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May 2014

Updates announced for BCBSM’s Prescriber Prescription Block Policy

Blue Cross Blue Shield of Michigan has updated its Prescriber Prescription Block Policy. The policy, which became effective on Sept. 1, 2013, was previously announced in the June 2013 edition of The Record.

Criteria under which a provider may be recommended for the Prescriber Prescription Block Program now include:

  • Any felony or misdemeanor conviction, guilty plea, plea of nolo contendere or placement in a diversion program for any crime related to the payment of pharmacy claims involving BCBSM, Medicare, Medicaid and other health care insurers.

  • Prescribers who continue to be noncompliant in their prescribing patterns after documented notification by BCBSM, law enforcement or any government agency.

  • Prescribers demonstrating a pattern of prescribing medications that are significantly aberrant from their peers with similar board certifications as confirmed by data and expert medical consultant opinion.

  • Prescribers consistently prescribing medications or combinations of medications that have been shown to put patients at high risk for overdose or death as confirmed by an expert medical consultant.

  • Prescribers demonstrating a pattern of billing for services not rendered or not medically necessary as documented by internal or external investigations.

  • Prescribers refusing access to records which substantiate the medical necessity for the services rendered and which are deemed essential by BCBSM for BCBSM to determine its liability.

For more information, see the updated Prescriber Prescription Block Policy.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
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