Categorization for outpatient physical therapy services changing in 2020

As previously announced in an article in the August 2019 Record, Blue Cross Blue Shield of Michigan and Blue Care Network are changing the use management categorization process for physical therapy. Beginning Jan. 1, 2020, profile reports for categorization will include physical therapy claims from Blue Cross commercial PPO, Medicare Plus Blue^SM PPO, BCN commercial and BCN Advantage^SM HMO.

Having one assigned category covering all four networks should make it easier for you to manage therapy requests.

About the program
The program:

• Applies to in-state, outpatient services
• Includes independent, outpatient, hospital outpatient and occupational therapy services
• Includes the current preauthorization program for three of the four networks
• Will be based on a single categorization score across the plans

About the new category assignments

• Category assignments will be determined by 12 months of combined independent, outpatient and hospital outpatient paid claims data.
• Categories will be based on risk-adjusted visits by age, gender and diagnosis.
• Visits will be appropriately weighted through eviCore healthcare’s process to develop a combined peer average, and will be tiered into three categories:

A — Up to 80% of the peer average
B — Greater than 80 to120% of the peer average
C — Greater than 120% of the peer average

• IPT services will be categorized individually by their type 1 NPI, based on all rendered services, not as a group.
• Physical therapists must have at least 10 episodes of service to be categorized.
• Providers with less than 10 episodes will default to category B.
• New providers with 10 or more episodes will no longer default to category B but will be categorized into their appropriate tier based on their average risk-adjusted visits or episodes.
• When multiple therapists in a practice treat the same patient and bill therapy services for a distinct member episode using a common tax ID, eviCore uses visit attribution (a method to avoid under-reporting utilization) and will attribute all PT utilization to the provider who billed the most visits for that episode of care. 
• Provider Performance Summary TREND reports will be available on eviCore’s website in November 2019.

Next steps
In late January 2020, eviCore will mail letters identifying your provider category based on your combined claims data. Physical therapists will continue to have the option to request a reconsideration of category status within 15 days from the date of the category notification letter if they have additional information that may change their category.

Preauthorization process
Preauthorization will continue for BCN, BCN Advantage and Medicare Plus Blue PPO based on your combined category. There’s no change to the preauthorization program for M.D.s, D.O.s, speech and language therapists and occupational therapists. And you’ll continue to receive a Provider Performance Summary if you received one previously.

Corrective Action Plan
CAP will continue for Blue Cross’ commercial PPO.

• If a provider in category C has more than 50% of the total number of patients categorized as commercial PPO patients:
• Warning letters will be sent by Blue Cross to providers who remain in category C for three consecutive categorization periods
• Disaffiliation letters will be sent by Blue Cross to providers in category C for four consecutive categorization periods
• A first- and second-level appeal process will be available to providers receiving a disaffiliation letter.
• All providers previously on a CAP will continue to be monitored by Blue Cross but will have additional time to comply before any disaffiliation will be implemented because this is a new program.
• Blue Cross will continue to work with all providers to comply with standards.

If you have questions regarding the change, contact Physical Therapy Inquiry at 313-448-6371.