Corrective action plans can affect PGIP physicians’ value-based reimbursement eligibility

Primary care physicians and specialists participating in the Physician Group Incentive Program are eligible to receive value-based reimbursement as set forth in the Value-Based Reimbursement Fee Schedule. Value-based reimbursement is available to practitioners who meet the criteria for quality programs developed under PGIP.

However, practitioners may become ineligible for value-based reimbursement if Blue Cross Blue Shield of Michigan places them on a corrective action plan because they don’t meet utilization standards. They’ll remain ineligible until the designation cycle following the completion of the requirements of their corrective action plan.

The review process

Blue Cross’ PPO credentialing and network management teams review PPO/TRUST practitioner credentialing and profile information to help determine which applicants should be accepted for initial and continued affiliation in the network.

The network management team:

• Evaluates each practitioner’s business practice profile against established demographic and utilization criteria
• Compares the practitioner’s utilization to that of his or her peers who also practice in Michigan and have a similar specialty

Every practitioner in the PPO/TRUST network contractually agrees to provide PPO members with efficient, cost-effective care that meets prevailing utilization standards. Blue Cross monitors utilization patterns with the understanding that the unique aspects of a practitioner’s individual practice may affect his or her ability to perform within the averages established by the practitioner’s peers.

Individual practice profile data is reviewed twice a year (March and September). Blue Cross monitors PPO practice profiles to evaluate practice patterns and ensure PPO standards are met. The network management team typically evaluates TRUST practices based on the cost of care.

Working with Network Management

Practitioners who receive a formal communication from PPO Network Management regarding utilization have an opportunity to provide valid reasons for the variance in their practice profile. A practitioner may be placed on a corrective action plan, or CAP, after PPO Network Management has reviewed the practitioner’s rationale for the variance. Failure to respond to communications will result in being placed on a CAP.

Any practitioner placed on a CAP will lose any applicable value-based reimbursement 60 days after being placed on the CAP.

After successful completion of a CAP, practitioners will be eligible for value-based reimbursement evaluation during the next designation cycle.

Moving forward, in additional to letters being sent to the individual practitioner, a copy will be sent to the practitioner’s physician organization (if the practitioner is a PGIP participant).

For more information

For more information about the PPO Network Management corrective action process, see the November 2012 Record article titled TRUST PPO network information in review.

For more details on the value-based reimbursement criteria, see the February 2018 Record article titled Corrective action affects your value-based reimbursement eligibility.