Requirements for Participation
The PGIP Agreement defines a Physician Organization as "a [legal designation] whose members are licensed to practice medicine in the state of Michigan and who are in good standing with both Blue Cross Blue Shield of Michigan's PPO TRUST and Traditional Networks."
A PO selected for PGIP participation must:
- Have 75 or more TRUST panel or Traditional providers, 50 of whom must be practicing as primary care providers (for instance Internal Medicine, Pediatrics, Family Practice, and General Practice). A PGIP physician can be a member of only one PGIP PO during any given time period.
- Be a partnership, association, corporation, individual practice association or other legal entity which has its own Tax ID, can receive and distribute income among the PO's members and has contractual authority to represent its providers for this program
- Is able to coordinate and facilitate practice improvements and program administration on behalf of its members.
- Meet and continue to comply with the PGIP program standards (which are subject to change), the Physician Group Incentive Program Agreement (which includes data-sharing guidelines), and Blue Cross Blue Shield of Michigan's policies and procedures.
A Physician Organization is considered to be "participating in PGIP" after Blue Cross Blue Shield of Michigan has:
- Received and reviewed the PO's application materials (including the PGIP physician list, a signed PGIP Agreement, a signed W9 and completed and signed Automated Clearing House form
- Sent final approval for PGIP participation (this will include a welcome letter from Blue Cross Blue Shield of Michigan and copy of a counter-signed PGIP Agreement)
A PO is considered a new PO if:
The majority (51 percent or more) of its member providers were not enrolled in PGIP during the time period preceding the new PO application submission, or as determined by Blue Cross Blue Shield of Michigan.
A PO is considered a "splinter" PO if:
The PO is formed from parts of existing POs. A PO is considered a "splinter" PO if 50 percent or more of its member providers were enrolled in PGIP with other POs during the time period preceding the PO application submission, or as determined by Blue Cross Blue Shield of Michigan.
Splinter POs applying for PGIP are required to meet the following expectations:
- Ensure that all POs from which the splinter PO is formed are aware of the change in their organization(s) as well as the splinter POs intent to apply for participation in PGIP.
- Establish all processes necessary for a smooth transition to a splinter PO.
- Communicate all developments regarding new, independent PO status, such as infrastructure development, clinical leadership changes, etc. to the PGIP Field Operations staff.
PGIP Field Operations may also advise the splinter PO not to split if it is deemed unlikely that the splinter PO can successfully transition to an independent PO participating in PGIP. For example, if Field Operations staff determines that the splinter PO lacks the required infrastructure (adequate staffing, technology support, etc), physician leadership or provider buy-in to be successful in PGIP, the splinter PO may be advised to not apply for participation in PGIP.
Splinter POs desiring historical datasets, reports, etc. must contact their parent POs as Blue Cross Blue Shield of Michigan cannot create past datasets, reports, etc. Splinter POs may have a lapse in data/reporting as a result of splitting from their parent POs. Current PGIP POs are expected to share relevant data with the new splinter PO. It is the responsibility of the splinter PO to request all historical data from their parent PO. Blue Cross Blue Shield of Michigan will communicate these expectations to the parent and splinter POs.
Both "new" and "splinter" Physician Organizations are eligible to participate in initiatives in their first year of PGIP participation; however, Blue Cross Blue Shield of Michigan reserves the right to evaluate the appropriateness of the PO's participation in these initiatives.