PGIP expands number of specialty types eligible for fee uplifts in 2015

Since 2012, Blue Cross Blue Shield of Michigan’s Physician Group Incentive Program has continually expanded the number of specialty types eligible for fee uplifts. Our efforts support the transition from a payment approach based solely on fee-for-service to an approach that layers fee-for-value upon the fee-for-service foundation.

Beginning in 2015, PGIP member practices in the following specialties will be considered for fee uplifts:

MDs and DOs in other specialty areas not identified above (such as, but not limited to, addiction medicine**, sports medicine, occupational medicine**, sleep medicine** and urgent care**) will also be considered for fee uplifts. Anesthesiologists will not be eligible for fee uplifts at this time.

**Denotes a new specialty type eligible for fee uplifts in 2015

To receive a fee uplift, the following criteria apply:

• Practitioners must be a member of a PGIP physician organization and participating in PGIP through the physician organization as of July 1, 2014.
• At least one PGIP physician organization (or two in some cases) must have nominated each specialty practice by Oct. 13, 2014.
• Once nominated, specialist practices must meet performance metric rankings developed by Blue Cross Blue Shield of Michigan.

PGIP POs may nominate specialist practices that:

• Include at least one practitioner from one or more of the eligible specialties
• Have signed a Primary Care-Specialist Agreement with the PO
• Have displayed a high level of engagement with the PO
• Are actively involved in managing and optimizing the use of services and quality of care
• Are partnering with primary care physicians to improve care processes and coordination

Nomination is a necessary, but not sufficient, factor for receipt of the fee uplifts. Blue Cross uses population-based, specialty-specific measures of performance to rank and select the nominated specialist practices to receive the fee uplifts.

More than 5,000 specialists are receiving fee uplifts in 2014. With the rapid growth in the number of specialists who have joined PGIP and the expansion of eligible specialty types, we anticipate that over 6,000 specialists will receive fee uplifts in 2015, an increase of more than 20 percent.

The growth in the number of specialists in PGIP is substantial and gratifying. In order to extend the fee uplifts to additional specialty types in 2015, it is necessary to make a slight reduction in the proportion of each specialty type receiving the fee uplifts. In 2015, the top quartile of fully nominated adult specialty practices will receive a 10 percent fee uplift and the second quartile will receive a 5 percent fee uplift. The top half of fully nominated pediatric specialty practices will receive a 10 percent fee uplift and the second half will receive a 5 percent fee uplift.

The selected practices will receive a fee uplift for one year — from Feb. 1, 2015, through Jan. 31, 2016. The nomination and selection process will be repeated annually.

Thinking ahead to 2016, practitioners will need to have been enrolled in PGIP as of summer 2014 to be nominated for a fee uplift that will become effective Feb. 1, 2016. Nominations must occur by the fall of 2015.

The specialist fee uplifts are applied to most procedure codes, except those for ambulance, durable medical equipment, prosthetics and orthotics, anesthesia, immunizations, hearing, routine vision services, non-RVU lab services, dental and most injections.

In addition, the fee uplifts are not applied in the following circumstances:

• Services billed through a BCBSM-participating urgent care center***
• Professional services billed on a facility claim
• Services billed through independent pathology laboratories***
• Services billed through a freestanding radiology center (new network to be launched Jan. 1, 2015)***

***Blue Cross is exploring approaches that would allow for fee uplifts for these services in the future.

Other changes to the specialist fee uplift program in 2015 include the following:

• Oncologists who are not selected for the performance based fee uplifts described above will no longer be eligible for a 5 percent fee uplift based on their participation in the Michigan Oncology Clinical Treatment Pathways Program and the Michigan Oncology Quality Collaborative or certification through the Quality Oncology Practice Initiative. This change is designed to make the fee uplift options available to oncologists more consistent with those offered to other specialty types. 
• The 2 percent fee uplift associated with the Collaborative Quality Initiatives physician recognition program is being discontinued, effective Jan. 31, 2015. Alternate options more suitable for CQI participation and engagement are being considered. More details to come in 2015.

For more information, contact your provider consultant.