requirements information for bqpp application effective 2 ... · requirements information for the...

Requirements Information for the Blue Quality Physician Programsm Application Effective 02/01/2012

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Criteria Definition NCQA Physician Practice Connections® – Patient- Centered Medical HomeTM (PPC®- PCMHTM) *Mandatory

PPC-PCMH is appropriate for all primary care medical practices including: Family Practice, Internal Medicine, General Practice, and Pediatrics. Mid-levels practitioners may achieve PPC-PCMH recognition. Please Note: OBGYN practices should seek the Physician Practice Connection (PPC) Recognition not the Patient Centered Medical Home Recognition. PCMH recognition is only for primary care providers. NCQA considers OBGYN specialist. All locations must be PPC or PPC- PCMH recognized. A Recognition Program developed by the National Committee for Quality Assurance (NCQA) with input from the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP) and American Osteopathic Association (AOA) and designed to recognize practices that use systematic, patient-centered, coordinated care management processes. The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Among the aspects of care measured by PPC-PCMH are: Access and Communication, Patient Tracking and Registry Functions, Care Management, Patient Self-Management Support, Electronic Prescribing, Test Tracking, Referral Tracking, Performance Reporting and Improvement and Advanced Electronic Communications.

Please refer to the NCQA website www.ncqa.org for more information. NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. Blue Cross Blue Shield of North Carolina is considered your sponsor. Please enter the NCQA code- CNCBCA on your NCQA application to receive the discount. Check the NCQA website and fee schedule for discounts


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and information regarding changing levels within a program or converting from PPC to PCMH.

There are three levels of NCQA PPC-PCMH Recognition (Basic, Intermediate, and Advanced). To participate in the Blue Quality Physician Program your practice must be recognized in PPC-PCMH. If your practice has multiple sites, all sites must be PPC-PCMH recognized. The BQPP awards points to practices that are recognized in PPC-PCMH based on their level of recognition. Achieving and maintaining recognition in the PPC-PCMH OR PPC Recognition Program is a mandatory requirement for participation in the Blue Quality Physician Program. Check out the Community Care of North Carolinas (CCNC) website for NCQA PCMH cheat sheets and tools to assist practices through the process: https://www.communitycarenc.org/emerging-initiatives/pcmh-central1/ Please Note: NCQA PCMH 2011 tool is considered a MOC Part IV module. The NCQA PCMH 2011tool is a mandatory element for practice level points; however it cannot be used again in the physician education section as a MOC Part IV module to receive additional points. Validation Source: NCQA Data Feed

NCQA Physician Practice Connection® (PPC®)*Mandatory

PPC is appropriate for all primary care and specialties practices including OBGYN. Please Note: Existing BQPP practices applying for their second cycle as a BQPP Practice must move from PPC to PCMH recognition at their next NCQA recognition cycle. All locations must be PPC or PPC-PCMH recognized. A Recognition Program developed by the National Committee for Quality Assurance (NCQA) designed to recognize practices that use systematic processes and information technology to enhance the quality of patient care. Meeting PPC® standards shows practices have established connections to information, patients and other providers that allow them to:


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• Know and use patient histories • Follow up with patients and other providers • Manage patient populations and use evidence –based care • Employ electronic tools to prevent medical errors.

Among the aspects of care measured by PPC are: Access and Communication, Patient Tracking and Registry Functions, Care Management, Patient Self-Management Support, Electronic Prescribing, Test Tracking, Referral Tracking, Performance Reporting and Improvement, and Interoperability.

Please refer to the NCQA website www.ncqa.org for more information. NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. Blue Cross Blue Shield of North Carolina is considered your sponsor. Please enter the NCQA code- CNCBCA on your NCQA application to receive the discount. Check the NCQA website and fee schedule for discounts and information regarding changing levels within a program or converting from PPC to PCMH.

There are three levels of NCQA PPC Recognition (Basic, Intermediate, and Advanced). To participate in the Blue Quality Physician Program your practice must be recognized in PPC. If your practice has multiple sites, all sites must be PPC recognized. The Program awards points to practices that are recognized in PPC based on their level of recognition.

Achieving and maintaining recognition in the PPC-PCMH OR PPC Recognition Program is a mandatory requirement for participation in the Blue Quality Physician Program.

Validation Source: NCQA Data Feed NCQA Diabetes Recognition Program (DRP or DPRP) & Education

A Recognition Program developed by the National Committee for Quality Assurance (NCQA) in partnership with the American Diabetes Association (ADA) designed to recognize physicians and mid-level practitioners who use evidence-based measures and provide excellent care to their patients with diabetes. This program was formerly known as the Diabetes Physician Recognition Program (DPRP).


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*Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

The DRP Program has 10 measures which cover areas such as:

� HbA1c control � Blood Pressure control � LDL control � Eye examinations � Nephropathy assessment � Smoking status and cessation advice or treatment

Please refer to the NCQA website www.ncqa.org for more information. NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. Blue Cross Blue Shield of North Carolina is considered your sponsor. Please enter the NCQA code- CNCBCA on your NCQA application to receive the discount.

The Blue Quality Physician Program awards points to Physicians & Mid-levels that are recognized in DRP. The Blue Quality Physician Program will award points for successful completion of one of the following diabetes programs:

• NCQA Diabetes Physician Recognition Program (DRP or DPRP) • Diabetes Practice Improvement Module (PIM) from the American Board of Internal Medicine

(ABIM) • Diabetes Performance in Practice Module (PPM) from the American Board of Family Medicine

(ABFM)

Validation Source: NCQA Data Feed, data file from ABIM, or Attestation from physician that ABFM Diabetes PPM is completed.

NCQA Heart/Stroke Recognition Program

A Recognition Program developed by the National Committee for Quality Assurance (NCQA) in partnership with the American Heart Association (AHA/ASA) designed to recognize physicians and mid-


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(HSRP) & Education *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

levels practitioners who use evidence-based measures and provide excellent care to persons with cardiovascular disease (CVD) or who have had a stroke.

The HSRP assesses key quality performance measures for secondary prevention of cardiovascular disease and stroke. Program measures include:

� Blood pressure control � Complete lipid profile � Cholesterol control � Use of aspirin or another antithrombotic � Smoking status and cessation advice or treatment


The Blue Quality Physician Program awards points to Physicians & Mid-levels that are recognized in HSRP. The Blue Quality Physician Program will award points for successful completion of one of the following cardiac programs:

• NCQA Heart/Stroke Recognition Program (HSRP) • Preventive Cardiology Practice Improvement Module (PIM) from the American Board of Internal

Medicine (ABIM) • Hypertension Practice Improvement Module (PIM) from the American Board of Internal

Medicine (ABIM) • Hypertension Performance in Practice Module (PPM) from the American Board of Family

Medicine (ABFM)


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• Heart Failure Performance in Practice Module (PPM) from the American Board of Family Medicine (ABFM)

• Coronary Artery Disease Performance in Practice Module (PPM) from the American Board of Family Medicine (ABFM)

Please Note: NCQA HSRP counts as a MOC Part IV module. A provider cannot receive points for NCQA HSRP recognition and education MOC Part IV modules. Validation Source: NCQA Data Feed, data file from ABIM, or Attestation from physician that ABFM Cardiac PPM is completed.

NCQA Back Pain Recognition Program (BPRP) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

A Recognition Program developed by the National Committee for Quality Assurance (NCQA) designed to recognize physicians and chiropractors who deliver superior care to patients who suffer from low back pain. The BPRP program consists of 13 clinical measures and three structural standards such as the elements of the physical exam and advice for the return to normal activities. These requirements address the broad spectrum of low back pain and focus on under use, misuse and overuse of treatment modalities.


The Blue Quality Physician Program awards points to Physicians & Mid-levels that are recognized in BPRP. Validation Source: NCQA Data Feed

Diabetes Practice Improvement Module (PIM) from the American

The American Board of Internal Medicine (ABIM) Diabetes Practice Improvement Module (PIMSM) is a self-evaluation tool designed to give the physician a snapshot of his/her practice. It shows how outcomes and processes of care for their patients compare with national guidelines for managing diabetes.


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Board of Internal Medicine (ABIM) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

A PIM is a Web-based tool that enables physicians to conduct a confidential self-evaluation of the medical care that they provide. PIMs help physicians gain knowledge about their practices through analysis of data from the practice, and the development and implementation of a plan to target areas for improvement. PIMs are part of ABIM’s Maintenance of Certification program, within the Self-Evaluation of Practice Performance requirement. Please refer to http://www.abim.org/online/pim/demo.aspx for more information. The Blue Quality Physician Program will award points for successful completion of one of the following diabetes programs:



(ABFM)

Please Note: NCQA DRP counts as a MOC Part IV module. A provider cannot receive points for NCQA DRP recognition and education MOC Part IV modules. Validation Source: NCQA Website, data file from ABIM, Attestation from physician that ABFM Diabetes PPM is completed.

Cardiology Practice Improvement Modules (PIM) from the American Board of Internal Medicine (ABIM) *Physicians & Mid-levels

The American Board of Internal Medicine (ABIM) offers Cardiology Practice Improvement Modules (PIMSM ). A PIM is a Web-based tool that enables physicians to conduct a confidential self-evaluation of the medical care that they provide. PIMs help physicians gain knowledge about their practices through analysis of data from the practice, and the development and implementation of a plan to target areas for improvement. PIMs are part of the ABIM Maintenance of Certification program, within the Self-Evaluation of Practice Performance requirement. The ABIM Preventive Cardiology PIM is a self-evaluation tool designed to give the provider a snapshot


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can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

of his/her practice buy showing them how the outcomes and processes of care for their patients compare with national guidelines for preventing primary and secondary coronary heart disease (CHD). The ABIM Hypertension PIM is a self-evaluation tool designed to give the provider a snapshot of his/her practice by showing them how the outcomes and processes of care for their patients compare with national guidelines for managing hypertension. Please refer to http://www.abim.org/online/pim/demo.aspx for more information. The Blue Quality Physician Program will award points for successful completion of one of the following cardiac programs:




Medicine (ABFM) • Heart Failure Performance in Practice Module (PPM) from the American Board of Family

Medicine (ABFM) • Coronary Artery Disease Performance in Practice Module (PPM) from the American Board of

Family Medicine (ABFM)

Please Note: NCQA HSRP counts as a MOC Part IV module. A provider cannot receive points for NCQA HSRP recognition and education MOC Part IV modules. Validation Source: NCQA Data Feed, data file from ABIM, Attestation from physician that ABFM Cardiac PPM is completed.

Diabetes Performance in Practice Module (PPM)

The American Board of Family Medicine (ABFM) offers Performance in Practice Modules (PPM) as part of the Part IV Maintenance of Certification. These modules are web-based, quality improvement


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from the American Board of Family Medicine (ABFM) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

modules in health areas which generally correspond to the Self-Assessment Modules.

Each physician will assess his or her care of patients using evidence-based quality indicators. After a physician enters data from ten patients into the ABFM website, feedback is provided for each of these quality indicators. The performance data is used by the physician to choose an indicator for which a quality improvement plan will be designed. Using a menu of interventions available from various online sources, the physician designs a plan of improvement, submits the plan, and implements the plan in practice. After a minimum of three months, the physician assesses the care provided to ten patients in the chosen health area and inputs the data to the ABFM website. The physician then is able to compare pre- and post-intervention performance, and compare their results to those of their peers.

Please refer to https://www.theabfm.org/moc/part4.aspx for more information.

The Blue Quality Physician Program will award points for successful completion of one of the following diabetes programs:



(ABFM)

Please Note: NCQA DRP counts as a MOC Part IV module. A provider cannot receive points for NCQA DRP recognition and education MOC Part IV modules. Validation Source: NCQA Website, data file from ABIM, Attestation from physician that ABFM Diabetes PPM is completed.

Cardiac Performance in Practice Module (PPM) from the American Board of Family Medicine

The American Board of Family Medicine (ABFM) offers Performance in Practice Modules (PPM) as part of the Part IV Maintenance of Certification. These modules are web-based, quality improvement modules in health areas which generally correspond to the Self-Assessment Modules.


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(ABFM) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

Each physician will assess his or her care of patients using evidence-based quality indicators. After a physician enters data from ten patients into the ABFM website, feedback is provided for each of these quality indicators. The performance data is used by the physician to choose an indicator for which a quality improvement plan will be designed. Using a menu of interventions available from various online sources, the physician designs a plan of improvement, submits the plan, and implements the plan in practice. After a minimum of three months, the physician assesses the care provided to ten patients in the chosen health area and inputs the data to the ABFM website. The physician is then able to compare pre- and post-intervention performance, and compare their results to those of their peers.

The ABFM offers 3 Cardiac Performance in Practice Modules. They are:

• Hypertension • Heart Failure • Coronary Artery Disease

Please refer to https://www.theabfm.org/moc/part4.aspx for more information.

The Blue Quality Physician Program will award points for successful completion of one of the following cardiac programs:




Medicine (ABFM) • Heart Failure Performance in Practice Module (PPM) from the American Board of Family

Medicine (ABFM) • Coronary Artery Disease Performance in Practice Module (PPM) from the American Board of

Family Medicine (ABFM)


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Please Note: NCQA HSRP counts as a MOC Part IV module. A provider cannot receive points for NCQA HSRP recognition and education MOC Part IV modules. Validation Source: NCQA Website, data file from ABIM, Attestation from physician that ABFM Cardiac PPM is completed.

Asthma Education in Quality Improvement for Pediatric Practice (EQIPP) from the American Academy of Pediatrics (AAP) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

The American Academy of Pediatrics (AAP) Education in Quality Improvement for Pediatric Practice (EQIPP) course entitled Diagnosing and Managing Asthma in Pediatrics is designed to help physicians create a plan for improvement to address gaps that are identified in key clinical activities of asthma care. Activities include:

• Collect and analyze baseline data to establish a starting point for improvement • Identify one or more quality gaps in one or more key clinical activities of asthma care • Create an improvement plan for closing the quality gap(s) in which you:

o Identify a specific aim; o Establish a target goal; o Generate ideas for change; and o Consider potential barriers.

• Implement change(s) designed to close the quality gap(s). • Collect and analyze follow-up data to measure the results of your improvement efforts • Create additional improvement plans and repeat the change-improvement cycle until you reach

your goal of providing the best possible asthma care to patients.

Please refer to http://www.eqipp.org for more information.

The Blue Quality Physician Program will award points to Physicians & Mid-level Practitioners that have successfully completed the Asthma EQIPP. Validation Source: Physician & Mid-levels Certificate indicating successful completion of EQIPP course.


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Immunizations Education in Quality Improvement for Pediatric Practice (EQIPP) From the American Academy of Pediatrics (AAP) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

The American Academy of Pediatrics (AAP) Education in Quality Improvement for Pediatric Practice (EQIPP) course entitled Give Your Immunization Rates A Shot In the Arm is designed to identify immunization rates in the practice, barriers to immunization delivery systems and techniques to overcome those barriers through the use of clear aims that reflect expert principles and proven quality improvement methods and tools. Objectives of the Immunization EQIPP include:

• Apply recommended storage and handling guidelines for vaccines. • Identify payment and coding issues as potential barriers to best immunization practices. • Improve payment and coding issues related to improving immunization rates.


The Blue Quality Physician Program will award points to Physicians & Mid-level Practitioners that have successfully completed the Immunization EQIPP. Validation Source: Physician & Mid-levels Certificate indicating successful completion of EQIPP course.

Safe and Healthy Beginnings in Quality Improvement for Pediatric Practice (EQIPP) From the American Academy of Pediatrics (AAP) *Physicians & Mid-levels can only receive 30 points maximum (10 points each)

The goal of the EQIPP Safe and Healthy Beginnings course is to help pediatric health care providers create plans for improvement to address gaps identified in key activities of safe transition and continued care of newborns between the newborn nursery and primary care practice.

EQIPP courses help identify and close gaps in your practice using practical tools. CME credit and meet MOC Part 4: Performance in Practice requirements can be met all at once. Activities include:

• Reviewing course content • Analyzing data


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for Clinical Education and Recognition.

• Creating improvement plan(s) • Participating in guided activities • Collecting chart data • Implementing ideas for change • Working with your practice team to improve care


The Blue Quality Physician Program will award points to Physicians & Mid-level Practitioners that have successfully completed the Safe and Healthy Beginnings EQIPP. Validation Source: Physician & Mid-levels Certificate indicating successful completion of EQIPP course.

Differentiate and Manage – GER and GERD in Quality Improvement for Pediatric Practice (EQIPP) From the American Academy of Pediatrics (AAP) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

The goal of the EQIPP: Differentiate and Manage - GER and GERD course is to help you create a plan for improvement to address gaps you identify in key clinical activities in GER and GERD. By using EQIPP, you will collect data to measure your current level of care at baseline as you work to improve care through Plan, Do, Study, Act (PDSA) cycles.

EQIPP courses help identify and close gaps in your practice using practical tools. CME credit and meet MOC Part 4: Performance in Practice requirements can be met all at once. Activities include:

• Reviewing course content • Analyzing data • Creating improvement plan(s) • Participating in guided activities • Collecting chart data • Implementing ideas for change


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• Working with your practice team to improve care


The Blue Quality Physician Program will award points to Physicians & Mid-level Practitioners that have successfully completed the Differentiate and Manage - GER and GERD EQIPP. Validation Source: Physician & Mid-levels Certificate indicating successful completion of EQIPP course.

Bright Futures in Quality Improvement for Pediatric Practice (EQIPP) From the American Academy of Pediatrics (AAP) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

The goal of the EQIPP Bright Futures course is to help practitioners create a plan for improvement to address gaps you identify in key clinical activities. In this course, you will use baseline practice measurements to identify opportunities to implement Bright Futures priorities through Plan, Do, Study, Act (PDSA) cycles. EQIPP courses help identify and close gaps in your practice using practical tools. CME credit and meet MOC Part 4: Performance in Practice requirements can be met all at once. Activities include:

• Reviewing course content • Analyzing data • Creating improvement plan(s) • Participating in guided activities • Collecting chart data • Implementing ideas for change • Working with your practice team to improve care


The Blue Quality Physician Program will award points to Physicians & Mid-level Practitioners that


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have successfully completed the Bright Futures EQIPP. Validation Source: Physician & Mid-levels Certificate indicating successful completion of EQIPP course.

Eliminate Tobacco Use and Exposure Improvement for Pediatric Practice (EQIPP) From the American Academy of Pediatrics (AAP) *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

The goal of the EQIPP: Eliminate Tobacco Use and Exposure course is to help you create plans for improvement to address gaps in key activities of tobacco control. You will collect baseline and follow-up data as you work to improve care and processes through Plan, Do, Study, and Act (PDSA) cycles. EQIPP courses help identify and close gaps in your practice using practical tools. CME credit and meet MOC Part 4: Performance in Practice requirements can be met all at once. Activities include:

• Reviewing course content • Analyzing data • Creating improvement plan(s) • Participating in guided activities • Collecting chart data • Implementing ideas for change • Working with your practice team to improve care


The Blue Quality Physician Program will award points to Physicians & Mid-level Practitioners that have successfully completed the Eliminate Tobacco Use and Exposure EQIPP. Validation Source: Physician or Mid-levels Certificate indicating successful completion of EQIPP course.

Improving Performance in Practice (IPIP) from the

IMPROVING PERFORMANCE IN PRACTICE (IPIP) is a national initiative with practice-based improvements at its core which is delivered via state- and local-level agencies as part of the North


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NC Healthcare Quality Alliance and NC AHEC *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

Carolina Healthcare Quality Alliance. In North Carolina, the regional AHEC offers IPIP at no charge to practices. IPIP participants must provide direct or consultative care to patients with asthma, diabetes, and hypertension. The IPIP initiatives use clinical data from the practice EHR to guide improvement in patient care; an important component of EHR “meaningful use.”

Please refer to http://www.ahecqualitysource.com for more information.

The Blue Quality Physician Program will award points to Physicians who actively participate in IPIP for at least past 12 months to receive ABP, ABFM, ABIM, ABMS, MOC, Part IV credit. Validation Source: BCBSNC receives a spreadsheet from NC AHEC which identifies the practices/physicians that completed at least 12 months of the IPIP to earn credit toward MOC, Part IV.

Bridges to Excellence (BTE)

Bridges to Excellence programs recognize and reward clinicians who deliver superior patient care.

The Bridges to Excellence programs measure the quality of care delivered in provider practices. They place a special emphasis on managing patients with chronic conditions, who are most at risk of incurring potentially avoidable complications. There Recognitions cover all major chronic conditions, plus office systems. The BTE website is http://www.hci3.org/recognition_programs

Below are the BTE recognitions that are approved for BQPP:

• Adult Primary Care • Asthma Care • Cardiac Care • Cardiology Practice Recognition • Congestive Heart Failure • COPD Care • Coronary Artery Disease Care • Depression Care • Diabetes Care


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• Hypertension Care • Spine Care

Modules from the American College of Obstetrics and Gynecology (ACOG) and the American Board of Obstetrics and Gynecology (ABOG)

Please Note: Effective January 2011 ACOG confirmed that physicians are only allowed to take one module per year. OBGYN Physicians are awarded points for completing one of the following modules offered by ACOG/ABOG:

• Management of Atypical Cells of Uncertain Significance (ASCUS) • Ambulatory Treatment of Pelvic Inflammatory Disease (PID) • Osteoporosis • Chronic Hypertension in Pregnancy • Gestational Diabetes (GDM) • Preeclampsia • Safe Use of Medications • Informed Consent • Informed Refusal

The American Board of Obstetrics and Gynecology (ABOG) and the American College of Obstetrics and Gynecology (ACOG) have created a joint program for Part IV, Continuous Quality Improvement (Practice Performance and Self-Assessment), of the Maintenance of Certification (MOC) program. The Road to Maintaining Excellence program is designed to help ACOG members and diplomats remain current and knowledgeable with best practice recommendations. The Road to Maintaining Excellence program consists of reviewing “modules” on current recommended or best practices along with a “self-assessment” of one’s practice to ascertain if current recommendations have been adopted. This latter aspect of Part IV is accomplished via a chart review of diagnoses or conditions covered in a specific module. Please refer to https://moc.acog.org for more information.


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Validation Source: ACOG MOC Data Patient Safety Improvement Program from the American Board of Medical Specialties (ABMS)

The American Board of Medical Specialties (ABMS) Patient Safety Improvement Program combines online patient safety education, quality improvement education and performance improvement activities that focus on identifying and analyzing errors, determining improvements based on best practices and implementing changes. Results are measured and benchmarked against national standards.

This Web-based program is self-paced and focuses on identifying and analyzing errors, determining improvements based on best practices and implementing changes. The program aligns with key initiatives, including The Joint Commission National Patient Safety Goals, and Institute for Healthcare Improvement 5 Million Lives Campaign.

The ABMS Patient Safety Improvement Program consists of the following four key components:

1. Scenarios that illustrate common errors and the complex systems involved, 2. Patient safety curriculum in four broad categories, 3. Quality improvement fundamentals to apply methods and techniques to clinical environments and 4. Patient safety improvement activities that introduce changes that can be incorporated into

practice.

The Patient Safety Improvement Program from the ABMS is comprised of three (3) modules. They are:

• Core Curriculum Sections including Epidemiology, Systems, Communication, and Safety Culture • Quality Improvement Fundamentals • Performance Improvement Activities

Please refer to http://www.abms.org/Products_and_Publications/Performance_Improvement/PSIP.aspx for additional information.

The Blue Quality Physician Program will award points to physicians that have successfully completed all three modules listed above in the Patient Safety Programs.


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Validation Source: ACOG MOC Data or Physician Attestation that they have completed the ABMS Patient Safety Improvement Program.

Mid-level Practitioners Courses *Physicians & Mid-levels can only receive 30 points maximum (10 points each) for Clinical Education and Recognition.

Any organization granting ANCC, ACCME, AAPA, AMA, AOA or AAFP Category 1 CME courses for Mid-level Practitioners is acceptable. The North Carolina Area Health Education has courses on their website http://my.ncahec.net/education.php?d=a that meet this requirement. The EQIPP courses can also meet this requirement. The EQIPP http://www.eqipp.org courses that are also located on this document give AMA PRA Category 1 Credit. The Blue Quality Physician Program will award points to mid-level practitioners that submit a certificate of completion of ANCC, ACCME, AAPA, AMA, AOA or AAFP Category 1 CME course. Validation Source: Mid-level Practitioners Certificate indicating successful completion of AAPA, AMA, AOA or AAFP Category 1 CME courses.

Provider Performance Analytics (PPA)

Blue Cross and Blue Shield of North Carolina (BCBSNC) is utilizing administrative claims data to provide physicians with current member-specific reports and a performance analysis of these members compared to their North Carolina peers (like specialty) against nationally recognized quality measures. These reports are provided for primary care providers (Family Practice, General Practice, Geriatrics, Internal Medicine, Pediatrics, and OBGYN) and cardiologists who contract with BCBSNC. BCBSNC reporting on nationally recognized measures that focus on preventive care, cardiac services, heart failure, and diabetes. These specific areas were chosen because the National Quality Forum (NQF) and the National Committee for Quality Assurance (NCQA) have endorsed multiple quality measures reflecting care of these conditions that are well-accepted in the physician community. Reports are produced approximately every 6 months and are housed on a physician portal within Blue e. The Blue e link to review PPA report is https://providers.bcbsnc.com/providers/selfRegister.faces Physicians are encouraged to utilize these reports to close care gaps and to augment their practice quality initiatives. BCBSNC recognizes that the data in these reports may be incomplete based on limitations of


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administrative claims data, and that more complete data may reside the physician office records. BCBSNC anticipates that providers may find patients that they feel have been incorrectly attributed to them, or have documentation that a patient has met the specific measure. BCBSNC encourages providers to report additional information to make these reports more accurate (for example, a patient who had a hysterectomy 5 years ago and is therefore not in need of further Pap smears.) If provided, this information will be carried through to future reports. The Blue Quality Physician Program will award points to the practices that send the PPA Attestation to BCBSNC. Each physician in the practice must access their PPA reports when sent (every 6 months). Each physician must sign the practice attestation stating that they have reviewed the reports and attached request for reconsideration if necessary. The Attestation is sent to BCBSNC within 45 days of each PPA report mailing. The PPA Attestation is located on the www.bcbsnc.com/bqpp website. Validation Source: Provider Performance Analytics signed attestation and reconsideration reports received from the practice.

BCBSNC Medical Record Review Score

BCBSNC Quality Management Consultants conduct periodic assessments to monitor and evaluate the quality and appropriateness of physicians' documentation in office medical records. The purpose is to ensure that the medical record keeping practices conform to the Plan's medical record standards and meet the targets specified in the Quality Improvement Work Plan. Practices are reviewed at a minimum every three years and given a Medical Record Review Score. The Blue Quality Physician Program will take into consideration the most recent Medical Record Review Score. Points will be awarded to practices that achieve a score of 96% or above on their Medical Record Review. If the practice or group has several sites, the average Medical Record Review Score of all sites must be 96% or above in order to earn points. Validation Source: BCBSNC Internal Data

Behavioral Health Co-Management

Coordinated care between the primary care and behavioral health providers leads to enhanced screening and care of patients with mental health and/or substance-abuse issues. This results in better health


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outcomes for the member. To provide this care, increased coordination between these providers should take place in one of the following ways:

• A behavioral health provider is employed by or contracted with the practice.

• The practice partners with a behavioral health provider with the use of a Co-Management Agreement to provide mental health/substance abuse treatment and care coordination for the patients of the practice.

The Behavioral Health Co-Management Agreement is located at www.bcbsnc.com/bqpp. Validation Source: A copy of the Behavioral Health Co-Management Agreement is sent to BCBSNC or the Behavioral Health Provider is listed on the practice website as being a part of the practice.

Patient Care Summary (PCS)

The Patient Care Summary Report (available in 2012) will provide physicians and office staff with a patient specific summary report. This report will utilize BCBSNC claims data to provide: member diagnosis and provider history (including place of service- ER, Inpt, Office etc), prescription history, and actionable care alerts. This report is a single page and can be accessed and uploaded to an Electronic Health Record or printed from Blue e. The Blue Quality Physician Program will award points to practices that sign up for and use the Patient Care Summary in Blue e. Validation Source: BCBSNC Internal Data

Electronic Prescribing *Mandatory

Electronic Prescribing refers to the use of a secure computer network so that providers, pharmacies, pharmacy benefit managers and health plans can share patient prescription information. As a decision-support tool, Electronic Prescribing lets providers access an individual patient’s medication history, see the particulars of the patient’s prescription insurance coverage, and review details about the medication of choice – all in order to make more informed choices about patient care. Physicians interested in Electronic Prescribing must use either a standalone Electronic Prescribing


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software or an Electronic Medical Record (EMR) that has been certified to connect to the Surescripts network. Only prescriptions sent over the Surescripts network will be tracked for this program.

The Blue Quality Physician Program will award points for use of an electronic prescribing standalone software or EMR that has been certified to connect to the Surescript network.

Usage of Electronic Prescribing is a mandatory requirement for participation in the Blue Quality Physician Program.

Validation Source: Data feed from Surescripts Claims submitted electronically *Mandatory

Claims submitted by providers electronically constitute the percentage of claims that BCBSNC receives from a provider in an electronic format (non-paper) as a function of their total claims submissions. Methods for electronic submission include direct submission from the provider using ANSI X12 batch 837 transactions, use of a vendor or clearinghouse for ANSI X12 submission, RealMed realtime claims submission, or direct data entry (keying the claim) through Blue e. The Blue Quality Physician Program will award points for electronic claims submission based on the percentage of claims that the practice submits electronically. Electronic submission of claims is a mandatory requirement for participation in the Blue Quality Physician Program. Validation Source: BCBSNC Internal Data

Utilization of Blue e Transactions

Usage of the BCBSNC electronic provider portal, Blue e has multiple uses. For example, a provider may make an electronic inquiry through Blue e to obtain information on patient eligibility, claim status, and remittance information. Blue e is also used to capture educational or operational updates from the What’s New application. The provider’s purpose for using Blue e is to receive detailed information in an accurate and timely manner thereby reducing the amount of time spent on the phone and in the generation of correspondence by the provider’s office. The four Blue e service modules that contribute the Blue Quality Physician Program score from the


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include the following:

• What's New – The Blue e application that gives the provider community important updates about BCBSNC. It includes information on upcoming changes, billing questions and general information.

• Eligibility – This transaction displays general benefit and eligibility information (copays,

deductibles, etc) for BCBSNC, Blue Card, FEP and the State Health Plan. Eligibility information is available for a rolling 36 months.

• Claim status – This transaction provides information to a provider on the processing system status

of a claim (paid, processed, denied, etc.) It includes payment amounts as well as patient liability if the status in the system is paid.

• Self Administration –The capability of a provider to be able to add/delete Blue e users as well as

reset passwords without having to contact BCBSNC for assistance in performing these functions. The Blue Quality Physician Program will award points for use of the Blue e transaction modules. Validation Source: BCBSNC Internal Data

Use of Council for Affordable Quality Healthcare (CAQH) for credentialing

The Council for Affordable Quality Healthcare (CAQH) maintains a Universal Provider Datasource (UPD) to be used for providing credentialing information to health plans. The Blue Quality Physician Program awards points to practices that have active credentialing applications for their providers on the UPD. For more information go to www.caqh.org The Blue Quality Physician Program will award points for maintaining complete and updated provider information on CAQH.


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Validation Source: Universal Provider Data source from CAQH

Electronic Funds Transfer (EFT)

Blue Cross and Blue Shield of North Carolina (BCBSNC) Financial Services offers electronic transfer of funds (“EFT”) for claim payments from BCBSNC to a contracted health care provider’s bank account. Generally, EFT funds are accessible by providers sooner than remittances received through a traditional process of paper checks deposited by the provider. Each provider number can only be associated with one account number. All EFT's are made at the group number level. Upon receipt of all documentation from provider, set up takes around 5 days. The Blue Quality Physician Program will award points to practices signed up for electronic transfer of funds for claim payments. Validation Source: BCBSNC Internal Data

Office hours for Practices with 7 or fewer physicians *Mandatory

All practices must have a triage protocol. This may include the use of a nurse line, or an MD or PA on call. This Protocol must include the ability of the patient to get to a practitioner 24/7. May include a documented agreement between two or more practices sharing after hours care. The triage protocol must be posted on the practice website and answering machine. The Blue Quality Physician Program will award points to practices that sign the Triage Protocol Attestation located on the www.bcbsnc.com/bqpp website. Validation Source: Practice Website and/or confirmatory phone call to the practice.

Office hours for Practices with 8 or more physicians * Mandatory

All practices must have a triage protocol. This may include the use of a nurse line, or an MD or PA on call. This Protocol must include the ability of the patient to get to a practitioner 24/7. May include a documented agreement between two or more practices sharing after hours care.


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The triage protocol must be posted on the practice website and answering machine. The Blue Quality Physician Program will award points to practices that sign the Triage Protocol Attestation located on the www.bcbsnc.com/bqpp website. Validation Source: Practice Website and/or confirmatory phone call to the practice.

After Hours Care Regularly scheduled weekday office hours between 5:00 pm and 8:00 am, in addition to 35 hours of regularly scheduled weekday hours between 8:00 am and 5:00 pm. The Blue Quality Physician Program awards points to practices that have 7 or more regularly scheduled office hours after 5:00 pm and before 8:00 am in addition to 35 hours of regularly scheduled weekday hours between 8:00am and 5:00pm. Validation Source: Practice Website and/or confirmatory phone call to the practice.

Weekend Office Hours

Regularly scheduled office hours on Saturdays and/or Sundays The Blue Quality Physician Program awards points to practices that have 7 or more regularly scheduled weekend office hours in addition to 35 hours of regularly scheduled weekday hours. Validation Source: Practice Website and/or confirmatory phone call to the practice.

Cultural Competency Training * Mandatory for those practices applying to the BQPP for the first time.

Complete interactive training focused on cultural competency in medical practice, (such as provided by the US Department of Health and Human Services [DHHS] or Quality Interactions). The purpose of this training is to help enhance skills toward the provision of care in a culturally competent clinical practice. Culturally competent care includes providing patient-centered care, tailoring delivery to meet patients' social, cultural, and linguistic needs; identifying and applying appropriate strategies to reduce racial and ethnic healthcare disparities; understanding the impact that stereotyping can have on medical decision making; and identifying techniques to deal with language barriers and other communication needs, including working with interpreters. The purpose of this training is to help enhance skills toward the provision of care in a culturally competent clinical practice.


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Cultural Competency course- More information on the US DHHS Office of Minority Health Cultural Competency Training can be obtained at https://www.thinkculturalhealth.hhs.gov/ Cultural Competency course options:

a) Quality Interactions is an innovative e-learning program that provides effective cultural competency and cross-cultural communication training. For more information please visit http://www.qualityinteractions.org/ . This promo-code (BCBS_NorthCarolina1) will give the providers a 20% discount on all the clinical courses. The cost with the discount is $79.

b) Cultural Competency course- https://www.train.org/DesktopShell.aspx - Unified Health Communication 101- addressing Health Literacy, Cultural Competency, and Limited English Proficiency (LEP) approved by the AAFP. This is a web-based training that is 5 hours. Select Course Search and then click on search by Course ID. Course ID: 1010510

The Blue Quality Physician Program awards points to practices that have completed one of the following Cultural Competency Training programs:

1. Quality Interactions training, 2.5 hour course��2. US DHHS (completion of 2 themes), 6 hour course��3. US DHHS (completion of 3 themes), 9 hour course�4. Unified Health Communication 101, 5 hour course��

Option 1 or 2 = 10 points towards the BQPP score Option 3 or 4 = 15 points towards the BQPP score Completion of one of the above Cultural Competency training courses is a mandatory requirement for the Blue Quality Physician Program. This course must be added to new hire orientation. Practices applying for BQPP for the first time must complete the cultural competency course. Practices have the option to receive additional points (15) if they complete one more of the courses below :


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Courses must be completed by all nurse practitioners, physician assistants, and physicians.

• Cultural competency course completed by all existing and newly hired staff that interacts with patients on the phone or face to face such as receptionists and practice managers.

• Advanced Illness Management • Introduction to Motivational Interviewing for Healthcare Providers

All physicians and mid-levels that didn’t complete the cultural competency course in the first BQPP cycle must complete it in the second cycle. This is a mandatory element. Practices applying to the BQPP for their second cycle must have all nurse practitioners, physician assistants, and physicians complete one of the following elements. Practices will receive an extra 15 points for completing an additional course from the choices listed below (practices can complete 2 out 3 courses).



Validation Source: Physician, nurse practitioner, and physician assistant in the practice must submit a certification of completion of the course.

Advanced Illness Management *Mandatory option for practices applying to BQPP for their second

Advanced Illness Management is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from symptoms, pain, and stress of a serious illness- whatever the diagnosis. The physician must complete the online course through Education in Palliative and End- of - life (EPEC).


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cycle. To use your BCBCS-NC promo code to receive 4 modules for $96, follow these four steps:

1. Create an EPEC website account at: www.epec.net 2. Go to the EPEC Distance Learning page at: www.epec.net/category.php 3. Click on EPEC under available curricula and pick at least 4 modules 4. From the list of modules, select the modules you would like to purchase and

click “add to cart”. 5. Click “proceed” to the check-out, review your selected modules and enter your

promo code BCBS2012 in the bottom right hand corner. The discount will allow the purchase of 4 modules for $96.00.

The Blue Quality Physician Program awards points when each physician, nurse practitioner, and physician assistant in the practice submits a certification of completion (4 modules) of the course. All physicians and mid-levels that didn’t complete the cultural competency course in the first BQPP cycle must complete it in the second cycle. This is a mandatory element. Practices applying to the BQPP for their second cycle must have all nurse practitioners, physician assistants, and physicians complete one of the following elements. Practices will receive an extra 15 points for completing an additional course from the choices listed below (practices can complete 2 out 3 courses).



Validation Source: Confirmation of BCBSNC receipt of EPEC certificate.

Introduction to Motivational Interviewing (MI) is a client-centered directive method of communication for enhancing


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Motivational Interviewing for Healthcare Providers *Mandatory option for practices applying to BQPP for their second cycle.

intrinsic motivation to change by exploring and resolving ambivalence. MI has also been shown to improve the doctor–patient relationship while increasing the efficiency of the consultation. By completing this training you will be given an opportunity to practice this guiding style; add practical tools to your toolbox, and respond to your patients using reflective listening and strategies to elicit change talk language from the patient. This is an online course through Benchmarks. More information on the http://aso-online.cm-hosting.com/catalog.php?item=16 website.

• The length of the course- approximately 2 hrs • Cost - $50 • Course is Evidence – Based Practice

The Blue Quality Physician Program awards points when each physician, nurse practitioner, and physician assistant in the practice submits a certification of completion of the course. All physicians and mid-levels that didn’t complete the cultural competency course in the first BQPP cycle must complete it in the second cycle. This is a mandatory element. Practices applying to the BQPP for their second cycle must have all nurse practitioners, physician assistants, and physicians complete one of the following elements. Practices will receive an extra 15 points for completing an additional course from the choices listed below (practices can complete 2 out 3 courses).



Validation Source: Confirmation of BCBSNC receipt of MI certificate.

E Visits E-Visits refer to a Practice’s ability to interact with patients through a secured electronic channel in place


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of a formal office visit. Patients can contact their provider through a Web-based interface, or “Portal,” which includes an online questionnaire that the patient must complete. Practices can use one of several external (not associated with BCBSNC) vendor companies for their Portal service. Data collected can include symptoms, pharmacy, and payment information. E-Visits are typically used to address non-urgent, ongoing, or new symptoms. Practices must sign an attestation that they are in compliance with BCBSNC Corporate Medical Policy E-Visits (online medical evaluation) MED1141. The attestation form can be found at http://wwwdev.bcbsnc.com/content/providers/index.htm The Blue Quality Physician Program awards points to practices that have a signed Provider E Visit Attestation on file at BCBSNC Network Management Department. Validation Source: Confirmation of BCBSNC receipt of Provider’s E Visit Attestation.

Generic Prescribing Generic Prescribing: Prescriptions written are dispensed as generics.

The Blue Quality Physician Program awards points to physicians when the physician generic dispensing rate (average for the past three months) is equal to or greater than the percentage in the chart below. BQPP goals for generic dispensing rates by specialty:

• Pediatrics – 62% • Family Medicine – 72% • Internal Medicine – 72% • General Medicine – 72% • Obstetrics & Gynecology – 69%

Validation Source: BCBSNC Internal Data

Practice Cost & Efficiency Evaluation of the cost efficiency & utilization metrics of a practice in comparison to peer groups across


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the state of North Carolina. Peer groups are determined by the practice specialty. Member total cost includes: office visits, ER, Urgent Care, inpatient, imaging and prescription drug. The cost index is the practice data divided by the peer practice data. The Blue Quality Physician Program awards points to practices that have a cost index < 1.1. Practice Cost Reports are available by request. Validation Source: BCBSNC Internal Data

Bonus Points - Medical Students and/or Mid-level Students

During the previous 12 months, if a minimum of 60 days was spent precepting medical students and mid-level students, 10 bonus points will be added on to a physician score. Please fill out the Medical Students & Mid-level Students Attestation on the BQPP website. Validation Source: Confirmation of BCBSNC receipt of Medical Students & Mid-level Students Attestation on www.bcbsnc.com/bqpp website.

Bonus Points- Give a presentation on NCQA "PCMH" recognition at a specialty society event

NCQA PCMH recognition at a specialty society event- A formal presentation lasting at least one hour with slides, discussion, and a question and answer period. The Blue Quality Physician Program awards bonus points to practices that submit the society event agenda with the name of the speaker, presentation title, and duration of the presentation to BCBSNC. Validation Source: Confirmation of BCBSNC receipt of society event agenda.

Precept practices through the process of becoming a PCMH

An NCQA PCMH recognized practice precepts a practice through the PCMH recognition process by meeting on a regular basis (at least monthly) providing guidance and answering questions. The PCMH practice acts as a “mentor” to the practice striving to achieve NCQA Recognitions. The Blue Quality Physician Program awards bonus points to practices that submit an attestation signed by lead physician of practice striving to achieve NCQA Recognition and the lead physician of the precepting practice.


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Validation Source: Confirmation of BCBSNC receipt of PCMH Precepting Attestation located on www.bcbsnc.com/bqpp website.

This chart indicates individual physician and mid-levels recognition and educational options based on the physician specialty.

Family Practice Internal Medicine General Practice OBGYN Pediatrics NCQA Diabetes Recognition Program (DPRP) or (DRP) OR Diabetes PPM from ABFM

NCQA Diabetes Recognition Program (DPRP) or (DRP) OR Diabetes PIM from ABIM

NCQA Diabetes Recognition Program (DPRP) or (DRP)

ACOG MOC Part 4 Modules for OBGYN Office Practice which include all of the following: • Management of

Atypical Cells of Uncertain Significance (ASCUS)

• Ambulatory Treatment of Pelvic Inflammatory Disease (PID)

• Osteoporosis

Asthma EQIPP from AAP

NCQA Heart Stroke NCQA Heart Stroke NCQA Heart Stroke • Chronic Safe and Healthy


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Recognition Program (HSRP) OR Coronary Artery Disease PPM from ABFM OR Hypertension PPM from ABFM OR Heart Failure PPM from ABFM

Recognition Program (HSRP) OR Preventive Cardiology PIM from ABIM OR Hypertension PIM from ABIM

Recognition Program (HSRP)

Hypertension in Pregnancy

• Gestational Diabetes (GDM)

• Preeclampsia • Safe Use of

Medications • Informed

Consent • Informed Refusal

Beginnings EQIPP

NCQA Back Pain Recognition Program (BPRP)



OR 1. ABMS Patient

Safety Modules which include: • Core Curriculum

Sections (Epidemiology, Systems, Communication, Safety Culture)

• Quality Improvement Fundamentals

• Performance Improvement Activities

Immunizations EQIPP from AAP


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Differentiate and Manage- GER and GERD EQIPP

Bright Futures EQIPP

Eliminate Tobacco Use and Exposure EQIPP

IPIP MOC Part 4 Certification

• Asthma • Diabetes • Hypertension







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