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.

Here’s how primary care physicians can participate in Value Partnerships’ quality programs

The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to better align provider reimbursement with quality of care standards, improve health outcomes and control health care costs for Blue Cross customers. We call this value-based reimbursement.

Select primary care physicians who participate in the Physician Group Incentive Program and meet the standards of quality programs developed under PGIP will, for a designated period, be eligible for reimbursement in accordance with the value-based reimbursement fee schedule.

The VBR fee schedule sets reimbursement rates for particular codes at greater than 100 percent of the TRUST/Traditional/BPP maximum or standard fee schedule. These rates apply to commercial payments only.

Participation guidelines for quality programs for primary care physicians are as follows. Doctors who have questions about participating in a quality program, or who would like more information about the opportunities described in this article, should contact their provider consultant or physician organization or email valuepartnerships@bcbsm.com. All requirements are subject to change annually.

Primary care physicians

There are five ways a primary care physician can participate in Blue Cross’ quality programs and be eligible to earn reimbursement in accordance with the value-based reimbursement fee schedule.

1. Primary care physicians designated as a Patient-Centered Medical Home are eligible for reimbursement at the VBR fee schedule rates applicable to such designations. These physicians can receive designation as a PCMH by demonstrating the following:
   
   
• Nomination from their physician organization

• Meeting the PCMH capability requirements, which are tasks that medical practices undertake to change their care processes and become more patient-centered. Examples include providing 24-hour access to a clinical decision-maker so patients can avoid emergency room visits and creating patient registries or offering access to patient web portals. In 2018, the capability requirement for PCMH designation requires 50 out of more than 150 PCMH capabilities, including six required foundational capabilities. The extent to which a provider has implemented PCMH capabilities represents 50 percent of the PCMH designation score.

• Meeting the minimum PCMH percentile ranking for quality and use criteria. Quality and use criteria are analyzed using claims data from the prior calendar year for a doctor’s attributed patient population, and the metrics for 2017 performance include 20 adult quality metrics, 15 pediatric and adolescent quality metrics, high- and low-tech radiology use and primary care sensitive emergency room visits. In 2018, the minimum percentile ranking is 20 percent. This represents 50 percent of the designation score.
  
  
2. Primary care physicians with PCMH designation who are also part of a physician organization that meets Blue Cross’ cost benchmarking criteria are eligible for reimbursement at the VBR fee schedule rates for such designations.
   
   For 2018, cost benchmark performers are defined as sub-physician organizations or organized systems of care that are in the top 15 percent for total per member per month cost or trend, or groups that have combined cost and trend performance in the top 50 percent, based on Blue Cross claims data. Specific cost benchmarking metrics include:
   
   
• Cost of care
• Overall cost of care per member per month for the previous calendar year
• Overall monthly trend in cost of care per member per month for the calendar year two years prior
• Combined performance measure for cost of care per member per month and monthly trend in cost of care per member per month

3. PCMH-designated primary care physicians who attest that they have or do the following will receive reimbursement for Provider-Delivered Care Management according to the fee schedule.
• A qualified care manager in the office
• A provider engaged in care management and willing to refer patients to care management
• Staff working to close gaps in care
• Care management services to 3 percent of their eligible, attributed patient population

4. PCMH-designated primary care physicians who are currently eligible for reimbursement for Provider Delivered Care Management according to the fee schedule can be considered for the new advanced practice value-based reimbursement. This advanced reimbursement is available if the practice delivered care management services to at least 4 percent of patients with PDCM benefits, engaged in medication reconciliation and implemented the Admission/Discharge/Transfer PCMH capability.

5. PCMH-designated and non-PCMH-designated primary care physicians are eligible for value-based reimbursement if Blue Cross determines they’re performing well on measures of clinical quality performance related to preventive service use, chronic condition management and medication adherence. There are 30 measures in this value-based reimbursement opportunity, based on the Healthcare Effectiveness Data and Information Set measures of the National Committee on Quality Assurance. Not all measures apply to each type of primary care practice. The adult measures are used for internal medicine practitioners, the pediatric measures are used for pediatricians, and a combination of adult and pediatric measures is used for family practitioners. All measures use claims data from the prior calendar year for the providers’ attributed patient population.

We’ve streamlined the Blue Cross, BCN e-referral systems

The e-referral system has recently been upgraded to enhance users’ experience. The biggest change is the consolidation of the separate Blue Cross Blue Shield of Michigan and Blue Care Network e-referral systems into one portal.

Once logged in to the Provider Secured Services homepage, users only need to click the e-referral link to access the system for both Blue Cross and BCN cases. We’ve added a new sortable plan column within e-referral denoting the different cases.

Other e-referral changes include:

• Updated language at the top of the dashboard homepage
• Case communications are now sent to Utilization Management instead of Care Management
• All references to BCN contact information have been removed from the Contact Us page

The e-referral User Guide and elearning modules have been updated on the Training Tools page of ereferrals.bcbsm.com to reflect these changes.

Provider forums continue in June

Blue Cross Blue Shield of Michigan and Blue Care Network’s 2018 provider forums continue in June at various locations across the state.

The morning sessions will have content specifically geared to physician office staff who are responsible for closing gaps related to quality measures and coding. A special morning presentation on understanding the patient experience will be targeted to office managers and staff.

Topics for the morning sessions will include:

• The patient experience — why it’s important to your practice and how you can improve it
• HEDIS^® measures
• 2018 CPT updates and coding scenarios for primary care physicians and specialists

Afternoon sessions will be geared toward all office personnel and will cover topics such as:

• New provider service model
• Authorizations
• e-referral
• The opioid epidemic
• Behavioral health
• Updates for Provider Enrollment and Data Management and the Provider Automated Response System

Here’s the schedule of events:

• Registration begins at 7:30 a.m.
• The morning session starts at 8 a.m., includes a continental breakfast and ends at 11:30 a.m. Lunch is served at noon.
• The afternoon session begins at noon (includes lunch) and ends at 4 p.m.

You can register for the full day or choose to attend just the morning or afternoon session.

These forums provide valuable information to keep your staff up to date on the latest developments. We look forward to seeing you soon.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Helpful hints for completing applications for Provider Secured Services

Use the following guide while completing an application for Provider Secured Services. These section-by-section hints help you fill out the application accurately, which helps us process your application — and give you access to the portal — faster.

Section 1 — Applicant demographics

• We need all information requested in this section to process the application.
• Fill out this section in its entirety and electronically (we can’t process handwritten data).
• The address must be the user’s physical location, not a post office box (it’s an invalid address).
• If the practice has multiple locations, give the actual, physical location of the specific user.
• If there’s a specific suite number in the user’s address, include it here, too.
• The Use and Protection Agreement is also within the application document; send it with each application.
• The practice’s name must match on both the Provider Secured Services application and the Use and Protection Agreement.
• Send all pages of both the application and Use and Protection Agreement to us.

Section 2 — Clone IDs

• If your practice doesn’t have access to Provider Secured Services currently, leave this section blank.
• If your practice does have Provider Secured Services access, cloning a user ID will give new users the same PINs that are assigned to it currently, but it doesn’t duplicate its access (the access request is in Section 6).
• Only the user ID that needs cloning goes in Section 2.
• If you’ve listed a clone ID in Section 2, leave Section 4 blank.

Section 3 — e-referral

• For offices requesting e-referral access for the first time, leave Section 3 blank.
• If your office has e-referral access, add your set ID here.
• No other information should be in this section.

Section 4 — New access NPIs

• This is where you add NPIs when there’s no user ID listed for cloning in Section 2.
• If you’ve put a clone ID in Section 2, leave this section blank.
• If your office needs access to more NPIs than space allows in this section, fill out an additional page and attach it to the application.
• If your office has existing users who need additional PIN access, submit the Authorization to Modify BCBSM and or BCN Provider Codes on your Provider Secured Services ID.

Section 5 — Health e-Blue access

• Health e-Blue helps you generate reports about patient health and helps you fill out Healthy Blue Living^SM qualification forms.
• Specialty and mental health providers don’t qualify for Health e-Blue access.
• Add users or remove access by submitting an Authorization to Add/Remove access for BCN, MAPPO, Commercial Health e-Blue form.

Section 6 — User features

• List all users’ names, phone numbers and select the access features each user needs.
• We can’t create a user ID without a user phone number. A user phone number is mandatory, and it must be the practice phone number, not the user’s personal cell number.

Access features include:

• Claims Tracking & EFT — This access allows Blue Cross Blue Shield of Michigan and Blue Care Network providers and facilities to track claims online, and receive electronic funds deposits and vouchers online.
• BCN PCP Claims Summary — Access to this feature allows BCN primary care physicians to view BCN claim summaries.
• E-referral — Allows users to submit and review referrals
• Health e-Blue — Allows users to view patient information about gaps in care and make updates to patient health information online. BCN primary care physicians also use this feature to enter BCN Qualification Form details for Healthy Blue Living^SM HMO members.
• Medical Drug PA — Allows physicians to complete medical drug prior-authorization requests online (only Type 1 NPIs qualify for this access).
• Behavioral health providers don’t qualify for BCN PCP Claims Summary or Health e-Blue.
• If new users only need access to eligibility, don’t check any of the access boxes in this section.
• As a reminder, if the user is only requesting eligibility access, there shouldn’t be a user ID (for cloning) in Section 2 or NPIs listed in Section 4.

Section 7 — Authorization

• This section is mandatory. Fill it out completely.
• The Date field must have a date.
• Make sure the authorized signer’s printed name matches with his or her signature.
• If the name and signature don’t match or the name and signature is missing, we’ll return your application for correction (which will delay the processing of your application).
• We don’t accept stamped signatures. We’ll return applications to you for correction.

If you have any questions while completing these forms, contact the Web Support Help Desk at 1-877-258-3932, from 8 a.m. to 8 p.m. Monday through Friday.

Medical record signatures: What’s acceptable?

With everyone moving to electronic health records to meet the regulatory and insurance requirements of "meaningful use," it is important to know what the Centers for Medicare & Medicaid Services considers an acceptable signature. Of every document placed in a chart, the signature is among the most important. With this simple validation, the provider or author is verified and attests to everything that’s been written in the record about a patient. The appropriate signature depends on whether the report is generated by an electronic health record or is handwritten.

Electronic signatures

The signature commonly generated by encryption software for use solely by the author of the report or record is referred to as the electronic signature.

The Medicare Integrity Manual (Ch. 3, 3.3.2.4) states:

“Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products which are protected against modification, etc., and should apply administrative procedures which are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided.”

Therefore, if electronic signatures are used as a form of authentication, electronic health records systems must authenticate the signature at the end of each note. This is paired with an attestation statement showing that the physician attests to everything he or she has written in the report.

An electronic signature must contain the following key elements:

• Practitioner’s name
• Credentials
• Date
• Printed attestation statement

Some examples of an acceptable attestation statement may include:

• Accepted by
• Acknowledged by
• Approved by
• Authenticated by
• Closed by
• Digitally signed by
• Electronically authored by
• Finalized by
• Generated by
• Released by
• Reviewed by
• Signed by
• Validated by
• Performed by (when exam and related documentation are performed by the same provider)

All electronic signatures are not acceptable. Some auto-authentication or auto-signature systems don’t mandate that the provider reviews an entry before signing, as it’s automatically done.

Examples of unacceptable statements from the systems described above include:

• Signature on file
• Electronically signed by agent of provider
• Signed but not read
• Electronically signed, but not authenticated
• Electronically signed, but not validated/verified

These reports are not authenticated because the content hasn’t been reviewed by the provider. See the examples below:

• Acceptable provider signatures:
• Electronically signed by: Eli Carson, M.D. 08/01/2016
• Closed by: Peter Wilsby, NP 09/16/2016

• Unacceptable signatures:
• Electronically signed, but not authenticated George Hudson, M.D.
• Peter Cunningham, M.D. 06/13/2014
• Signed Jessica Kastle (No credentials)

Handwritten signatures

Handwritten signatures may only be used on handwritten, transcribed or dictated reports. Handwritten signatures aren’t valid on reports generated from an electronic health records system.

The CMS Medicare Program Integrity Manual (Chapter 3) states that a provider’s handwritten signature is acceptable if it’s:

• A fully legible signature, including credential.
• A legible first initial, last name and credential.
• An illegible signature, or initials, is allowed when over a typed or printed name and credential.
  

• An illegible signature is allowed when the letterhead or other information on the page indicates the identity and credential of the signer.

It’s very important for provider signatures to meet this criterion. The validity and authenticity of the report can be determined by this simple signature. As stated by the CMS Medicare Program Integrity Manual, “Medicare requires that services provided/ordered be authenticated by the author.” This means that without a proper signature, the record can be deemed invalid, thus hindering patient care. If using an electronic health records system, consulting with technical staff and software vendors can ensure the integrity of your documentation and signatures.

For guidance, refer to the Medicare Program Integrity Manual.

Blue Cross won’t cover 4 more infusion drugs at outpatient hospital sites without approval, starting July 1

Beginning July 1, 2018, Blue Cross Blue Shield of Michigan is adding four drugs to its infusion site of care requirement for groups currently participating in the commercial Medical Drug Prior Authorization Program:

Blue Cross won’t cover infusions for these drugs at a hospital outpatient facility without a prior authorization for that approved location. If the member now receives his or her infusions in a professional location (such as a physician’s office or an approved infusion center) or the patient’s home, the only requirement is approval of the drug.

Help your patient switch his or her infusion therapy location by July 1

If your patient gets one of these drug infusions in a hospital outpatient facility, follow these steps to switch him or her to your office, an infusion center or home:

1. Submit your patient’s prior approval request to Blue Cross. If this request isn’t submitted and approved, he or she will be responsible for the full cost of the medicine.
2. Find out where your patient can continue infusion therapy. Check the directory of participating home infusion therapy providers and infusion centers.
3. Tell your patient to contact any in-network infusion therapy providers (we’re sending this information to your patient as well). If the chosen provider can accommodate your patient, they’ll work with you and your patient to make the change easy.
4. Confirm network participation for your patient before his or her infusion.

If a patient must receive one of these infusions in a hospital outpatient facility, follow the normal steps for a prior authorization request and include:

• The previously approved authorization number
• Clear rationale describing the reason the infusion must be administered in a hospital setting
• Supporting chart notes

For more information about hospital outpatient infusion therapy, view our previous October 2017, December 2017 and March 2018 articles in The Record.

Medication management for asthmatics

Commitment to a plan of treatment is crucial for asthma patients. Nonadherence results in increasing morbidity and mortality rates, and higher health care costs. Each day in the United States, according to the Centers for Disease Control and Prevention, asthma causes:

• 30,000 asthma attacks
• 5,000 emergency room visits
• 1,000 hospital admissions
• 11 deaths

It’s important to understand the needs and behaviors of asthma patients so you can develop treatment plans that promote adherence. This includes talking with them about:

• How the medications help
• Proper use of medications
• Identifying asthma triggers
• Symptom management
• The importance of follow-up visits with doctors

For more information on helping your patients manage their asthma, visit bcbsm.com or cdc.gov.**

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Comprehensive diabetes care: Improve patient health, reduce need for medical record reviews

Diabetes requires consistent medical care and monitoring to reduce the risk of severe complications and improve outcomes. Interventions to improve diabetes outcomes go beyond glycemic control as diabetes affects the entire body.

The table below provides:

• Brief descriptions about the measures for the Healthcare Effectiveness Data and Information Set and Medicare star ratings
• Ways you can close gaps in care for patients with diabetes
• Common chart deficiencies to help you keep on top of proper documentation

Note: The descriptions include CPT^® II codes that can facilitate data collection for HEDIS^®. This may reduce the need for you to provide medical records to Blue Cross Blue Shield of Michigan for review.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

How to comply with HEDIS^® measure for controlling high blood pressure

Accurate blood pressure readings mean more personalized care, which can help patients better reach their goals for controlling high blood pressure.

The Centers for Medicare & Medicaid Services uses the Healthcare Effectiveness Data and Information Set to measure health care quality. The HEDIS measure for controlling high blood pressure includes patients who:

• Are ages 18 to 85 as of Dec. 31 of the measurement year
• Have a diagnosis of hypertension

A member is compliant if his or her last blood pressure reading of the year is in control.

How is a patient included in the measure?

The patient must have at least one outpatient visit claim with a diagnosis of hypertension on or before June 30 of the measurement year. Patients diagnosed with hypertension in prior years aren’t automatically eligible for the measure. They must meet the inclusion criteria each year.

Patients are excluded from the measure if they:

• Have evidence of end stage renal disease or had a kidney transplant or dialysis on or prior to Dec. 31 of the measurement year
• Have a diagnosis of pregnancy during the measurement year
• Have a non-acute inpatient admission during the measurement year
• Are in hospice at any point in the measurement year

What are the criteria for blood pressure control?

Although the American Heart Association and the American College of Cardiology have recently updated their blood pressure guidelines, the 2017 HEDIS criteria for controlling blood pressure control are:

• < 140/90 (139/89 or less) for patients ages 18 to 59
• < 140/90 (139/89 or less) for patients ages 60 to 85 with diabetes
• < 150/90 (149/89 or less) for patients ages 60 to 85 without diabetes

Readings may be higher at the beginning of the office visit, so take another reading at the end of the visit as it may be lower. It’s important to not round up readings.

Submit blood pressure CPT II codes on each office visit claim

HEDIS requires a medical record review to determine blood pressure compliance. However, when you submit blood pressure CPT Category II codes, it will help support member-facing programs and outcomes:

• 3074F — Most recent systolic blood pressure < 130 mm Hg
• 3075F — Most recent systolic blood pressure 130 – 139 mm Hg
• 3077F — Most recent systolic blood pressure > 140 mm Hg
• 3078F — Most recent diastolic blood pressure < 80 mm Hg
• 3079F — Most recent diastolic blood pressure 80 – 89 mm Hg
• 3080F — Most recent diastolic blood pressure > 90 mm Hg

Questions about HEDIS compliance? Visit bcbsm.com/providers for additional resources.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Talk with your patients about osteoporosis

Many people don’t know they have osteoporosis until they suffer a fracture. That’s why it’s important to maintain ongoing conversations with your older patients about the risks of falls and the benefits of osteoporosis screening.

Starting the conversation

• Proactively evaluate the risk of falls with older patients at each office visit:
• Ask your patients if they’ve fallen or had issues with balance and walking.
• As appropriate, suggest:
• A cane or walker
• An exercise program
• Vision testing
• Assess the potential causes such as medications.
• Consider the need for vitamin D supplementation.

• For women age 65 and older, reinforce the importance of screening for osteoporosis with bone mineral density testing. This test is the only one that can diagnose osteoporosis.

• For women age 67 and over who’ve already incurred a fracture, order a bone mineral density test and prescribe an osteoporosis medication within six months of the fracture. Do this unless BMD testing was done within two years of the fracture or osteoporosis treatment has occurred 12 months before the fracture.

Checking on osteoporosis care
HEDIS^®* star measures, including the Health Outcomes Survey, evaluate osteoporosis care and the risk of falls.

• HEDIS measures:
• The Osteoporosis Management in Women Who Had a Fracture Measure. This measure assesses the percentage of women age 67 and older who had a bone mineral density test or treatment for osteoporosis within six months of a fracture.
• Patients who had bone mineral density testing two years prior to a fracture or osteoporosis treatment 12 months before the fracture are excluded.
  
  
• The Risk of Falls measure assesses the percentage of members 65 and older who:
• Were seen by a practitioner in the past 12 months.
• Discussed falls or problems with balance or walking with their current provider.

• The Health Outcomes Survey asks patients:
• Have you ever had a bone mineral density test to check for osteoporosis?
• Has your doctor discussed the risk of falls, how to prevent falls or treat problems with balance or walking?

For more information
The U.S. Preventive Services Task Force webpage on osteoporosis indicates that doctors should screen all women age 65 and older for osteoporosis.

The American College of Physicians published evidenced-based osteoporosis treatment guidelines in the Annals of Internal Medicine on May 9, 2017. The group recommends that doctors offer pharmacologic therapy to reduce the risk for hip and vertebral fractures in women with known osteoporosis.

You can also check out the Centers for Disease Control and Prevention’s Older Adult Falls webpage.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Submit provider directory updates to Blue Cross Complete

Blue Cross Complete requires that you submit a written notice of any changes to the provider directory at least 60 days in advance, if possible.

Changes submitted to Blue Cross Blue Shield of Michigan and Blue Care Network aren’t automatically updated in the Blue Cross Complete system. You must also send them directly to Blue Cross Complete for the provider directory.

You can use the Blue Cross Complete Provider Change Form at mibluecrosscomplete.com/provider. Completed change forms must be submitted by:

In addition, you must make these changes with NaviNet at navinet.net.** Contact NaviNet at 1-888-482-8057 or support@navinet.net.

** Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Reminder: Changes made to the 2018 FEP skilled nursing facility benefit

The below chart describes the Federal Employee Program^® skilled nursing facility benefit coverage for both the Basic and Standard Options.

If you have benefit questions, contact the FEP Customer Service line at 1-800-482-3600. If you have facility precertification questions, contact Precertification at 1-800-572-3413. If you have questions about case management services, call 1-800-325-6278.

Federal Employee Program uses Teladoc for telehealth services

Telehealth services are available to Federal Employee Program^® members for acute conditions, such as sinus problems, rashes, colds or flu. These telehealth services are also available for behavioral health counseling and substance use disorder counseling.

Standard and Basic Option members are responsible for their copayment only when using the FEP preferred telehealth provider, Teladoc^®. Members whose primary insurance is Medicare won’t be charged the telehealth copayment. If a member uses a provider other than Teladoc for telehealth services, then the member will pay all charges.

If members need information on how to sign up for telehealth services, they should call Teladoc at 1-855-636-1579 or FEP Customer Service at 1-800-482-3600.

Laborers’ Metropolitan Detroit Health Care Fund group will participate in medical drug prior authorization program

Beginning Aug. 1, 2018, Laborers’ Metropolitan Detroit Health Care Fund will participate in the medical drug prior authorization program.

You can find information about the medical drug prior authorization program by logging into web-DENIS, clicking on BCBSM Provider Publications and Resources, and selecting Newsletters and Resources. The information is located under Forms in a section titled Physician administered medications.

Keep in mind that the prior authorization requirement doesn’t apply to Federal Employee Program^® members.

The list below reflects all the medications that are part of the medical drug prior authorization program.

New billing requirements for telemedicine services start June 1

Starting June 1, 2018, billing requirements for telemedicine services will change. You’ll need to:

• Report all telemedicine services, including telephone and online visits, with the place of service 02.
• Use modifiers GT and 95 only if you’re providing telemedicine services with live audio and video telecommunication.

If you deliver an audio-only telehealth service, don’t use modifier GT or 95. However, you need to bill POS 02 in all situations.

Your Dedicated Nurse program offers enhanced care management services

Do you know about our new Your Dedicated Nurse program?

Your Dedicated Nurse is a care management program targeted to patients who are most at risk, including those with multiple chronic conditions. Patients who participate in Your Dedicated Nurse receive additional care management services beyond what’s available through our standard care management programs.

Through Your Dedicated Nurse, patients work with a specially trained nurse care manager who takes a holistic approach to health care. The care manager works collaboratively with behavioral health specialists, social workers, pharmacists, dietitians, the patient’s primary care doctor and other clinicians to improve the patient’s health.

“We believe this program can help you provide better outcomes for your patients,” said Marc Keshishian, vice president of Health and Clinical Affairs for Blue Cross Blue Shield of Michigan and senior vice president and chief medical officer for Blue Care Network. “We also anticipate it will also reduce hospital admissions, readmissions and visits to the emergency room.”

The program provides a single point of contact for the patient, family and integrated clinical team. The nurse care manager will:

• Educate patients to ensure that they adhere to their medication plan, can identify signs and symptoms that indicate their conditions are worsening, and know when it’s appropriate to follow up with their primary care physician.
• Provide care coordination, education and support to help patients make a smooth transition from the hospital to home or a skilled nursing center facility setting to avoid preventable readmissions within 30 days of discharge.
• Offer referrals to community resources that can provide emotional, financial and other support services to assist with treatment plan adherence.
• Conduct depression screening or refer to a behavioral health specialist, if appropriate.
• Refer patients to an employee assistance program or health and wellness program at their workplace, if appropriate.

Your Dedicated Nurse is available for groups that purchase the program for their employees. It’s part of Blue Cross^® Health & Wellness.

Clarification: How to report telemedicine services in an outpatient psychiatric care facility

In the June 2017 edition of The Record, we provided instructions on how to submit claims for telemedicine services using your individual national provider identification number. The intent of the article was to instruct providers to bill with their individual NPI number, only if they have one. We didn’t intend for outpatient psychiatric care providers to start billing for telemedicine services using their facility NPI.

Although an OPC provider submits claims using a professional claim form, he or she is still considered a facility provider. Telemedicine is a professional benefit and isn’t payable to a facility. Services rendered via telemedicine will only be considered for payment when billed with an individual or professional NPI — not a facility NPI.

Clarification: Orthopedic footwear, therapeutic shoes are limited to 1 pair per year

In the March 2017 edition of The Record, we provided the following information related to submitting claims for orthopedic footwear and therapeutic shoes:

• Updated billing rules
• Quantity and frequency guidelines

We’ve received feedback indicating that there is confusion about the quantities we listed in the article. To clairify, the quantity/unit of “two per year” means that we’ll cover one pair of two items per year.

A pair can be defined as:

• One item for the left foot and one item for the right foot
• Two items for the left foot
• Two items for the right foot

Any combination of items is limited to a quantity/unit of two and one pair per year.

Battling the opioid epidemic: A roundup of news and information

Consider a patient's alcohol use when screening for opioid use disorder

Did you know that approximately 1 in 5 opioid overdoses are alcohol related? That’s why it’s so important to screen for alcohol use disorder when assessing the risk of opioid use disorder. The Centers for Disease Control and Prevention recently issued a fact sheet on alcohol screening for people who consume alcohol and use opioids. The CDC also developed a new portal detailing the effects of drinking alcohol on your health.

Blue Cross develops opioid resource guide for employers

Blue Cross Blue Shield of Michigan has developed an opioid resource guide to help employers navigate the opioid epidemic. It includes a wide range of information including flyers on the following topics:

• Opioid 101 — key facts about opioids and how to prevent opioid misuse
• Medication safety, storage and disposal
• List of opioid resources

To access it, go to bcbsm.com/engage and scroll down to “Opioid resources.”

SAMHSA publishes guidance on using medications to treat opioid use disorder

The Substance Abuse and Mental Health Services Administration has published guidance to help expand health care providers' understanding of using medications to treat people with opioid use disorder. Treatment Improvement Protocol 63, Medications for Opioid Use Disorder, reviews the use of the three U.S. Food and Drug Administration-approved medications to treat opioid use disorder:

• Methadone
• Naltrexone
• Buprenorphine

TIP 63 is the latest in a series of topic-specific best-practice guidelines that SAMHSA has developed to help educate and inform health care professionals of the most up-to-date practices for treating opioid use disorder. For more information, click here.** You may also want read the column on medication-assisted treatment by Dr. William Beecroft, medical director of behavioral health, in the March — April issue of Hospital and Physician Update.

Using checklists can help prevent opioid overdose and drug diversion

In the May — June issue of Hospital and Physician Update, guest columnist Manveen Saluja, M.D., discusses how using a checklist can help prevent opioid overdose and drug diversion. You can read it by clicking here.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website

Addressing avoidable use of the emergency room

Emergency rooms are an important part of our health care system. However, many people misunderstand their purpose and visit the ER when other options are available.

Avoidable ER use is defined as using the ER for symptoms or conditions:

• That aren’t true emergencies
• Could be treated by a primary care doctor
• Are preventable with better health condition management

The Federal Employee Program^® offers alternative options for nonemergency services. Telehealth services through Teladoc^® and the 24/7 Nurse Line are available to FEP members. They can also seek care for minor medical issues from Preferred primary care doctors, retail clinics and urgent care centers.

View the FEP Appropriate Site of Service Quick Reference Guide to help educate your FEP patients on the appropriate use of the ER and where they can go for care, day or night.

Zegerid^® to be excluded from Blue Cross and BCN non-Medicare, commercial plans, starting July 1

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan and Blue Care Network non-Medicare, commercial plans will no longer cover brand-name or generic Zegerid, or omeprazole/sodium bicarbonate. This change will be effective July 1, 2018, and it applies to all HMO and PPO pharmacy drug lists and all strengths and formulations of Zegerid.

Zegerid OTC is available over the counter at a fraction of the cost of prescription Zegerid. The following over-the-counter alternatives are available without a prescription:

• Esomeprazole (Nexium^® 24HR)
• Lansoprazole (Prevacid^® 24HR)
• Omeprazole (Prilosec OTC^®)
• Omeprazole/sodium bicarbonate (Zegerid OTC^®)

We’ll notify affected members of these changes and encourage them talk to their doctor about the available over-the-counter alternatives.

As part of this ongoing initiative, Blue Cross and BCN will continue to identify and cease coverage of select drugs when more cost-effective or over-the-counter alternatives available for our commercial members.

CPT update: New codes added

The Centers for Medicare & Medicaid Services has added several new CPT codes. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Pathology and Laboratory — Administrative codes

Pathology and Laboratory — Proprietary laboratory analysis codes

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

We’ve streamlined the Blue Cross, BCN e-referral systems

The e-referral system has recently been upgraded to enhance users’ experience. The biggest change is the consolidation of the separate Blue Cross Blue Shield of Michigan and Blue Care Network e-referral systems into one portal.

Once logged in to the Provider Secured Services homepage, users only need to click the e-referral link to access the system for both Blue Cross and BCN cases. We’ve added a new sortable plan column within e-referral denoting the different cases.

Other e-referral changes include:

• Updated language at the top of the dashboard homepage
• Case communications are now sent to Utilization Management instead of Care Management
• All references to BCN contact information have been removed from the Contact Us page

The e-referral User Guide and elearning modules have been updated on the Training Tools page of ereferrals.bcbsm.com to reflect these changes.

Medical record signatures: What’s acceptable?

With everyone moving to electronic health records to meet the regulatory and insurance requirements of "meaningful use," it is important to know what the Centers for Medicare & Medicaid Services considers an acceptable signature. Of every document placed in a chart, the signature is among the most important. With this simple validation, the provider or author is verified and attests to everything that’s been written in the record about a patient. The appropriate signature depends on whether the report is generated by an electronic health record or is handwritten.

Electronic signatures

The signature commonly generated by encryption software for use solely by the author of the report or record is referred to as the electronic signature.

The Medicare Integrity Manual (Ch. 3, 3.3.2.4) states:

“Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products which are protected against modification, etc., and should apply administrative procedures which are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided.”

Therefore, if electronic signatures are used as a form of authentication, electronic health records systems must authenticate the signature at the end of each note. This is paired with an attestation statement showing that the physician attests to everything he or she has written in the report.

An electronic signature must contain the following key elements:

• Practitioner’s name
• Credentials
• Date
• Printed attestation statement

Some examples of an acceptable attestation statement may include:

• Accepted by
• Acknowledged by
• Approved by
• Authenticated by
• Closed by
• Digitally signed by
• Electronically authored by
• Finalized by
• Generated by
• Released by
• Reviewed by
• Signed by
• Validated by
• Performed by (when exam and related documentation are performed by the same provider)

All electronic signatures are not acceptable. Some auto-authentication or auto-signature systems don’t mandate that the provider reviews an entry before signing, as it’s automatically done.

Examples of unacceptable statements from the systems described above include:

• Signature on file
• Electronically signed by agent of provider
• Signed but not read
• Electronically signed, but not authenticated
• Electronically signed, but not validated/verified

These reports are not authenticated because the content hasn’t been reviewed by the provider. See the examples below:

• Acceptable provider signatures:
• Electronically signed by: Eli Carson, M.D. 08/01/2016
• Closed by: Peter Wilsby, NP 09/16/2016

• Unacceptable signatures:
• Electronically signed, but not authenticated George Hudson, M.D.
• Peter Cunningham, M.D. 06/13/2014
• Signed Jessica Kastle (No credentials)

Handwritten signatures

Handwritten signatures may only be used on handwritten, transcribed or dictated reports. Handwritten signatures aren’t valid on reports generated from an electronic health records system.

The CMS Medicare Program Integrity Manual (Chapter 3) states that a provider’s handwritten signature is acceptable if it’s:

• A fully legible signature, including credential.
• A legible first initial, last name and credential.
• An illegible signature, or initials, is allowed when over a typed or printed name and credential.
  

• An illegible signature is allowed when the letterhead or other information on the page indicates the identity and credential of the signer.

It’s very important for provider signatures to meet this criterion. The validity and authenticity of the report can be determined by this simple signature. As stated by the CMS Medicare Program Integrity Manual, “Medicare requires that services provided/ordered be authenticated by the author.” This means that without a proper signature, the record can be deemed invalid, thus hindering patient care. If using an electronic health records system, consulting with technical staff and software vendors can ensure the integrity of your documentation and signatures.

For guidance, refer to the Medicare Program Integrity Manual.

Blue Cross won’t cover 4 more infusion drugs at outpatient hospital sites without approval, starting July 1

Beginning July 1, 2018, Blue Cross Blue Shield of Michigan is adding four drugs to its infusion site of care requirement for groups currently participating in the commercial Medical Drug Prior Authorization Program:

Blue Cross won’t cover infusions for these drugs at a hospital outpatient facility without a prior authorization for that approved location. If the member now receives his or her infusions in a professional location (such as a physician’s office or an approved infusion center) or the patient’s home, the only requirement is approval of the drug.

Help your patient switch his or her infusion therapy location by July 1

If your patient gets one of these drug infusions in a hospital outpatient facility, follow these steps to switch him or her to your office, an infusion center or home:

1. Submit your patient’s prior approval request to Blue Cross. If this request isn’t submitted and approved, he or she will be responsible for the full cost of the medicine.
2. Find out where your patient can continue infusion therapy. Check the directory of participating home infusion therapy providers and infusion centers.
3. Tell your patient to contact any in-network infusion therapy providers (we’re sending this information to your patient as well). If the chosen provider can accommodate your patient, they’ll work with you and your patient to make the change easy.
4. Confirm network participation for your patient before his or her infusion.

If a patient must receive one of these infusions in a hospital outpatient facility, follow the normal steps for a prior authorization request and include:

• The previously approved authorization number
• Clear rationale describing the reason the infusion must be administered in a hospital setting
• Supporting chart notes

For more information about hospital outpatient infusion therapy, view our previous October 2017, December 2017 and March 2018 articles in The Record.

Call center hours for Facility Provider Inquiry changing

Blue Cross Blue Shield of Michigan is changing the call center hours for Facility Provider Inquiry starting Aug. 1, 2018.

The new call center hours across the state will be 8:30 a.m. to 5 p.m. The call center will continue to be closed from noon to 1 p.m.

The phone number remains the same. Hospitals and facilities should continue to call 1-800-249-5103.

Clarification of Medicare Outpatient Observation Notice form requirements

Here’s when hospitals must notify members:
Hospitals must notify Blue Cross Medicare Plus Blue^SM PPO and BCN Advantage^SM members that they’re receiving outpatient, rather than inpatient, services by using the Medicare Outpatient Observation Notice form, available on the CMS website** under Downloads, when a member is:

• Being moved to observation status within the hospital from any other status or source
• In observation status for 24 hours or more, if the member hasn’t already received the form before being admitted for observation

This is a Centers for Medicare & Medicaid Services requirement. Hospitals should also review the instructions** for notifying members using the Medicare Outpatient Observation Notice.

Here’s when hospitals do not need to notify members:

• Blue Cross or BCN has approved an inpatient admission.
• The member isn’t being considered for inpatient care; there’s no need to notify the plan either in this case.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Laborers’ Metropolitan Detroit Health Care Fund group will participate in medical drug prior authorization program

Beginning Aug. 1, 2018, Laborers’ Metropolitan Detroit Health Care Fund will participate in the medical drug prior authorization program.

You can find information about the medical drug prior authorization program by logging into web-DENIS, clicking on BCBSM Provider Publications and Resources, and selecting Newsletters and Resources. The information is located under Forms in a section titled Physician administered medications.

Keep in mind that the prior authorization requirement doesn’t apply to Federal Employee Program^® members.

The list below reflects all the medications that are part of the medical drug prior authorization program.