Prepayment Utilization Review can affect physicians’ value‑based reimbursement

Primary care providers and specialists participating in Value Partnerships programs are eligible to receive value‑based reimbursement in accordance with the Value‑Based Reimbursement Fee Schedule. Value‑based reimbursement is available to practitioners who meet the criteria for quality improvement programs developed as part of Value Partnerships and the Physician Group Incentive Program.

Keep in mind that practitioners become ineligible for value‑based reimbursement if Blue Cross Blue Shield of Michigan places them on Prepayment Utilization Review, or PPUR. Providers on PPUR are reviewed on a six‑month basis. Practitioners will remain ineligible for value-based reimbursement until the value‑based program designation cycle following the discontinuation of the PPUR.

PPUR is a process we use to determine appropriate liability for covered health care services before paying claims. Providers on PPUR have a medical record review before claims are paid. Additional information about the PPUR process and reasons for review can be found in the provider manual. A link to the provider manual is on the homepage of web‑DENIS.

Practitioners receive a written notification when placed on PPUR. In addition to the letters sent to the practitioner, a copy will be sent to the practitioner’s physician organization if the practitioner participates in PGIP.

If you have questions about PPUR, call provider clinical consultant Tom Rybarcyzk at 248‑446‑3836.