Rewards for Specialists

Blue Cross Blue Shield of Michigan identifies and rewards practices that collaborate with their community of caregivers to effectively manage their shared patients. Specialists in the Physician Group Incentive Program can receive reimbursement in accordance with the Value-Based Reimbursement Fee Schedule if they collaborate with their Physician Group Incentive Program PO and other practitioners and if they’re associated with populations of patients receiving high-quality, cost-effective care. The Value-Based Reimbursement Fee Schedule sets reimbursement rates at greater than 100 percent of the standard fee schedule.

Our goals in extending the Value-Based Reimbursement Fee Schedule to specialists include:

  • Transforming reimbursement from traditional fee-for-service to fee-for-value
  • Encouraging conversations and collaboration among practitioners, especially between specialists and primary care physicians
  • Accelerating the adoption of Patient-Centered Medical Home-Neighbor principles
  • Supporting and promoting Organized Systems of Care
  • Assessing and improving population-based measures of performance

In 2016, all specialist types are eligible to be considered for Value-Based Reimbursement. POs nominate specialists who are acting as PCMH-Neighbors. We choose which specialists receive reimbursement based on optimization of use, cost and/or quality in the PO populations they serve.

We determine eligibility for reimbursement on an annual basis with an effective date of March 1. To be nominated for it, specialists need to participate in PGIP for at least one year.

We only apply reimbursement to PPO and Traditional commercial professional claims. We don't apply reimbursement to claims for ambulance, durable medical equipment, prosthetics and orthotics, immunizations, most injections, or hearing, lab, dental or routine vision services.