Don’t Miss Out!

Written on February 26, 2015

By: Tammie Lunceford, CPC, Our roundtable attendees occasionally ask, “Do you have something positive to share with us?” The answer is yes! Many carriers have quality programs based on the same criteria as the Physician Quality Reporting System. Carriers have researched data through the Health Effectiveness Data and Information Set or HEDIS. This data shows that quality is directly related to costs, therefore, carriers are willing to incentivize providers who demonstrate quality and control costs.

Insurance Incentives

In 2017, the value based modifier will reward Medicare providers who are successful and penalize providers who are not successful, or fail to participate in 2015. Blue Cross Blue Shield of Alabama started a value based primary care incentive in 2013 which offers up to a 30 percent incentive above the Blue Cross Blue Shield fee schedule. The incentive is comprised of 10 percent clinical effectiveness, 10 percent cost effectiveness and 10 percent patient focus. However, many primary care practices are unaware of the program. In a recent conversation, I discussed the program with a primary care physician showing him he was missing $5,000 a month in incentive money through non-participation. Cardiology and OB/GYN specialties will begin to see incentive in the last quarter of 2015. Pulmonology, Endocrinology and Asthma and Allergy specialties will see incentive sometime in 2016.

Quality Review

The data, sorted by physician, is available for review for all listed specialties on the BCBS website behind your username and password. Each physician has a scorecard which can be found by clicking the PPA tool in the physician profile. It is important to review the scores currently listed to gauge or benchmark how you are demonstrating quality. The new specialties can only achieve a 20 percent incentive because the patient focus category is only available to primary care physicians. The data is collected from the information within your claims; each specialty has target areas that should be reflected in the claim to raise the clinical effectiveness score. The cost effectiveness is measured by drug utilization, generic use and least costly alternative. As you drill down to the patient data you can see how you are being graded.

Tools, Documentation and Forms

As ICD 10 approaches, more specificity in documentation and diagnosis will be needed for accurate coding. The 1500 claim form has already been updated to allow up to 12 diagnoses per claim. Every 12 months the diagnoses will be reset. Physicians should record all diagnoses to allow carriers to risk adjust the patient or plan a budget for each patient’s care. Your costs will be compared to the risk adjustment for effectiveness.

The Blue Advantage Medicare replacement program also has a PPA tool for incentive. Cigna, United Healthcare and other carriers have quality programs, so investigate the websites or contact your carrier representative for information. Many believe some sections of the Affordable Care Act may be repealed but quality incentives preceded the ACA, since they are related to costs savings – and are here to stay. Warren Averett’s Healthcare Division has studied the quality programs and can assist you in being successful, don’t miss out!

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