A message from Steve Anderson
We’re changing the way we process inpatient acute care admissions
 As health care costs continue to rise, our customers are demanding that we move more quickly to reduce the amount spent on health care.
One of the many steps we’ve taken is to look more closely at our processes regarding inpatient acute care admissions and behavioral health admissions. This includes funneling inpatient acute care authorization requests through our e-referral system for review for select members and facilities.
This process began July 31, 2017, with our Medicare Plus BlueSM PPO members and commercial PPO members who are part of the UAW Retiree Medical Benefits Trust. Other lines of business, including Blue Care Network and BCN AdvantageSM, already have full inpatient review programs at Michigan hospitals.
Our data revealed that some cases are billed incorrectly or that patients are admitted to a hospital when it would have been more appropriate for them to receive a less costly, lower level of care, such as hospital observation or home care. For example, we found:
- Admissions that should have been billed as an observation stay
- Inpatient stays that were denied because they didn’t meet the necessary clinical criteria
Starting July 9, all inpatient acute care admissions to select facilities for Blue Cross Blue Shield of Michigan commercial PPO members must be submitted through e-referral and could be subject to clinical review. Facilities that will be required to submit authorization requests — and attach clinical records — for commercial PPO members through e-referral will be notified in advance. Blue Cross will conduct clinical reviews using InterQual® criteria.
Gender reassignment authorization requests can also be submitted through e-referral, along with authorization requests for ill newborns who are already on a subscriber’s policy. If a newborn isn’t on a policy, the authorization request must be faxed.
Behavioral health admission authorization requests will continue according to the current established process with the assigned behavioral health management vendor. However, requests processed through New Directions will now be subject to full clinical review from the first day of admission.
The application of clinical criteria is required in some cases to receive authorization for Blue Cross inpatient stays. For more information, see Blue Cross’ Authorization Requirements & Criteria page on the e-referral website.
If you’re not already using e-referral, you can sign up on the Sign Up or Change a User page on the e-referral website. If you have any questions, contact your provider consultant.
Want to learn more about our other efforts to create more affordable health care?
Check out these links to previous columns on the following topics:
Pathway to Risk
Value-based reimbursement
Blue Distinction® Total Care
Bundled payments
Reference-based benefits
High-cost claims
Last but not least, our Value Partnerships program (which includes our value-based reimbursement and Blue Distinction Total Care programs) is one of the key tools we use to curb rising health care costs. We work together with our hospital and physician partners on more than 50 initiatives to better manage health care costs while improving the quality of care patients receive.
Our hospital and physician partners lead these initiatives, and we provide the forum and support to help them work together in a noncompetitive atmosphere. We couldn’t be prouder of them.
We celebrated their achievements in our recently released Value Partnerships Annual Report. You can access it at bcbsm.com/valparreport.
Steve Anderson is vice president of Hospital Contracting & Network Administration with Blue Cross Blue Shield of Michigan. |
