A look at the Value-Based Reimbursement Fee Schedule, effective March 1, 2016

Value-based reimbursement is one of the ways Blue Cross Blue Shield of Michigan is working with providers to create value for users of the health care industry. The following details the Value-Based Reimbursement Fee Schedule that is effective March 1, 2016.

Primary care physicians

Primary care physicians in the Physician Group Incentive Program will receive value-based reimbursement at 105 percent to 130 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for certain evaluation and management and preventive procedure codes depending on the program(s) in which they participate.

Reimbursement for PGIP primary care physicians who are not designated as Patient-Centered Medical Home providers but who perform well on measures of clinical quality will be 105 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the following procedure codes:

• 99201-99215
• 99381-99397

Reimbursement for primary care physicians who are and remain designated as PCMH providers will be 110 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the procedure codes listed above.

Primary care physicians with PCMH designation can receive additional value-based reimbursement:

• Primary care physicians who are part of a physician organization that meets Blue Cross’ cost-benchmarking criteria receive an additional 10 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the procedure codes listed above.
• Primary care physicians who perform well on measures of clinical quality receive an additional 5 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the procedure codes listed above.
• Primary care physicians who participate in the Michigan Primary Care Transformation Project receive an additional 5 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the procedure codes listed above, plus the following additional procedure codes:
• G9001-G9002
• 98961-98962
• 98966-98968
• G9007
• 99487
• 99489
• S0257

The total amount of value-based reimbursement depends upon the programs in which the primary care physicians participate. For instance, primary care physicians who are PCMH designated, are a member of a physician organization that meets Blue Cross’ cost benchmark criteria, participate in MiPCT and perform well on measures of clinical quality will receive reimbursement at 130 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule.

The table below summarizes the potential value-based reimbursement available under the VBR Fee Schedule to primary care physicians for the procedure codes indicated above:

Specialists

Specialists in PGIP will, depending on their ranking, receive value-based reimbursement at 105 percent or 110 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for all relative value unit-based procedure codes (relative value unit codes are most procedure codes billed by specialists, except those for ambulance service, durable medical equipment, prosthetics and orthotics, anesthesia, immunizations, hearing, routine vision services, lab, dental and most injections).

Reimbursement for specialists treating adult members and ranked in the top third will be 110 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value unit-based procedure codes. Those ranked in the second third will receive 105 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value unit-based procedure codes.

Reimbursement for specialists treating primarily pediatric members and ranked in the top half of pediatric practices will be 110 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value unit-based procedure codes. Those ranked in the second half will receive 105 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value-unit based procedure codes.

For oncologists only: Reimbursement for oncologists who participate in the Provider Delivered Care Management-Oncology Program and are not receiving any other value-based reimbursement will be 105 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value unit-based procedure codes and the following care management procedure codes:

• G9001-G9002
• 98961-98962
• 98966-98968
• G9007
• 99487
• 99489
• S0257

Oncologists who are receiving other value-based reimbursement and participate in PDCM-O will receive an additional 5 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the relative value unit-based procedure codes and the care management procedure codes listed above.