American Well, other providers to be reimbursed for online health care

As announced in the October Record, Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with American Well^®, a best-in-class telehealth company, to provide online doctor visits to our members using the award-winning Amwell™ online health care technology.

The company will provide HIPAA-compliant, 24/7 online health care to Blue Cross and BCN members of self-funded groups that have opted to receive this benefit, effective Jan. 1, 2016.

BCN fully insured individual and group members will also have this benefit, effective Jan. 1, and Blue Cross will expand its offerings to include fully insured individual and group members, effective July 1, 2016. Note: This option is not available to Medicare or Medicaid members at this time.

As you know, we encourage members to coordinate their health care through their primary care doctors. However, when a primary care doctor isn’t available, this service offers members the ability to connect with a doctor by online video 24 hours a day, seven days a week for common illnesses.

Members with this benefit can talk to one of American Well’s extensive practice group of U.S. board certified doctors from their laptop, tablet or smartphone. Members will be encouraged to follow up with their primary care doctor and will have the option to send a report about the online consultation to their doctor.

What about doctors not affiliated with American Well?

Blue Cross Blue Shield of Michigan

All Blue Cross providers credentialed to perform evaluation and management services can be reimbursed for HIPAA-compliant online services for members of any self-funded group that opts in as of January 2016. After July 1, the code will be reimbursable to Blue Cross providers for all insured individual and group members.

As more details become available, we’ll share them in future issues of The Record.

Blue Care Network

For BCN, some special guidelines apply:

• Only primary care physicians can participate.
• Online visits can be conducted with established patients only.
• Special software must be used to structure an automated clinical encounter. Online visits are not covered for BCN Advantage^SM members.
• For Healthy Blue Living^SM HMO members, online visits cannot be used for the initial visit required to complete the Blue Care Network Qualification Form, but can be used for other visits, as appropriate.
• For online visits, all physician consultative services must be documented in the member’s medical record. BCN reserves the right to audit these records and confirm billing integrity and accuracy. Online visits are subject to retrospective review.

For more information and billing guidance related to BCN participating providers, refer to the Claims section of the BCN Provider Manual.

Changes to wellness platform bring enhancements to Healthy Blue Achieve ^SM, Healthy Blue Living ^SM

Blue Cross Blue Shield of Michigan has launched the new Blue Cross^® Health & Wellness platform, powered by WebMD^®, that lets us provide our members with a more robust online wellness experience — one that’s interactive, easy to use and mobile-enabled.

The new wellness platform launched on Nov. 1, 2015, for most Blue Cross members. All other Blue Cross members and Blue Care Network members will be moved to the new wellness platform by Jan. 1, 2016. Base benefits for Blue Cross and BCN include access to the Blue Cross Health & Wellness platform, the online health assessment, Digital Health Assistant programs and more. BCN base benefits also include Tobacco Cessation Coaching.

The new wellness platform will also bring enhancements to both of our wellness products — Healthy Blue Achieve PPO and Healthy Blue Living HMO. Enhancements will include the new online health assessment, tobacco cessation program and a walking program, all powered by WebMD.

Here’s a list of the key changes to each product:

Healthy Blue Achieve

Healthy Blue Living

For more information, contact your provider consultant.

Providers and vendors required to take CMS fraud and compliance training

The Centers for Medicare & Medicaid Services requires providers, vendors and their contractors to complete training for fraud, waste, abuse and compliance.

Providers and vendors should make sure that governing body members, employees, contractors and volunteers who provide health or administrative services, in connection with Medicare Advantage, complete the training within 90 days of being hired or contracted and then annually thereafter.

Make sure you keep the certificate generated by the website as proof you took the training and keep it for 10 years from the end date of your contract with Blue Cross Blue Shield of Michigan or Blue Care Network. You’ll need to provide proof of this compliance to Blue Cross, BCN or CMS upon request.

Click here for information on CMS compliance training.

Blue Cross and BCN will send out renewal and discontinuation notices starting this week.

Understanding family and individual level deductible maximums

For family and individual contracts, when an individual’s deductible is not met, the individual will not owe a balance if the family contract deductible is met. When the family level deductible is met, the individual member’s deductible is also met, even if the individual’s "Remaining Deductible Required" shows a balance.

To help you better understand this billing scenario, check out the Deductible/Maximum screen shot below:
 

If you have any questions, contact your provider consultant.

Medical Drug Utilization Management Program to include limits on some medical drugs

Blue Cross Blue Shield of Michigan is expanding its utilization management program to include some limits on medical drugs administered under the professional medical benefit. This effort will begin in January and continue through the first two quarters of 2016.

One or more of the following drug limits will be enforced on some medical drugs:

• Maximum dose per day
• Interval time periods (how often a drug can be administered)
• Lifetime maximums (number of doses per lifetime)
• Number of doses per time period

Note: Not all medical drugs will have a quantity limit.

These limitations are based on U.S. Food and Drug Administration and manufacturer labeling, as well as Blue Cross medical and drug policies.

You can find the specific quantity limitations on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

BlueCard^® connection: Data analysis supports need to verify eligibility and benefits

As part of our ongoing series on the BlueCard program, this month we want to share the results of our BlueCard claims data analysis.

The BlueCard Provider Advocate department recently completed data analysis on BlueCard claims we processed in January and June 2015. The top five rejections for both professional and facility claims related to eligibility and benefits. You can avoid getting these rejections by verifying the out-of-state member’s coverage before rendering the service.

There are several ways to verify benefits and whether your member has active coverage. You can also determine if an authorization is required for the service or treatment you’re going to provide.

Here are your options for verifying the information:

• Call the BlueCard line toll-free at 1-866-676-2583. The member’s three-letter alpha prefix will route you to his or her home plan. It’s also important to know that:
• Prompt 1 will provide you with eligibility and benefit information.
• Prompt 2 will allow you to verify and execute a required authorization.
• After completing the automated response for benefits and eligibility, most plans offer you an option to speak with a representative. The option to speak with a representative is generally only available after you have completed the automated process.

• BlueExchange on web-DENIS enables you to obtain eligibility and benefit information for out-of-state Blue Cross and Blue Shield patients directly from their home plans. Follow these steps to receive the information you need:
  • Complete all of the fields marked with an asterisk.
  • Enter the information exactly as it appears on the member’s ID card, including the correct spelling of his or her name and accurate birthdates. 
  • If the member is not the subscriber of the plan, you’ll need to provide information for both people.
  Note: The amount of information you receive from each plan — and how the information is displayed — will be different based on the individual Blue plan.

• Check the medical policy or pre-authorization router for out-of-state plans’ medical policies and authorization requirements. The member’s three-letter alpha prefix will route you to the website of the member’s home plan. A link to the router is available on Provider Secured Services, web-DENIS and in the BlueCard chapter of every online provider manual. Clinicians who don’t have a Blue Cross Blue Shield of Michigan web-DENIS ID may access the same information via a link to the router under the Quick Links tab on Provider Secured Services at bcbsm.com.

Benefits and eligibility can also be requested via the American National Standards Institute — or ANSI — ASCX12N270/271 (005010X279A1) electronic transactions. Information on these transactions can be found on the Blue Cross website here. The Health Care Eligibility Benefit Inquiry and Response Technical Report Type 3, or TR3, is standard for eligibility transactions.

As we prepare for our 2016 initiatives, discuss with your consultant what we can do to improve your BlueCard experience. Topics and suggestions will be communicated in future Record articles.

For more information on the BlueCard program, including links and articles on online tools, reference the BlueCard chapter of the online provider manuals.

If you’re experiencing issues with the information provided in the BlueCard chapter or any of the online tools — or if you’d like more information on a particular topic — contact your provider consultant. If you’d like to suggest a topic to be covered in a future issue of The Record, send an email to ProvComm@bcbsm.com and put “BlueCard series” in the subject line.

Coding corner: properly documenting autism spectrum disorder

As you’ve read in “Coding corner” articles in The Record before, proper clinical documentation is crucial to ensuring complete, consistent and accurate information about a patient encounter — and also for delivery of high-quality treatment and care.

Background
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), released in 2013, the four autistic subtypes were combined under one umbrella diagnosis of “autism spectrum disorder,” also known as pervasive developmental disorder.

The coding assignment for this condition depends on accurate and thorough documentation in the medical record. It’s important that providers include some or all of the following detailed descriptions to achieve more accurate and specific documentation:

Condition category

• Autistic disorder (autism)
• Asperger’s disorder
• Childhood disintegrative disorder
• Pervasive developmental disorder — not otherwise specified

Symptoms

• Age of onset
• Clinically significant impairment in social, occupational and other crucial areas of current functioning

Severity level

• Requiring (substantial or very substantial) support
• Social communication impairments
• Restrictive patterns of behavior

Specificity

• With or without accompanying intellectual impairment
• With or without accompanying language impairment
• Associated with a known medical or genetic condition or environmental factor

Screenings/assessments/laboratory testing

• It’s necessary to document the results and any diagnosis in the medical record in the patient encounter. For example, MRI or electroencephalogram tests.

Medications

• Be sure to review and identify medications in each patient encounter. For example, Risperdal^® is commonly used to treat schizophrenia and bipolar disorder. Documentation is required to prescribe this medication to treat autism.
• Or Haldol^® for aggression, for example, reviewed today and no refills at this time.
• Or Topamax^® for seizures, for example, reviewed today, reference date of encounter.

In addition, it’s important that all associated medical conditions, such as epilepsy, mental retardation, tuberous sclerosis, etc., are reviewed in the patient encounter. Here are a few examples:

• A child with a diagnosis of autism. The progress note further mentions having a language deficit.
• An encounter for autistic spectrum disorder follow-up. Past medical history indicates the patient has tuberous sclerosis. The correct code selection is R48.8 because of the underlying medical diagnosis contributing to the language problems. When medical etiology is not documented, F80.2 should be assigned.

It’s equally important to evaluate all conditions mentioned in the patient encounter, including other impairment or behavior issues that could affect the current patient encounter and treatment. For example:

• An encounter for an autistic child with an upper-respiratory infection. In the History of Present Illness the provider refers to the patient as autistic but doesn’t assess the condition by itself or how it affects the treatment for the upper-respiratory infection.

A review of past medical history is important for overall patient care. Chronic conditions that are actively being treated should be assessed for diagnosis closure submission(s) or to support a higher specificity ICD-10 code for autistic spectrum disorder/pervasive developmental disorder. For example, a patient encounter for autistic spectrum disorder follow-up. The past medical history indicates the patient has tuberous sclerosis.

To recap, it’s important that all conditions are addressed in the patient encounter and thoroughly documented in the medical record to help ensure coding accuracy and high-quality care delivery.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.

Blue Cross to update McKesson ClaimsXten for first quarter 2016

McKesson ClaimsXten — software that uses the most current Common Procedural Terminology and Health Care Procedure Coding System codes to determine clinical edits — will be updated in January 2016.

McKesson updates the ClaimsXten information base quarterly, using CPT code updates and Centers for Medicare & Medicaid Services guidelines, specialty society guidelines and information gathered from industry seminars and publications. In turn, Blue Cross Blue Shield of Michigan implements changes to ClaimsXten quarterly to ensure we’re following the most current rules.

That’s why it’s important you report the most current CPT and HCPCS codes on your claims. Doing so will help us process claims and send accurate reimbursement more quickly and efficiently.

Review upcoming issues of The Record for future ClaimsXten updates. If you have any questions, contact your provider consultant.

Reminder: determining if out-of-state lab participates with Blue Cross Blue Shield of Michigan

As you’ve read before, independent laboratories must file claims with the Blue Cross plan in the state where the specimen is drawn, which is determined by where the referring (or ordering) physician is located. If you’re thinking of referring a patient to a lab outside of Michigan and want to determine if the lab participates with us, go to bcbsm.com and follow these steps:

• Click on Find a Doctor.
• Click on Get Started.
• Click on I want to find doctors or hospitals.
• Type in your ZIP code.
• Using the drop-down menu, select PPO Plans - Group Enrollees.
• Type in Out-of-State Independent Laboratories.
• Click on Go.

If you have any questions, contact your provider consultant.

Reminder: Blue Cross won’t pay for unused patient care items

In accordance with our participation agreements with providers, medical implants, devices or other equipment that aren’t used by a member for his or her treatment aren’t payable and shouldn’t be billed to Blue Cross Blue Shield of Michigan or to the patient.

This means that providers shouldn’t bill Blue Cross or our members for incorrectly ordered, manufactured, packaged or otherwise unusable implants, devices or equipment, including discarded and returned items. In addition, the cost of these unusable, discarded or returned items shouldn’t be included in any charges submitted or costs reported to Blue Cross.

This policy applies to all service sites, including, but not limited to, hospital inpatient and outpatient, ambulatory surgical facilities, physician offices and any other facility or professional setting where implants, devices or equipment are provided or implanted into patients.

Payments for any items that are charged to Blue Cross or the patient and are not used in the care of the patient will be recovered during any audits. We encourage you to work with your suppliers to ensure that all unusable items can be returned and are appropriately refunded.

Correction: article on behavioral health upgrades in Living Healthy

We’d like to issue a correction to the article titled “Behavioral health member satisfaction survey spurs upgrades” in the Summer 2015 issue of Living Healthy, published in August.

The last bullet point in the article, which addressed changes to behavioral health services, contained some incorrect information. Following is how it should have read:

• Psychological testing prescribed by a physician or licensed psychologist, and administered by a licensed psychologist or under the supervision of a licensed psychologist. The tests must be directly related to the condition for which the patient is admitted or have a full role in rehabilitative or psychiatric treatment programs.

If you require more information, send an email to ProvComm@bcbsm.com.

Billing chart
Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

Benefit Explainer enhanced with more information

We’ve added some new information to Benefit Explainer. Here are highlights.

You’ll find these changes under the QuickView tab in the Benefit Package Report, or BPR:

• There could be up to nine tiers that show in- and out- of-network copays and other cost-shares.
• We added a hyperlink in the Summary that automatically expands with details about deductibles, coinsurance and other out-of-pocket costs.
• In the QV Summary area, the heading General has been changed to Topic and the heading None has been changed to Value.
• Topic — displays which topic the copay has been assigned to
• Value — displays the copay name and value amount
• Stop loss has been changed to Coinsurance Maximum under Summary

These changes were made to the BPR:

• Under Maximums, when you click on Dollar Value Summary, you’ll see additional or expanded choices.
• The benefit tiers are more detailed, showing in- and out-of-network copays and coinsurance.
• The Value column now shows current deductibles and coinsurance, as well as detailed amounts.
• The link in the Maximum Name area is new. A pop-up window will show more details about deductibles and other out-of-pocket costs.
• The heading Benefit Tier limitation replaced the heading Network Status limitation. The information remains the same.
• Under Copayments, you now see the specific copay for the specialty type. For example, “primary care physician copayment $25; urgent care copayment $50.”

To view a BPR screen shot showing the more detailed in- and out-of-network copay and coinsurance information, click here.

We’re changing effective date for value-based reimbursement for specialists in PGIP

The effective date for specialist eligibility for value-based reimbursement in the Physician Group Incentive Program, determined on an annual basis, is changing.

Beginning in 2016, PGIP value-based reimbursement (formerly termed “fee uplifts”) for specialists will start, continue or be discontinued on March 1 of each year, instead of Feb. 1. This reimbursement will continue through the end of February of the subsequent year.

Specialists who are receiving value-based reimbursement this year will continue to receive increased reimbursement through Feb. 29, 2016.

If you have any questions, contact your PGIP physician organization.

Re-evaluation of applied behavior analysis autism treatment only required in certain instances

After careful consideration, Blue Cross Blue Shield of Michigan and Blue Care Network have determined that a re-evaluation of applied behavior analysis autism treatment every three years will only be required when:

• A member has shown only minimal progress in autism treatment.
• There is a significant question about the continued accuracy of a member’s diagnosis or treatment plan.

Note: State of Michigan employees, URMBT members, Denso Corporation employees and other group accounts not managed by New Directions, our behavioral health care manager, aren’t affected by this change.

Background
As part of the state’s autism mandate, insurance companies may require a re-evaluation of ABA autism treatment for members at three-year intervals. Because the mandate went into effect three years ago, many of our members are now approaching the time that re-evaluation would be required.

Blue Cross and BCN have decided that a mandatory review isn’t needed for many of our members who are receiving ABA autism treatment. We expect that those needing re-evaluation and redirection of their ABA treatment will be identified through the continual monitoring and evaluation providers are doing in conjunction with New Directions’ behavioral health care managers.

We also rely on providers to identify a member’s additional needs during the utilization review process, which may include various evaluations (psychiatric, pediatric, neurological, speech therapy, occupational therapy, physical therapy, etc.) and services. These needs should be discussed by the providers and the behavioral health care managers as part of the ongoing utilization management process for a member in ABA treatment. We may also require annual developmental testing to measure treatment progress.

Collaboration is key
Blue Cross and BCN appreciate the collaborative relationship we have with our autism treatment providers and their treatment teams. We also know how crucial this collaboration is to our members’ achieving enhanced functioning within their family and social networks.

For more information
You can find more information on autism on web-DENIS.

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources.
• Under Resources, click on Autism.

Learn about upcoming webinars, enrollment information for licensed professional counselors

Licensed professional counselors participating in the Blue Cross Blue Shield of Michigan and Blue Care Network provider networks will receive direct reimbursement for covered mental health services within the scope of their licensure, beginning Jan. 1, 2016.

To learn more about this important change, we’re inviting LPCs to attend a Licensed Professional Counselors Update Webinar on one of these dates: Tuesday, Dec. 1; Thursday, Dec. 3; or Tuesday, Jan. 12.

The webinars will take place at 10 a.m. and 1 p.m. on each of the above dates. They’ll include information about:

• The change to direct reimbursement
• Billing requirements
• How to enroll with Blue Cross and BCN
• Signing up to use our electronic systems

To register, download the invitation, complete the information requested and respond via email or fax. Please respond by Nov. 25 for the December webinars and by Jan. 8 for the January webinars.

Enroll now with Blue Cross and BCN
Licensed professional counselors can find the practitioner agreements and enrollment forms for the Traditional, TRUST (PPO), Mental Health and Substance Abuse Managed Care and BCN networks on bcbsm.com. Click on Providers, then Join the Blues Network and Enrollment and Changes to find enrollment information.

Specific qualification requirements are identified within each agreement. Qualified licensed professional counselors may apply for a Blue Cross provider identification number by completing the enrollment applications available on the same Web section. Individual enrollment requests for BCN will only be accepted through Feb. 1, 2016.

Behavioral health vendor to provide authorization training for freestanding substance abuse facilities Dec. 3

As reported in the September edition of The Record, authorization for treatment at freestanding substance abuse residential facilities will be required for Blue Cross Blue Shield of Michigan commercial PPO members, beginning in 2016. New Directions LLC will perform the authorizations.

This requirement will only apply to the substance abuse residential level of care, not outpatient. The current authorization requirements for residential treatment at hospital-based substance abuse facilities remain the same.

Also note that accounts that have behavioral health currently managed by a vendor other than New Directions will not be affected by this change. This includes, but is not limited to, the State of Michigan group account, auto groups, URMBT members and Denso Corporation.

Submit authorizations with WebPass
Admission authorization requests from freestanding substance abuse facilities will be made using the New Directions WebPass application. The authorization requests will also be made in accordance with New Directions’ medical necessity criteria, which are available here. WebPass is a secure Internet portal that allows providers to document and submit clinical information online to New Directions for initial authorizations and continued stay reviews. A demonstration of WebPass is available here.

Following a one-time facility registration process at the WebPass website, facility providers will receive individual user names and passwords used to log in to WebPass. As of Nov. 16, 2015, facilities can register as a user on WebPass. After logging in to the website, providers can enter a Blue Cross member ID (or name and date of birth information) to perform a variety of tasks related to the member. These tasks include admission requests and reviews.

A WebPass training webinar for freestanding substance abuse facilities is scheduled for Dec. 3, 2015. Details about this webinar will be emailed to these facilities and will also be posted on web-DENIS.

About New Directions
New Directions is a managed behavioral health organization accredited by the National Committee for Quality Assurance. It has more than 20 years of experience in utilization and case management services, in addition to extensive experience working with Blue plans nationwide. With its offices located in Kansas City, Missouri, New Directions currently manages Blue Cross’ employee assistance program.

Blue Cross members and providers benefit from a number of program and service enhancements that were previously unavailable, including:

• An award-winning service center providing 24/7 toll-free access for members and providers
• Integrated care programs that use an evidence-based approach to services for members across the continuum of care
• Discharge planning and follow-up appointment scheduling (for members admitted to inpatient and residential levels of care) that is closely monitored to ensure supportive transitions to and within the community.
• Case managers that work one-on-one with members to improve care transitions, foster self-management and remove barriers to care
• Use of claims data to build predictive models that identify members at-risk for relapse or readmission, and that subsequently enable targeted outreach efforts to these members

Visit ndbh.com for more information about New Directions.

Blue Cross recognizes Blue Distinction Center+ designations for bariatric surgery

Thirteen Michigan facilities received distinction in the area of bariatric surgery this year. As you may recall from previous Record articles, a facility can earn the designation of either a Blue Distinction^® Center — for delivering quality care resulting in better overall outcomes for bariatric patients — or Blue Distinction^® Center+ for delivering the same quality care as a Blue Distinction Center while also meeting key requirements for cost-efficiency. See a list of designated facilities at the end of this article.

To receive a Blue Distinction Center for bariatric surgery designation, a health care facility must:

• Demonstrate success in meeting patient safety measures.
• Demonstrate success in meeting bariatric-specific quality measures, including complications and readmissions for gastric stapling or gastric banding procedures.
• Have earned national accreditations at both the facility level and the bariatric care-specific level.

To receive a Blue Distinction Center+ for bariatric surgery designation, a health care facility must:

• Demonstrate quality. Only those facilities that first meet Blue Distinction’s nationally established, objective quality measures will be considered for Blue Distinction Center+ designation
• Meet the criteria for a Blue Distinction Center for bariatric surgery.
• Demonstrate better cost-efficiency compared to its peers.

This year’s bariatric surgery designation includes facilities that are recognized for gastric banding, in addition to those recognized for gastric stapling.
Designated bariatric facilities
Here are the Michigan facilities that received distinction in the area of bariatric surgery as of Oct. 1, 2015:

Reminder: Blue Cross doesn’t cover digital breast tomosynthesis

We want to remind you that Blue Cross Blue Shield of Michigan doesn’t cover digital breast tomosynthesis.

This procedure uses modified digital mammography equipment to obtain additional radiographic data to reconstruct cross-sectional “slices” of breast tissue. Conventional mammography produces 2-D images of the breast.

Digital breast tomosynthesis is considered experimental for both the screening and diagnosis of breast cancer. Blue Cross contracts exclude coverage for experimental services or procedures.

Blue Cross providers can find out whether a procedure is experimental or investigational (not a covered benefit) by following these steps:

• Go to bcbcm.com.
• Log in as a provider.
• Click on web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Go to Benefit Explainer and enter the necessary information.

Utilization management program to include medical drugs administered to outpatients in hospital setting

Blue Cross Blue Shield of Michigan is expanding its Medical Drug Utilization Management Program to include medical drugs administered to hospital outpatients, starting Jan. 1, 2016. The program has required prior authorization for services rendered in a professional setting since 2013.

The select drugs require administration (injection or infusion) by a physician or other health care professional. The health care practitioner who is treating the patient for the disease state and orders the drug treatment is responsible for obtaining authorization and verifying patient benefits. A prior authorization is required whether the administration is in an office, hospital-based infusion center, clinic or outpatient hospital that submits billing on a UB-04, but it is not a guarantee of payment.

Ordering practitioners may begin submitting requests Dec. 14, 2015, for therapy that begins Jan. 1, 2016, or later for services rendered in an outpatient hospital setting. If prior authorization is not obtained before services are rendered, the service will be rejected. The ordering provider can request an authorization after the patient receives medications. However, the patient still needs to meet all of the requirements and have the necessary coverage in order for the claim to be payable.

We won’t consider a request for coverage until we receive a physician-signed medication authorization request form either faxed to Blue Cross or a request uploaded to the online-based tool NovoLogix^®. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

You can find the form linked within the current list of medications that require prior authorization, as well as a list of groups that have opted out, on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• From this page, click on Pharmacy prior authorization/Step Therapy forms link at the top of the page
• Click on Physician administered medications link

Our Blue Cross clinical team will continue to review requests based on our clinical criteria. Ordering physicians can get real-time status on prior authorizations and immediate approvals for certain medications when patients meet the criteria by using the secure online tool, NovoLogix.

We’ve included criteria for authorization and the medication request forms on the medical router for in- and out-of-state physicians. In-state physicians only can also view it on web-DENIS.

When additional medications are placed in the program, we’ll update the forms list and alert providers through messages on web-DENIS.

Reminder: Always check prescription order date before filling

Confusion about the order date of prescriptions is causing some unauthorized prescription fills to occur. By always checking the order date of a prescription before filling it, you’ll avoid having to reimburse us for expired prescriptions.

Determining the order date

• The original order date is the date the prescription is first written or phoned in by the prescribing physician to the pharmacist.
• For electronic prescriptions, the original order date is the written date, not the transmitted date.

What’s causing the confusion
Our auditors are finding that some pharmacists use the date they originally fill the prescription as the original order date. Since patients sometimes don’t bring their prescriptions to the pharmacy immediately, we sometimes pay for prescription fills that are unauthorized as they exceed the time limit following the original order date. We’ll seek a recovery when we identify these unauthorized refills during an audit. We also don’t accept documentation to appeal this audit finding.

How to get paid
Blue Cross Blue Shield of Michigan will pay for authorized refills of prescription drugs (non-controlled substances) dispensed within one year of the original order. For controlled substances, Schedule III and IV, we’ll pay for a maximum of five authorized refills within six months of the original prescription date. Schedule II controlled substances must be filled within 90 days of the original prescription date with no refills allowed.

Because the original order date determines the life of a prescription, please be sure that:

• Refills for non-controlled substances are billed to us within one year of the date the prescriber wrote the prescription.
• Refills for Schedule III and IV controlled substances are billed to us within six months of the date the prescriber wrote the prescription.
• Schedule II drugs are billed to us within 90 days of the date the prescriber wrote the prescription. This applies to the original fill only, as refills are not permitted.

Reminder: flu shots, other vaccines

Flu shots and other vaccines administered to non-Medicare members should be submitted as medical, not pharmacy claims. (For Medicare Advantage members, you should continue to follow the Medicare Advantage billing process for vaccines.) For complete details, see the September Record article.

Prior authorization required for Depo^®-Testosterone and its generic

Depo-Testosterone and its generic, testosterone cypionate, are both part of the Medical Drug Prior Authorization Program. This drug requires a medical prior authorization, as of July 1, 2015.

Keep in mind that a prior authorization approval isn’t a guarantee of payment. Health care practitioners will need to verify coverage for medical benefits. This will help ensure appropriate utilization and address potential safety issues for these medications. Note: The prior authorization requirement doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Blue Cross Blue Shield of Michigan won’t consider a request for coverage until we receive a physician-signed medication request form, faxed or mailed to Blue Cross, or a request uploaded to the online tool, NovoLogix^®. The standard processing time for reviewing a request is 15 days. An urgent request is reviewed within 72 hours.

The list below reflects the current National Drug Codes available for this medication:

Blue Cross reserves the right to change this list at any time.

You can find medication request forms for medications that require prior authorization by going to web-DENIS and following these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

There’s still time to register for provider forums in Marquette and Sault Ste. Marie

As you read in The Record previously, we scheduled a series of forums for professional providers across the state this fall. Two of them are still available for November — both in the Upper Peninsula.

Billing and office managers and their staff are strongly encouraged to attend. The classes cover such key topics as:

• ICD-10 (professional)
• Medicare Advantage
• Provider Inquiry
• BlueCard^®
• EviCore healthcare (formerly CareCore/Med Solutions Inc.)
• Transparency
• Provider enrollment

The remaining forums begin at 9:30 a.m., with classes starting at 10 a.m. Continental breakfast will be served.
Following is additional information. To register, click on the link next to the event you’d like to attend.

If you have questions, contact your provider consultant.

Re-evaluation of applied behavior analysis autism treatment only required in certain instances

After careful consideration, Blue Cross Blue Shield of Michigan and Blue Care Network have determined that a re-evaluation of applied behavior analysis autism treatment every three years will only be required when:

• A member has shown only minimal progress in autism treatment.
• There is a significant question about the continued accuracy of a member’s diagnosis or treatment plan.

Note: State of Michigan employees, URMBT members, Denso Corporation employees and other group accounts not managed by New Directions, our behavioral health care manager, aren’t affected by this change.

Background
As part of the state’s autism mandate, insurance companies may require a re-evaluation of ABA autism treatment for members at three-year intervals. Because the mandate went into effect three years ago, many of our members are now approaching the time that re-evaluation would be required.

Blue Cross and BCN have decided that a mandatory review isn’t needed for many of our members who are receiving ABA autism treatment. We expect that those needing re-evaluation and redirection of their ABA treatment will be identified through the continual monitoring and evaluation providers are doing in conjunction with New Directions’ behavioral health care managers.

We also rely on providers to identify a member’s additional needs during the utilization review process, which may include various evaluations (psychiatric, pediatric, neurological, speech therapy, occupational therapy, physical therapy, etc.) and services. These needs should be discussed by the providers and the behavioral health care managers as part of the ongoing utilization management process for a member in ABA treatment. We may also require annual developmental testing to measure treatment progress.

Collaboration is key
Blue Cross and BCN appreciate the collaborative relationship we have with our autism treatment providers and their treatment teams. We also know how crucial this collaboration is to our members’ achieving enhanced functioning within their family and social networks.

For more information
You can find more information on autism on web-DENIS.

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources.
• Under Resources, click on Autism.

Behavioral health vendor to provide authorization training for freestanding substance abuse facilities Dec. 3

As reported in the September edition of The Record, authorization for treatment at freestanding substance abuse residential facilities will be required for Blue Cross Blue Shield of Michigan commercial PPO members, beginning in 2016. New Directions LLC will perform the authorizations.

This requirement will only apply to the substance abuse residential level of care, not outpatient. The current authorization requirements for residential treatment at hospital-based substance abuse facilities remain the same.

Also note that accounts that have behavioral health currently managed by a vendor other than New Directions will not be affected by this change. This includes, but is not limited to, the State of Michigan group account, auto groups, URMBT members and Denso Corporation.

Submit authorizations with WebPass
Admission authorization requests from freestanding substance abuse facilities will be made using the New Directions WebPass application. The authorization requests will also be made in accordance with New Directions’ medical necessity criteria, which are available here. WebPass is a secure Internet portal that allows providers to document and submit clinical information online to New Directions for initial authorizations and continued stay reviews. A demonstration of WebPass is available here.

Following a one-time facility registration process at the WebPass website, facility providers will receive individual user names and passwords used to log in to WebPass. As of Nov. 16, 2015, facilities can register as a user on WebPass. After logging in to the website, providers can enter a Blue Cross member ID (or name and date of birth information) to perform a variety of tasks related to the member. These tasks include admission requests and reviews.

A WebPass training webinar for freestanding substance abuse facilities is scheduled for Dec. 3, 2015. Details about this webinar will be emailed to these facilities and will also be posted on web-DENIS.

About New Directions
New Directions is a managed behavioral health organization accredited by the National Committee for Quality Assurance. It has more than 20 years of experience in utilization and case management services, in addition to extensive experience working with Blue plans nationwide. With its offices located in Kansas City, Missouri, New Directions currently manages Blue Cross’ employee assistance program.

Blue Cross members and providers benefit from a number of program and service enhancements that were previously unavailable, including:

• An award-winning service center providing 24/7 toll-free access for members and providers
• Integrated care programs that use an evidence-based approach to services for members across the continuum of care
• Discharge planning and follow-up appointment scheduling (for members admitted to inpatient and residential levels of care) that is closely monitored to ensure supportive transitions to and within the community.
• Case managers that work one-on-one with members to improve care transitions, foster self-management and remove barriers to care
• Use of claims data to build predictive models that identify members at-risk for relapse or readmission, and that subsequently enable targeted outreach efforts to these members

Visit ndbh.com for more information about New Directions.

Blue Cross recognizes Blue Distinction Center+ designations for bariatric surgery

Thirteen Michigan facilities received distinction in the area of bariatric surgery this year. As you may recall from previous Record articles, a facility can earn the designation of either a Blue Distinction^® Center — for delivering quality care resulting in better overall outcomes for bariatric patients — or Blue Distinction^® Center+ for delivering the same quality care as a Blue Distinction Center while also meeting key requirements for cost-efficiency. See a list of designated facilities at the end of this article.

To receive a Blue Distinction Center for bariatric surgery designation, a health care facility must:

• Demonstrate success in meeting patient safety measures.
• Demonstrate success in meeting bariatric-specific quality measures, including complications and readmissions for gastric stapling or gastric banding procedures.
• Have earned national accreditations at both the facility level and the bariatric care-specific level.

To receive a Blue Distinction Center+ for bariatric surgery designation, a health care facility must:

• Demonstrate quality. Only those facilities that first meet Blue Distinction’s nationally established, objective quality measures will be considered for Blue Distinction Center+ designation
• Meet the criteria for a Blue Distinction Center for bariatric surgery.
• Demonstrate better cost-efficiency compared to its peers.

This year’s bariatric surgery designation includes facilities that are recognized for gastric banding, in addition to those recognized for gastric stapling.
Designated bariatric facilities
Here are the Michigan facilities that received distinction in the area of bariatric surgery as of Oct. 1, 2015:

Reminder: Blue Cross doesn’t cover digital breast tomosynthesis

We want to remind you that Blue Cross Blue Shield of Michigan doesn’t cover digital breast tomosynthesis.

This procedure uses modified digital mammography equipment to obtain additional radiographic data to reconstruct cross-sectional “slices” of breast tissue. Conventional mammography produces 2-D images of the breast.

Digital breast tomosynthesis is considered experimental for both the screening and diagnosis of breast cancer. Blue Cross contracts exclude coverage for experimental services or procedures.

Blue Cross providers can find out whether a procedure is experimental or investigational (not a covered benefit) by following these steps:

• Go to bcbcm.com.
• Log in as a provider.
• Click on web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Go to Benefit Explainer and enter the necessary information.

Reminder: Here’s what you need to know about catastrophic case audits

Here’s what hospitals need to know to prepare for a catastrophic case audit.

• Blue Cross Blue Shield of Michigan sends appointment letters at least 30 days in advance, informing hospitals about the cases to be audited and the list of items needed to conduct the audit.

• Catastrophic case outlier audits need to include the complete medical record, progress notes and medication administration sheets. They should be in the order of the most recent date. Also include emergency room records, outpatient procedures, the utilization review worksheets and a copy of the most current itemized bill.

• Only late charges submitted to Blue Cross at least 30 days before the audit will be considered part of the review. Blue Cross must complete the late charge claim adjustments and post the new claim information to our financial systems before the audit.

• If the audit is held on-site and you have electronic medical records, provide a computer and log-on information for each auditor. Make someone available to help the auditor access and navigate your electronic medical records.

• Each auditor will need an electrical outlet for a Blue Cross computer and a telephone in the designated audit room.

• If the audit is conducted at our offices and you give us Web access, we’ll need log-on information for each auditor and a contact person to help access the electronic records.

• The Blue Cross auditor usually makes a courtesy call to the hospital’s contact person before beginning the audit to answer questions that may occur during the audit preparation.

• Blue Cross will give you daily deletion sheets during the audit so you can provide additional supporting documentation. While on-site, our auditor will identify the itemized bills that need to be mailed to Blue Cross.

• Provide the name and title of the person who will receive the reporting letter and include his or her email address. The hospital staff is responsible for sharing audit findings with other individuals and hospital departments.

After you receive the reporting letter, the appeal process gives you an opportunity to provide clarification or include missing documentation. Hospitals are allowed 50 calendar days from receipt of the audit reporting letter to submit a written request for an internal review.

Utilization management program to include medical drugs administered to outpatients in hospital setting

Blue Cross Blue Shield of Michigan is expanding its Medical Drug Utilization Management Program to include medical drugs administered to hospital outpatients, starting Jan. 1, 2016. The program has required prior authorization for services rendered in a professional setting since 2013.

The select drugs require administration (injection or infusion) by a physician or other health care professional. The health care practitioner who is treating the patient for the disease state and orders the drug treatment is responsible for obtaining authorization and verifying patient benefits. A prior authorization is required whether the administration is in an office, hospital-based infusion center, clinic or outpatient hospital that submits billing on a UB-04, but it is not a guarantee of payment.

Ordering practitioners may begin submitting requests Dec. 14, 2015, for therapy that begins Jan. 1, 2016, or later for services rendered in an outpatient hospital setting. If prior authorization is not obtained before services are rendered, the service will be rejected. The ordering provider can request an authorization after the patient receives medications. However, the patient still needs to meet all of the requirements and have the necessary coverage in order for the claim to be payable.

We won’t consider a request for coverage until we receive a physician-signed medication authorization request form either faxed to Blue Cross or a request uploaded to the online-based tool NovoLogix^®. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

You can find the form linked within the current list of medications that require prior authorization, as well as a list of groups that have opted out, on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• From this page, click on Pharmacy prior authorization/Step Therapy forms link at the top of the page
• Click on Physician administered medications link

Our Blue Cross clinical team will continue to review requests based on our clinical criteria. Ordering physicians can get real-time status on prior authorizations and immediate approvals for certain medications when patients meet the criteria by using the secure online tool, NovoLogix.

We’ve included criteria for authorization and the medication request forms on the medical router for in- and out-of-state physicians. In-state physicians only can also view it on web-DENIS.

When additional medications are placed in the program, we’ll update the forms list and alert providers through messages on web-DENIS.

Reminder: Always check prescription order date before filling

Confusion about the order date of prescriptions is causing some unauthorized prescription fills to occur. By always checking the order date of a prescription before filling it, you’ll avoid having to reimburse us for expired prescriptions.

Determining the order date

• The original order date is the date the prescription is first written or phoned in by the prescribing physician to the pharmacist.
• For electronic prescriptions, the original order date is the written date, not the transmitted date.

What’s causing the confusion
Our auditors are finding that some pharmacists use the date they originally fill the prescription as the original order date. Since patients sometimes don’t bring their prescriptions to the pharmacy immediately, we sometimes pay for prescription fills that are unauthorized as they exceed the time limit following the original order date. We’ll seek a recovery when we identify these unauthorized refills during an audit. We also don’t accept documentation to appeal this audit finding.

How to get paid
Blue Cross Blue Shield of Michigan will pay for authorized refills of prescription drugs (non-controlled substances) dispensed within one year of the original order. For controlled substances, Schedule III and IV, we’ll pay for a maximum of five authorized refills within six months of the original prescription date. Schedule II controlled substances must be filled within 90 days of the original prescription date with no refills allowed.

Because the original order date determines the life of a prescription, please be sure that:

• Refills for non-controlled substances are billed to us within one year of the date the prescriber wrote the prescription.
• Refills for Schedule III and IV controlled substances are billed to us within six months of the date the prescriber wrote the prescription.
• Schedule II drugs are billed to us within 90 days of the date the prescriber wrote the prescription. This applies to the original fill only, as refills are not permitted.

Reminder: flu shots, other vaccines

Flu shots and other vaccines administered to non-Medicare members should be submitted as medical, not pharmacy claims. (For Medicare Advantage members, you should continue to follow the Medicare Advantage billing process for vaccines.) For complete details, see the September Record article.

Prior authorization required for Depo^®-Testosterone and its generic

Depo-Testosterone and its generic, testosterone cypionate, are both part of the Medical Drug Prior Authorization Program. This drug requires a medical prior authorization, as of July 1, 2015.

Keep in mind that a prior authorization approval isn’t a guarantee of payment. Health care practitioners will need to verify coverage for medical benefits. This will help ensure appropriate utilization and address potential safety issues for these medications. Note: The prior authorization requirement doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Blue Cross Blue Shield of Michigan won’t consider a request for coverage until we receive a physician-signed medication request form, faxed or mailed to Blue Cross, or a request uploaded to the online tool, NovoLogix^®. The standard processing time for reviewing a request is 15 days. An urgent request is reviewed within 72 hours.

The list below reflects the current National Drug Codes available for this medication:

Blue Cross reserves the right to change this list at any time.

You can find medication request forms for medications that require prior authorization by going to web-DENIS and following these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

Utilization management program to include medical drugs administered to outpatients in hospital setting

Blue Cross Blue Shield of Michigan is expanding its Medical Drug Utilization Management Program to include medical drugs administered to hospital outpatients, starting Jan. 1, 2016. The program has required prior authorization for services rendered in a professional setting since 2013.

The select drugs require administration (injection or infusion) by a physician or other health care professional. The health care practitioner who is treating the patient for the disease state and orders the drug treatment is responsible for obtaining authorization and verifying patient benefits. A prior authorization is required whether the administration is in an office, hospital-based infusion center, clinic or outpatient hospital that submits billing on a UB-04, but it is not a guarantee of payment.

Ordering practitioners may begin submitting requests Dec. 14, 2015, for therapy that begins Jan. 1, 2016, or later for services rendered in an outpatient hospital setting. If prior authorization is not obtained before services are rendered, the service will be rejected. The ordering provider can request an authorization after the patient receives medications. However, the patient still needs to meet all of the requirements and have the necessary coverage in order for the claim to be payable.

We won’t consider a request for coverage until we receive a physician-signed medication authorization request form either faxed to Blue Cross or a request uploaded to the online-based tool NovoLogix^®. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

You can find the form linked within the current list of medications that require prior authorization, as well as a list of groups that have opted out, on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• From this page, click on Pharmacy prior authorization/Step Therapy forms link at the top of the page
• Click on Physician administered medications link

Our Blue Cross clinical team will continue to review requests based on our clinical criteria. Ordering physicians can get real-time status on prior authorizations and immediate approvals for certain medications when patients meet the criteria by using the secure online tool, NovoLogix.

We’ve included criteria for authorization and the medication request forms on the medical router for in- and out-of-state physicians. In-state physicians only can also view it on web-DENIS.

When additional medications are placed in the program, we’ll update the forms list and alert providers through messages on web-DENIS.

Reminder: flu shots, other vaccines

Flu shots and other vaccines administered to non-Medicare members should be submitted as medical, not pharmacy claims. (For Medicare Advantage members, you should continue to follow the Medicare Advantage billing process for vaccines.) For complete details, see the September Record article.

Year-end submission dates nearing for Diagnosis Closure Incentive Program

Blue Cross Blue Shield of Michigan and Blue Care Network are nearing the conclusion of this year’s Diagnosis Closure Incentive Program for primary care physicians who close diagnosis and treatment opportunity gaps for their Blues Medicare Advantage patients. Here are the details you need to know.

Schedule patient visits by end of year
Be sure to see your Blue Cross and BCN Medicare Advantage patients before the end of the calendar year to document and close diagnosis and treatment opportunity gaps. Information about gap closures should be submitted via Health e-Blue^SM under Panel – Diagnosis Evaluation and Treatment Opportunities by Condition/Measure by Jan. 28, 2016. You may also submit a claim as part of your documentation.

Close all diagnosis gaps
All the diagnosis gaps included in the 2015 Diagnosis Closure Incentive for Jan. 1 through Sept. 30, 2015, are listed on Health e-Blue under Panel – Diagnosis Evaluation. To earn incentives, physicians must close all the diagnosis gaps (identified through Sept. 30, 2015) that exist for a patient through a face-to-face visit before the end of 2015. Physicians can also notify Blue Cross or BCN that the patient doesn’t have the suspected or previously reported diagnosis.

Diagnosis gaps will continue to appear on Health e-Blue from Oct. 1 through Dec. 31, 2015. While we’ll continue to display new gaps, physicians are responsible for closing diagnosis gaps identified before Oct. 1 to earn an incentive.

More information is available in the Resources section of Health e-Blue, select 2015 Diagnosis Closure Incentive Program. A frequently asked questions and fact sheet can also be found on web-DENIS within BCBSM Provider Publications and Resources by clicking on Patient Care Reporting.

Submit diagnosis closure patient data
Diagnosis and treatment opportunity closures must be submitted to Blue Cross and BCN by the following dates:

If you don’t have access to Health e-Blue, sign up today. If you have questions, contact your provider consultant.

Looking ahead
The Diagnosis Closure Incentive Program will continue in 2016. Physicians are encouraged to continue to check Health e-Blue for patient conditions, schedule face-to-face office visits and close historical or suspected patient diagnosis and treatment opportunity gaps in the coming year.

New Medicare Advantage policy to block prescriptions that compromise integrity of Medicare Part D

At Blue Cross Blue Shield of Michigan, we’re committed to protecting the integrity of our Medicare Part D program while ensuring the health and safety of our members. That’s why we’re implementing a new Medicare Advantage policy that will block the plan’s share of the cost of a member’s prescription when written by a provider who the plan determines is engaged in fraud, waste or abuse.

This policy doesn’t limit a provider’s ability to prescribe drugs; it simply requires that patients shoulder the entire cost of a drug if the prescription is written by a provider whose prescription has been blocked.

Currently, this policy applies to our commercial membership and is being expanded to include Medicare Advantage as well. In accordance with the policy, prescriptions written for Medicare Advantage members by providers who prescribe drugs that are neither medically necessary nor appropriate for the documented medical condition will no longer be payable. This directive becomes effective Feb. 1, 2016.

The policy specifies that if, at the time of dispensing, a provider is being investigated for fraud, waste or abuse — or was sanctioned by the Office of the Inspector General, the Government Services Agency, the Centers for Medicare & Medicaid Services or state licensing boards — the plan’s share of the prescription cost will no longer be payable.

If a provider is found to be subject to the policy’s prohibitions, Blue Cross will notify him or her. Additionally, in accordance with CMS regulations, physicians subject to the block will be given an appeal right before implementation. Blue Cross will also provide notice to affected members who receive prescriptions from sanctioned providers.

Following member and provider notification, Blue Cross will implement claims processing edits to reject all prescription claims submitted to a pharmacy for prescriptions written or ordered by a sanctioned provider. These claims will no longer be considered covered member services. The block will be effective for a period of five years.

If it’s determined that: the drugs aren’t medically necessary, may cause significant patient harm or aren’t appropriate for the documented medical condition(s), additional action may be taken, including:

• Case management
• Intervention by Pharmacy Services to institute quantity limits or other restrictions
• Preliminary investigation by Blue Cross Corporate and Financial Investigations and possible referrals to law enforcement for an independent investigation to determine whether there is fraud, waste or abuse
• Prosecution of the prescriber or member will be pursued through law enforcement when appropriate

Before taking action under this new policy, Blue Cross will:

• Conduct an investigation and prepare a detailed findings report based on a review of the prescriber’s activity.
• Obtain an opinion from a Blue Cross medical consultant or contracted pain management consultant to confirm that the provider’s prescribing patterns aren’t medically necessary.
• Present findings and obtain approval for a Blue Cross provider sanction from Blue Cross executive leaders.
• Present the findings and approvals to the Audit Investigative Committee to gain approval to place a provider on Provider Prescription Block.
• The suspension of payments will be for a period of five years, as approved by the Audit Investigative Committee.
• The suspension will be effective 60 days after member notification.
• Members will be afforded a 60-day notice that prescriptions written by the prescriber will no longer be honored and that they may seek medical care from other providers for prescriptions deemed medically necessary for their health conditions.
• A notice will be sent to the provider.
• The physician may appeal a suspension in writing to Blue Cross within 30 days of receipt of the notice.
• The written appeal will be reviewed by a panel of physicians. A decision regarding the provider appeal would then be rendered within 30 days of receipt of the appeal. The decision of the review panel will be final.
• The appeal panel has the right to extend the effective date of the block, if additional information is required.
• If a provider’s appeal is unsuccessful, the provider may apply for reinstatement following the term of the prescription block.
• Blue Cross Pharmacy Services – Medicare will administer the Prescriber Prescription Block in conjunction with its pharmacy benefit manager.
• Pharmacies will be notified via a fax-blast communication and will receive an electronic message indicating “Prescriber not covered” at the point of sale. The member may choose to pay for the prescription out-of-pocket, but the member won’t be reimbursed by Blue Cross.

Taking prompt action in situations where providers are prescribing large quantities of controlled substances helps ensure that group and member benefits are used in a way that complies with the terms of their coverage.

Reporting fraud

• To learn about reporting health care fraud, visit the “Report Fraud” section of the Blue Cross website.
• To report Medicare-related fraud, call our confidential, dedicated Medicare Anti-Fraud Hotline at 1-888-650-8136.
• To report Medicaid-related fraud, call 1-855-MI-FRAUD (643-7283) or visit michigan.gov/mdhhs.