Value-based reimbursement for primary care physicians is changing, effective Sept. 1, 2018

We’re making some changes to the value-based reimbursement fee schedule for primary care physicians, effective Sept. 1, 2018. Blue Cross Blue Shield of Michigan uses the value-based reimbursement fee schedule to reward health care professionals who create value for health care users.

As noted in the April 2018 Record article, “Value-based reimbursement and PCMH designation effective dates are changing,” the effective date of primary care physician value-based reimbursement is changing this year to Sept. 1, 2018, through Aug. 31, 2019.

Primary care physicians in the Physician Group Incentive Program are eligible for reimbursement according to the VBR fee schedule, which sets reimbursement rates for specific codes at more than 100 percent of the TRUST/Traditional/BPP maximum or standard fee schedules.

Primary care physicians can receive value-based reimbursement at 105 percent to 150 percent of the standard fee schedules for certain procedure codes, depending on the programs they participate in and the criteria they meet. Previously, primary care physicians could receive value-based reimbursement at 105 percent to 140 percent of the standard fee schedules.

Effective Sept. 1, 2018, through Aug. 31, 2019, based on performance in 2017, three tiers of cost benchmark value-based reimbursement will be available to primary care physicians. Previously, only one tier was available.

Primary care practices without Patient-Centered Medical Home designation that:

• Rank in the 95th to 100th percentile for clinical quality performance can receive 115 percent of the standard fee schedule for the following procedure codes:
• *99201-*99215
• *99381-*99397
• Rank in the 85th to 94.99th percentile for clinical quality performance can receive 110 percent of the standard fee schedules for the procedure codes above
• Rank in the 80th to 84.99th percentile for clinical quality performance can receive 105 percent of the standard fee schedules for the procedure codes above

Primary care physicians with PCMH designation receive 110 percent of the standard fee schedule for the procedure codes above as well as additional value-based reimbursement.

PCMH-designated practices that:

• Rank in the 95th to 100th percentile for clinical quality performance can receive an additional 15 percent of the standard fee schedule for the procedure codes above
• Rank in the 85th to 94.99th percentile for clinical quality performance can receive an additional 10 percent of the standard fee schedule for the procedure codes above
• Rank in the 80th to 84.99th percentile for clinical quality performance can receive an additional 5 percent of the standard fee schedule for the procedure codes above
• Belong to a physician organization that meets Blue Cross’ cost benchmarking criteria can receive an additional 5 percent, 10 percent or 15 percent of the standard fee schedule for the procedure codes above
• Participate in Provider-Delivered Care Management can receive an additional 5 percent of the standard fee schedule for the procedure codes above and for the following procedure codes:

• G9001-G9002
• *98961-*98962
• *98966-*98968
• G9007
• *99487
• *99489
• S0257

Participants in PDCM can receive an additional 5 percent of the standard fee schedule for advanced practice (more comprehensive care management) for the procedure codes above the total amount of value-based reimbursement received depending on which programs the primary care physicians participate in and the criteria they meet. For instance, primary care physicians who are PCMH-designated, are a member of a physician organization that meets Blue Cross’ cost benchmark criteria for the top tier, participate in PDCM, meet advance practice criteria and perform in the highest tier on measures of clinical quality will receive reimbursement at 150 percent of the standard fee schedule.