Review of behavioral health providers’ utilization history will begin February 2020

As we mentioned in the December edition of The Record, our PPO network management team will begin reviewing the practitioner retrospective practice profiles of behavioral health professionals, beginning February 2020. The information below provides more detailed information about the review process for practitioner retrospective practice profiles.

Blue Cross Blue Shield of Michigan practice profile
The network management team evaluates each practitioner’s business practice profile against established demographic and utilization criteria. We compare the practitioner’s utilization history to that of his or her Michigan peers. This information may be used to determine which applicants should be accepted for initial and continued affiliation in the network.

Every practitioner in the PPO 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 a practitioner’s peers.

Individual practice profile data is reviewed twice a year. The Blue Cross network management team monitors PPO practice profiles to evaluate practice patterns and ensure PPO standards are met. We’ll evaluate PPO practice patterns for behavioral health based on the average payment per patient compared to the peers providing similar services.

How we review practice profiles
When comparing an individual practice profile to those of its peers, we consider 12 months of rendered paid claims data — meaning only those services it ordered, performed, billed and received reimbursement for from Blue Cross.

For a new PPO applicant, we review its Traditional and PPO claims utilization. We monitor PPO utilization for PPO network practitioners every six months when new practice data becomes available.

The PPO network management team selects profiles for evaluation, such as new applications, practitioners being recredentialed and practitioners whose paid claims place them in the top 10% when compared to their peers. We review and further analyze these profiles, using the following factors:

• Have at least $20,000 in paid services to analyze for statistical variation from peers
• Have an average annual payment per patient that exceeds their peer groups’ average by 25% or more
• If variant dollars exceed 25% of the peer group average by at least two standard deviations 

The profiles consider the size of a practice, use of nonphysician practitioners and patient volume. Adjustments to the annual summary level are used to analyze comparisons at the summary, type-of-service and procedure code levels.

Practitioners who receive a formal communication from PPO network management regarding overutilization should contact network management at 313-448-7371 or write to the address below to describe any unique aspects of their practice that may explain the variances found on the profile.

For more information regarding the review process, write to:

Profiling analyst
PPO Programs — Mail Code 508E
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd.
Detroit, MI 48226

Accelerated review process
The six-month accelerated review process is implemented when one or more of the following circumstances occur:

• Overall payment per patient exceeds the peer norm by at least two times or $300
• Variant dollars exceed 60% or more of the total payment
• Practitioner has a prior history of high utilization:
  • That resulted in disaffiliation from the PPO TRUST network
  • Was placed in the corrective action process within the last five years

If the practitioner is placed in the accelerated review process, he or she will receive a letter requesting an explanation for the variance. Practitioners who fail to give an acceptable reason for the variance or don’t achieve the level of improvement described in the letter may be disaffiliated from the TRUST network and are entitled to a two-step appeal process.

All practitioners are expected to monitor their utilization and request their PPO business practice profiles, which are updated biannually in the spring and fall, and available upon request throughout the year. To obtain copies of their Blue Cross PPO practice profile, practitioners should mail or email their request, including their name, signature, address and Blue Cross provider ID number, to:

PPO Network Management
Mail Code 508 E
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd.
Detroit, MI 48226 
Email: IMPRPProfileRequest@bcbsm.com