administrative Notes
Federal Requirements for Billing Hospital Inpatient Claims • Document that care was reasonable and necessary • Signed physician’s certification, including the practitioner order
Provider Satisfaction Survey
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Provider Satisfaction Survey Tell Us How We’re Doing
Tell us how we’re doing: • Quick • Easy • Only one page • Pick-up your survey in the lobby
Surveys completed TODAY are entered for a gift card drawing!
Questions?
Medicare Advantage
Mechanism used by CMS to set premium levels paid to Medicare Advantage plans Each member is assigned a risk score based upon their demographics and diagnosis codes Diagnosis codes for significant conditions map to Hierarchical Condition Categories (HCCs) Approximately 80 HCCs are derived from 3,000 ICD9 and ICD10 codes Purpose is to appropriately compensate Medicare Advantage plans for the risk assumed by insuring each member
Risk Adjustment What is Risk Adjustment?
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Diagnosis codes are submitted to CMS from two primary sources: • Claims processed by the health plan • Medical record review
CMS requires that diagnoses be documented every calendar year, even those for chronic conditions Appropriate documentation results in premium levels that: • Cover medical expenses • Maintain benefit levels • Prevent member funded premiums
Risk Adjustment What is Risk Adjustment?
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Document to the highest level of specificity given the patient’s health
Diagnose chronic conditions every year
Include all relevant ICD9/10 codes on each claim
Follow AAPC guidelines when creating medical records
Remember: More diagnoses on claims = fewer medical record requests. You may also add code 99080 to your claim to report additional diagnoses.
Risk Adjustment What is the Physician’s Role?
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Care and Case Management Case Management and Population Health
Case Management and Population Health Management • Fully Integrated Medical and Behavioral Health Case Management Team • Member Education & Support • Promote Quality and Cost Effective Coordination of Care
Targeted Interventions • Increase Member/Caregiver’s Knowledge of Condition • Improve Medication Adherence • Reduce Gaps in Care • Reduce Emergency Room visits • Timely Post-Discharge Follow-up • Increase Compliance with Treatment Plan • Reduce Barriers to Care
Complex Case Management
Transplant Case Management
Care Coordination
Discharge Care Coordination
Population Health Management
Social Services
To Make a Referral: 1-800-611-3489
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Care and Case Management Case Management and Population Health Programs Available
Effective Sept. 1, 2014, BlueAdvantage (PPO) and the BlueChoice (HMO) plans implemented two readmission programs that apply to same or similar diagnosis readmissions to acute care hospitals that occur within 31 days from the index admission discharge • Admission within 48 hours of discharge –readmission is not
reimbursed o Defined as the same or similar diagnosis from a
complication of the original hospital stay or admission resulting from a modifiable cause of the both admissions must occur at the same facility or a facility operating under the same contract
o BlueCross will follow for discharge planning needs only (i.e., no clinical updates)
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Care and Case Management Readmission Reduction Program
Admission within three to 31 days of discharge • Only the higher weighted DRG pays • Defined as the same or similar diagnosis from a complication of
the original hospital stay or admission resulting from a modifiable cause of the original hospital stay. Both admissions must occur at the same facility or a facility operating under the same contract
• Reimburse a single DRG (the higher weighted of the two admissions) and all other days will be reimbursed based on DRG outlier methodology
• Subject to inpatient medical review based on MCG criteria Provider Appeals • Standard provider appeal remedies are the same as usual for
administrative service denials
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Readmission Reduction Program What is the Readmission Reduction Program? Continued..
Risk Adjustment/Quality Improvement and STARS Programs East Region • Ashley Ward, Manager, Quality Finance • Office Phone: (865) 588-4628 • Email: [email protected]
Middle/West Region • Tamara Matos-Cruz, Manager, Quality Finance • Office Phone: (615) 386-8592 • Email: [email protected]
Care and Case Management
• Jeffrey Marvel, Director of Care/Case Management • Office Phone: (423) 535-7353
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Contact Us Who to Contact?
Commercial
Schedule patients for regular wellness visits
Proper CPT and Diagnosis Codes • Code the procedure accurately and timely
Preventive Visits Wellness Exams
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File claims for annual wellness accurately • Child Care Immunizations • Health Care Screenings – Colorectal cancer,
breast cancer, cervical cancer, osteoporosis, HbA1c, retinal eye and urine nephropathy, etc.
Preventive Visits Wellness Exams
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Preventive Visits Proactive Health Care Initiatives
Follow-up on missed appointments Gaps in care
Refer to the BlueCross BlueShield of Tennessee website at www.bcbst.com/providers/preventive-services for additional information.
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Referring Physicians
You are contractually obligated to refer to participating providers It’s especially important for members referred to hospitals for lab work, DME and any other ancillary services Reference our website before scheduling appointments Visit BlueAccessSM for a list of participating providers Cost Sharing
• Out of pocket expenses
Multiple classes held during the year Extended service hours (8 a.m. to 6 p.m. ET) Improved Service Levels Wait Times Improved
Service Level Improvements
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Cross Training • More efficient with less handoffs • Improved first call resolution
System Enhancements • Benefit summary redesign
Daily Intervention Meetings • SWAT Teams
Service Level Improvements
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Provider Data Management
Changing Landscape Regulations, Directory Oversight and Provider Data Accuracy
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In early 2015, CMS released a memo related to provider directories that changes how we do business. Provider data is no longer just used to pay claims. Provider data requires a tighter maintenance protocol because of Value Based Programs (THCII/QCPI/Etc.) and the requirement for accurate directories. These are becoming more data driven and require accuracy to be effective.
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Provider Data Verification
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Where Are We Today?
Quarterly outreach started in March. Technological industry solutions are still in development. Data verification forms to continue until industry solution is available. Regardless of the solution, cooperation and comprehensive review between the payers and providers will be critical.
Mandates Brief Overview
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CMS Medicare Advantage (MA) and Medicaid regulations • Regularly evaluate availability of contracted providers and update directory • Quarterly communications to providers to update availability and panel status • Updates to online provider directory within 30 days of change notification
Health and Human Services (HHS) regulations, applicable to Qualified Health Plans (QHPs) • Renewed focus on network adequacy standards, reporting on provider
accessibility for individuals with disabilities, network data collection • Increase updates to provider directories for non-address data fields, including
open panel status, medical group and institutional affiliations, specialties NCQA Accreditation Standards – Provider Network Management • Regularly assess the accuracy of provider directories • Update provider directories at least monthly
Mandates Other
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External Quality Review Organization (EQRO) Bureau of TennCare Recent changes to regulatory and accreditation standards require greater emphasis and attention on directory data accuracy
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Some Impacted Networks Blue Networks
Commercial • Blue Network PSM
• Blue Network SSM
• Blue Network ESM
Medicaid • BlueCare • TennCare Select • CoverKids • CHOICES
Medicare Advantage • Medicare Advantage • BlueAdvantage (PPO) SM
• DSNP • BlueChoice (HMO) SM
BlueCross BlueShield of Tennessee, Inc. is a PPO plan with a Medicare contract. BlueChoice Tennessee is an HMO plan with a Medicare contract. Enrollment in BlueCross BlueShield of Tennessee, Inc. and BlueChoice Tennessee depends on contract renewal.
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Using Technology
Vendor solutions in progress
• A single source of provider data verification for the industry is actively being worked through CAQH and other vendors
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Data Verification Forms
Quarterly outreach via “Data Verification Forms” continuing through 1st quarter 2017.
A single source of provider data verification for the industry is actively being worked through CAQH and other vendors.
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Questions - How can we help?
Provider Reconsideration and Appeals
What is a Provider Reconsideration?
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A reconsideration allows providers dissatisfied with a claims outcome/denial to ask us questions. Reconsiderations must be requested and completed before filing a formal appeal. Provider reconsiderations may be requested in reference to numerous topics, including, but not limited to:
• Corrected claims • Coordination of benefits • Diagnoses codes • Procedure or revenue codes • Recoupment disputes
For adjudicated claims to be reconsidered, provide adequate supporting documentation. You may initiate a reconsideration by calling us or using the Provider Reconsideration Form. If you still are dissatisfied after a reconsideration, you may file a formal appeal.
The kickoff point for a provider reconsideration is a denied claim and a frustrated provider.
The provider determines his/her reason for reconsidering a claim and begins the process of filing the reconsideration.
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Reconsiderations: A Case Study
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Case Study (continued)
Step 1: Does the provider understand why the claim was initially denied?
YES: The provider understands the reason and still disagrees.
NO: The provider does NOT understand the reason for denial. The
remittance code is reviewed, and the provider then determines whether he/she agrees or disagrees with the ruling.
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Case Study (continued)
Step 2: Are ancillary services impacted by the reconsideration?
YES: Durable Medical Equipment (DME), Lab and Specialty Prescription claims may only be reconsidered: If DME products were delivered or picked up in Tennessee If Lab or Specialty Rx were ordered by a provider in Tennessee FEP only: DME, Lab and Specialty Rx claims may be reconsidered if
the provider filing the claim is in Tennessee NO: Providers must complete and fax a reconsideration form to
(423) 535-1959 within 18 months of initial denial.
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Submitting a Reconsideration
Step 3: Submit the reconsideration form within 18 months of the initial claims denial.
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What is a Provider Appeal?
An appeal allows providers dissatisfied with a claim reconsideration to formally dispute the denial and provide additional documentation to BlueCross. Only one appeal is allowed per claim. Appeals must be filed and completed within a certain timeframe of receiving a reconsideration determination. (Refer to timeliness grids for each line of business.) NOTE: If the reconsideration process identified the decision was related to medical
necessity, you may be directed to a separate Utilization Management appeal form.
For adjudicated claims to be appealed, you must provide adequate supporting documentation. If you still are dissatisfied following an appeal, the arbitration process begins. Refer to the Provider Dispute Resolution Procedure documented in the BlueCross and
BlueCare Provider Administration Manuals.
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What Does the Appeals Process Look Like?
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Formal Appeals
You may file an appeal if you still are not satisfied with your claims outcome after the reconsideration process is complete.
Key questions: Have you filed a reconsideration, and was it denied? YES: Move forward with the appeals process NO: You will be redirected to the reconsideration process
Do you agree with the reconsideration ruling? YES: Accept the denial NO: Move forward with a formal appeal
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Formal Appeals (continued)
Step 1: For all appeals, are ancillary services affected?
YES: Claims may only be appealed: If DME products were delivered or picked up in Tennessee If Lab or Specialty Rx were ordered by a provider in Tennessee FEP only: DME, Lab and Specialty Rx claims may be appealed if the
provider filing the claim is in Tennessee NO: Proceed to Step 2
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Formal Appeals (continued)
Step 2: Is the appeal related to an authorization request?
YES: The appeal is related to an authorization request Is the authorization for a Commercial member?
YES: Fax the Commercial UM Appeal Form to (423) 591-9451 NO: Submit the Provider Appeal Form and fax to the dedicated fax
number for each line of business: BlueCare Tennessee: 1-888-357-1916 Medicare Advantage: 1-888-535-5243 BlueCare Plus: (423) 591-9163 CoverKids: 1-800-851-2491
NO: There is no pending authorization Submit the Provider Appeal Form
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Formal Appeals (continued)
Step 3: Complete the provider appeal form • It is critical to include the member ID
number (including the prefix) at the top of the appeals form.
• This ensures the appeal is routed appropriately.
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Timeliness
Timeliness standards vary between lines of business because of different regulatory requirements.
The following slides provide greater clarification on the timeliness standards for each line of business.
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Commercial Timeliness (Includes Federal Employee Program)
Type of Dispute Reconsideration Timeliness Appeal Timeliness *Non-Compliant
Arbitration
Claim 18 months from Adverse Determination (Remit)
Required before formal appeal
Fax: (423) 535-1959
30 days from Reconsideration Determination
Fax: (423) 535-1959
N/A 30 days from Appeal
Determination
Authorization (TN Members)
FEP Members: TN Providers
Optional Before or during services but
before formal appeal; Submit through normal authorization processes:
phone/fax/online
180 days from Original Adverse Determination
Submit through UM
Appeal Form
Fax: (423) 591-9451
*60 days from Adverse
Determination (UM Letter/ Claim/ EOB)
30 days from Appeal
Determination
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BlueCare Timeliness
Type of Dispute Reconsideration Timeliness Appeal Timeliness *Non-Compliant Arbitration
Claim 18 months from Adverse Determination (Remit)
Required before formal appeal
Fax: (423) 535-1959
30 days from Reconsideration Determination
Fax: (423) 535-1959
N/A 30 days from Appeal
Determination
Authorization Optional Before or during services
Submit through normal authorization processes: phone/fax/online
60 days from Original Adverse
Determination
Fax: 1-888-357-1916
*60 days from Adverse
Determination (UM Letter/ Claim/ EOB)
30 days from Appeal
Determination
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Medicare Advantage Timeliness
Type of Dispute Reconsideration Timeliness
Appeal Timeliness *Non-Compliant Arbitration
Claim 18 months from Adverse Determination (Remit) Required before formal
appeal Fax: (423) 535-1959
30 days from Reconsideration Determination
Fax: (423) 535-1959
N/A 30 days from Appeal
Determination
Pre-Service Authorization
Considered Member Appeal
N/A Must be filed within 60 days of the Original
determination notice
N/A 30 days from Appeal
Determination
Post-Service Authorization
Optional “Re-evaluation”; prior to
formal appeal
60 days from most recent determination
notice
Fax: 1-888-535-5243
60 days from Adverse
Determination (UM Letter/ Claim/ EOB)
30 days from Appeal
Determination
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BlueCare Plus (Dual Special Needs Plan) Timeliness
Type of Dispute Reconsideration Timeliness Appeal Timeliness *Non-Compliant
Arbitration
Claim 18 months from adverse determination (Remit)
Required prior to formal appeal
Fax: (423) 535-1959
30 days from Reconsideration Determination
Fax: (423) 535-1959
N/A 30 days from Appeal Determination
Pre-Service Authorization (considered a
member appeal)
N/A N/A N/A N/A
Post-Service Authorization
Optional; after initial denial but before formal appeal request
Provider can submit additional
clinical for re-evaluation
60 days from Original Adverse
Determination
Fax: (423) 591-9163
60 days from Adverse
Determination (UM Letter/ Claim/ EOB)
30 days from Appeal Determination
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BlueCard Host (Non-Tennessee Members) Timeliness
Type of Dispute Reconsideration Timeliness
Appeal Timeliness *Non-Compliant
Arbitration
Claim 18 months from adverse
determination (Remit)
Required prior to formal appeal
Fax: (423) 535-1959
30 days from Reconsideration Determination
Fax: (423) 535-1959
N/A 30 days from Appeal Determination
Authorization Follow normal claim reconsideration
Follow normal appeal guidelines
N/A N/A
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Key Points to Remember
Utilization management authorization appeals are handled by a medical team. Each line of business has dedicated UM appeal fax numbers. Claims appeals are handled by an administrative team. After the authorization appeals process is complete, you may not begin the claims appeal process. The next step is arbitration. Providers cover the costs associated with arbitration and independent reviews. The Provider Dispute Resolution process allows for one reconsideration, followed by one appeal per claim issue. Duplicate requests or improperly submitted forms will be returned without additional review.
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Common Terms
Reconsideration – Allows providers dissatisfied with a claims outcome/denial to request additional information or ask us questions. Appeal – Allows providers dissatisfied with a claim reconsideration to formally dispute the denial and provide BlueCross more documentation. Arbitration – Allows providers dissatisfied with reconsideration and appeals process outcomes to seek resolution by a third party. Timeliness – The time you have to pursue reconsideration or appeal an adverse determination. Non-Compliant – When prior authorization is required, you must obtain authorization before scheduled services and within 24 hours or the next business day of emergent services. Failure to comply within specified authorization timeframes will result in a denial or reduced benefits from non-compliance, and BlueCross participating providers will not be allowed to bill members for covered services rendered, except for any applicable copayment/deductible and coinsurance amounts.
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Resources
Visit www.bcbst.com/providers/forms for updated copies of each of the required forms.
Refer to the Provider Administration Manuals for each line of business: • Commercial Provider Administration Manual
www.bcbst.com/providers/manuals • BlueCare Tennessee Provider Administration Manual
www.bcbst.com/providers/manuals • BlueCare Plus Provider Administration Manual
http://bluecareplus.bcbst.com/provider-resources/
Breakout Session Presentations
eBusiness Solutions
Agenda
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BlueAccessSM Overview PCP Member Roster Electronic Claims PWK Attachments THCII Payments
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Providers
Login
Login
Quality Information
Provider Webpage – www.bcbst.com/providers
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Provider Webpage (Continued)
BlueAlert Newsletters
Quick Links
Important Initiatives Find
BlueCross Contacts
UM Resources
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BlueAccess Overview
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Service Center / Authorizations Submit Initial Authorizations and Update existing Authorizations
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Tennessee Health Care Innovation Initiative (THCII)
Blue Access: • Frequently Asked Questions • Guide to Reading Your Episode of Care Report • Adjustment Methodology • Risk Factors • Perinatal Thresholds of Episodes of Care
Tennessee government website https://www.tn.gov/hcfa/topic/episodes-of-care Episodes of Care:
• Wave 1 - In the interim phase for BlueCare/TennCare Select /CoverKids • Waves 2, 3 and 4 are all in the preview phase
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BlueAccess Overview (Continued)
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PCP Member Roster
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PCP Member Roster Report
Export Report Options
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100% - Electronic Claim Submission
Maintenance Phase Underway
0.00
0.50
1.00
1.50
2.00
2.50
Average PAPER CLAIMS FROM PROVIDER
Average one paper claim per provider per month across our entire provider network Monitor filing patterns for any outliers Continuing outreach efforts to any providers who exceed the normal average number of paper or paper equivalent submissions
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100% - Electronic Claim Submission
Maintenance Phase Underway
Contact eBusiness Service for help with alternative electronic filing methods such as Real Time Claims Adjudication if ever unable to file electronically New providers added to your practice are required to enroll in electronic billing as part of the Network Participation Criteria described in the Provider Administration Manual Be sure to include your EDI filing information with any new applications Notify us of any changes to ensure our records are current and you remain compliant with the network standards
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PWK Attachments
New Form Available
To address supplemental documentation sometimes needed to process claims, BlueCross has a system support to match faxed documentation to electronic claims. Process:
Submit EDI claim with PWK06 (short for “paperwork”) tracking number and proper qualifiers in your 837 data. On the same day as your claim submission, fax your documents with the new PWK coversheet (one per claim). BlueCross will match your claim and document for internal processing purposes which will help streamline adjudication.
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PWK Attachments
New Form Available
PWK IS for… Submitting documents or medical records you know will be needed for
processing (unlisted procedures, custom equipment, etc.) Initial claim submissions
PWK IS NOT for…
Submitting a medical record with every claim Responding to medical record requests post-adjudication Primary EOBs/Remits for secondary claims
Please visit the eBusiness resource table or the eBusiness section of www.bcbst.com for technical information and the new PWK Coversheet.
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Quality Care Rewards Technology Update
THCII Payments
• The THCII Episodes of Care program will have its first round of risk and gain shares issued in September for the BlueCare lines of business.
• The cover page on the Wave 1 Final Performance Reports will indicate the amounts to be paid or owed by the quarterback.
• Financial notices will soon be available in the “View/print your Remittance Advice” on BlueAccess to show the impact to the quarterback’s elected payee and indicate the method of payment if applicable.
• You will be able to match back to the Episode of Care data represented by the financial notice through the tracking numbers on the cover page of the Episodes of Care Final Performance report.
• If no risk or gain share is applied to your quarterback for the current Final Performance Wave(s), no financial notice will be produced.
• Watch for a notice on the BlueAccess landing page regarding when this data will be available.
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eBusiness Contact Information
Quality Updates
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Health care quality means payers, consumers and their health care team work together to ensure accessible, high quality, cost effective care
A range of private, industry, professional and governmental organizations
establish standards for health care quality
Improving Health Care Quality and Outcomes What is Health Care Quality? Who Decides?
Health Plans Providers
Centers for Medicare & Medicaid Services (CMS) – i.e. ACA, Marketplaces, Medicare Advantage
Centers for Medicare & Medicaid Services (CMS) – i.e. PQRS and MACRA
Bureau of TennCare Bureau of TennCare
America’s Health Insurance Plans (AHIP) Professional Societies (i.e. AAP, AAFP, ACOG)
National Quality Forum (NQF) National Quality Forum (NQF)
Accreditation Organizations: NCQA, URAC
Why the focus on Quality?
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Improving Health Care Quality and Outcomes
Health care spending in the U.S. is not sustainable • Pay for volume, regardless of outcome • High variance in care for like conditions • Aging population • Marked increase in chronic disease
There is no correlation between high cost and high quality in the U.S. health care system
Reimbursing health care based on value instead of volume aligns stakeholders (providers, patients/consumers, employers, the government) to promote the most effective, quality care at the lowest possible costs.
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Future Changes in BlueCross Reimbursement Methodology
% o
f Pr
ovid
ers*
**
2016 2018 2020 2019 2017 ***% Providers figures are for demonstration purposes only and do not reflect actual performance expectations.
---- Fee for Service ---- Pay for Gaps ---- Pay for Performance ---- Total Cost of Care
2015
Improving Health Care Quality and Outcomes
100%
0%
Working Together to Ensure Optimal Care
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BlueCross Support for Practice Quality
BlueCross BlueShield of Tennessee: Your Partner in Pursuit of Health
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Quality Care Rewards Tool – Practice Overview
Closing Evidence-Based Gaps in Care
Practice Name
Practice Name
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Quality Care Rewards Tool – Provider View
Closing Evidence-Based Gaps in Care
Provider Name
Provider Name
Provider Name
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Quality Care Rewards Tool – Member View
Closing Evidence-Based Gaps in Care
Patient Name
Patient Name
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Quality Care Rewards Tool – Scorecard View
Closing Evidence-Based Gaps in Care
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Quality Care Rewards Tool – Attestations
Closing Evidence-Based Gaps in Care
Patient Name
Patient Name
Patient Name
Data Integrity is Key to Monitoring Performance
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[Electronic] Clinical Data Exchange accomplishes three major things: 1. Captures measurement data that cannot be
obtained by claims data alone 2. Makes actionable data readily available 3. Reduces the administrative burden on offices
Who You Gonna Call? • Deana Hixson – (423) 535-7014;
[email protected] • Santosh Padhiari - (423) 535-7058;
Clinical Data Exchange
Data Integrity is Key to Monitoring Performance
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Supplemental Data Collection 1. BlueCross nurses review clinical records to
capture measurement data not already being transmitted to BlueCross such as BP readings.
2. Ensures providers receive credit for care provided
3. Minimizes disruption to provider’s practice while maximizing provider’s financial opportunities
Supplemental Data Collection
Additional Resources
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Closing Evidence-Based Gaps in Care
Clinical Guides
Gaps In Care Events
Member Scorecards
Data Integrity is Key to Monitoring Performance
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Supplemental Data Timeframes
Supplemental Data
Warehouse
Consolidated Business Data
Warehouse
Quality rules engine (Verisk)
Central Analytics
Warehouse
Quality Care Rewards Tool
(Electronic Scorecard)
The timeframes around the successful transfer of data may vary depending on the type of data being sent and
the way in which it is submitted.
Claims Data,
Lab Values, EMR Data
15th of each
month
20th of each
month
22ndh of each
month
Attestations sent to SDW every Monday QCR Tool updated
every Tuesday 4th of each
month
Daily
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Thank you for your time today!
Tennessee Healthcare Innovation Initiative (THCII): Episodes of Care
THCII Episodes of Care Agenda
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Episodes of Care Reporting Gain/Risk Sharing Provider Resources
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Overview – What is THCII Episodes of Care? THCII Episodes of Care
• Episode-based payment seeks to align incentives with successfully achieving a patient's desired
outcome during an “episode of care”, a clinical situation with predictable start and end points. - See more at: http://www.tn.gov/hcfa/topic/episodes-of-care#sthash.QRmbo6jW.dpuf
• The State determines the following: • The quarterback for an episode • The Detailed Business Requirements for each Episode • The reporting parameters and requirements • Sets the Acceptable Thresholds
• There are 74 episodes being released over the course of 5 years in 11 “waves” through the end of
2019.
• Reports are sent out quarterly, with a final report delivered in August of the year after the reporting period which shows if the provider has a payout or recoupment. It is also possible there is neither.
• Reports are available on BlueAccess
• Providers have opportunity to discuss reports and dispute results as quarterly reports are published
What is it?
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THCII Episodes of Care
Why are we doing it?
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THCII Episodes of Care
Today, most health care payment from payers to providers in Tennessee is “fee for service” (the provider is paid to perform a specific activity or task). Fee-for-service payments fail to reward providers who achieve higher quality, more efficient, integrated and coordinated care. Following a thorough review of outcomes-based payment strategies and with the input of stakeholders, Tennessee is implementing episodes of care to reward providers for providing high-quality and efficient care for acute medical and behavioral treatments and conditions.
Reporting
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THCII Episodes of Care
– Performance summary ▪ Total number of episodes (included and excluded) ▪ Quality thresholds achieved ▪ Average non-risk adjusted and risk adjusted cost
of care ▪ Cost comparison to other providers and gain and
risk sharing thresholds ▪ Gain sharing and risk sharing eligibility and
calculated amounts – Quality detail: Scores for each quality metric with
comparison to gain share standard or provider base average
– Cost detail: ▪ Breakdown of episode cost by care category ▪ Benchmarks against provider base average
– Episode detail: ▪ Cost detail by care category for each individual
episode a provider treats ▪ Reason for any episode exclusions
You are eligible for gain sharing
Episode cost summary
Overview
Cost of care (avg. adj. episode cost) comparison
1
2
3
[1. Asthma] A. Episode Summary
182122
4337
64
28
$1167-$1500
$833-$1167
$500-$833
Below$500
80
$1833-$2167
60
40
20
Above $2500
$2167-$2500
Distribution of provider average episode cost (risk adj.)
Your episode cost distribution (risk adj.)
Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Your average episode cost is commendable
YOUR GAIN/ RISK SHARE
# of
epi
sode
sAv
g. a
dj. e
piso
de
cost
($)
Commendable Not acceptableAcceptable
> $4000
Percentile of providers0
500
1,000
1,500
2,000
Not acceptableAcceptableCommendableYou
Less than $1,000 $1,750$1,000 to $1,750
Parameters You Providerbase average
Episode quality and utilization summary4
You achieved selected quality metrics
1. Follow-up visit w/ physician
2. Patient on appropriate medication
Quality metrics linked to gain sharing You Gain share
standard
61% 55%
77% 70%
+$10,391.80Number of episodes
Sharefactor
Your avg. cost: $911.80 Providers’ base avg. cost: $1,242.20 233 50%
Commendable cost ($)
Your avg. cost ($)
1,000 910.80
– x x
5. Avg. episode cost (risk adj.) $910.80Commendable
$1,242.20Acceptable
Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013
[Period: Start/end dates of period]
1. Repeat acute exacerbation within 30 days
You Providerbase average
Quality metrics not linked to gain sharing
5% 8%
1. Total cost across episodes
2. Total # of included episodes
3. Avg. episode cost (non adj.)
233 235
$1,012.00 $1,350.22
4. Risk adjustment factor* (avg.) 0.90 0.92
$235,796.00 $317,301.09
* Risk adjustment factor calculated for select provider’s patient base
Metstandard
Preliminary draft of the provider report template for State of TN (for discussion only) | All content/ numbers included in this report are purely illustrative
Quarterbacks Receive Quarterly Reports:
Thresholds
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THCII Episodes of Care
THRESHOLDS: ILLUSTRATIVE EXAMPLE
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THCII Episodes of Care Reporting: Downloading
This is the Quarterback report screen. The reports are based on lines of business and can be chosen by reporting period.
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THCII Episodes of Care Reporting: Downloading
Gain/Risk Share
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THCII Episodes of Care
Providers will receive a final report after the measurement period that includes a cover sheet or invoice. The invoice will be specific to the contracted entity and will inform you if you owe BlueCross a recoupment, are owed a payment or if no action is needed (along with instructions) BlueCross will distribute payment via EFT In the event of a risk share or recoupment, Providers will be given a time limit in which to respond with payment and instructions In August, providers will receive final invoices for the first time In September, Payments will be sent, and remits for recoupments and payouts will be posted on BlueAccess
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THCII Episodes of Care Reporting
On the first page of the Final reports which are published on BlueAccess in August, reports will have a cover letter or invoice. Depending on how the Quarterback performs, they will receive an invoice which looks similar to this example:
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THCII Episodes of Care Gain/Risk Share: Check Remittance Examples
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THCII Episodes of Care Gain/Risk Share – Risk Share Recoupments
You will be notified of your recoupment amount on the final report. However, considering the August report is the same reporting period as the May report, only with further runout, you will be notified you did not meet your target threshold for this episode. You will receive a recoupment remit in the mail as well as access to this remit in BlueAccess. You will be instructed to remit payment within 60 days. If you have not responded after 60 days, any risk share owed to BlueCross will be taken from your BlueCare/TennCareSelect claims. If you prefer we take owed payments from claims, we simply deduct from the claims after 60 days.
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THCII Episodes of Care Provider Resources
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THCII Episodes of Care Provider Resources
The August Blue Alert contained the following language to providers:
The Blue Alert is still one of our most efficient ways of communicating updates on BlueCross initiatives to our provider community. Please check them monthly!
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THCII Episodes of Care Provider Resources
THCII Provider Guide: • The THCII Provider Guide is in our BlueCare provider manual
• It includes important information about the design of the program, focusing initially on the Episodes of Care strategy
• This guide also offers resources to help health care providers understand how the program impacts their organization
• You can find a link to the provider guide on our THCII web page on the BlueCare website
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THCII Episodes of Care State Website: http://www.tn.gov/hcfa/section/strategic-planning-and-innovation-group
