We’re making changes to our practice profiles and providing TRUST PPO network information updates

As a reminder, it’s important to follow the TRUST Network Practitioner and Outpatient Physical Therapy Facility Network Affiliation Agreements, policies and procedures. Remember to:

• Refer our members only to TRUST practitioners, hospitals, imaging centers, end stage renal disease facilities and physical therapy providers. Referrals for laboratory services must be made to a Blue Cross-participating PPO lab and referrals for durable medical equipment must be made to a Blue Cross-participating DME supplier for supplies delivered in Michigan.
• Cooperate with TRUST’s utilization management and quality assurance programs.
• Participate in TRUST programs administered by vendors.
• Abide by reimbursement requirements.
• Provide services to Blue PPO members who reside outside of Michigan in accordance with the rules of the national BlueCard^® PPO network.
• Bill only for services you personally perform or which you directly supervise.

About our process

Blue Cross’ TRUST PPO Credentialing and Network Administration teams review practitioner credentialing and profile information to determine which applicants should be accepted for initial and continued affiliation in the network. The Network Administration team evaluates each practitioner’s business practice profile against established demographic and utilization criteria, comparing the practitioner’s utilization history to that of his or her Michigan peers practicing within the same specialty.

Every practitioner in the 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 parameters, or averages, established by a practitioner’s peers.

Individual practice profile data is reviewed twice a year. Blue Cross monitors PPO practice profiles to evaluate practice patterns and ensure PPO standards are met. Our evaluations are based, in large part, on the cost of care.

How we review practice profiles

When comparing your individual practice profile with those of your peers, we consider 12 months of allowed claims data for services you ordered, performed and billed, and for which you received payment from Blue Cross. Note: Payment consideration is based on “allowed amount.” (“Paid” data was previously used for these reports.)

If you’re a new TRUST applicant, we review both your Traditional and PPO claims utilization. We monitor TRUST utilization for TRUST network practitioners every six months when new practice data becomes available.

The Network Administration team selects profiles for evaluation, including new applications, practitioners being recredentialed and practitioners whose average payment per patient places them in the top 10% when compared against their peers. We review and further analyze these profiles, taking into consideration the following factors:

• Practice profiles must reflect at least $20,000 in allowed services to be subject to analysis for statistical variation from peers.
• If average annual payment per patient exceeds the specialty peer group mean by 25% or more, we consider utilization standards as not met.
• We also perform an analysis of variant dollars. Variant dollars reflect payment at the individual Current Procedural Terminology, or CPT, level that exceeds the peer group average by at least two standard deviations. If the sum of variant dollars exceeds 25% of the individual practitioner’s payment, we consider utilization standards as not met.
• The profiles take into account the size of a practice. Because not all practitioners treat the same number of patients, we apply a volume adjustment to the patient count in the annual summary and, when making comparisons at the summary, type-of-service and procedure code levels.

Practitioners who receive a formal communication from Network Administration regarding overutilization should immediately contact the PPO medical director via the Network Administration mailbox at ProviderCorrespondence@bcbsm.com to describe any unique aspects of their practices that may explain the variances shown on the profiles.

For additional information regarding the review process, you may do one of the following:

• Call 313-448-7371
• Email the Network Administration mailbox at ProviderCorrespondence@bcbsm.com

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

• The overall cost of care — as reflected in the payment per patient — exceeds the peer norm by at least two times.
• The practitioner’s variant dollar amount exceeds 60% or more of the total PPO funds allowed to the practitioner.
• The practitioner doesn’t meet utilization standards and has a prior history of high utilization that resulted in disaffiliation from the TRUST network or 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 an initial corrective action letter that includes a request for 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.

Reading your practice profile

Here are highlights of some changes you’ll see when reading your practice profile:

• In the Annual Summary, we’ve added a new column — “Payment to Peer Comparison %” — to help you determine how your payment per patient compares to the average of your peers.
• In the Type of Service Summary, we’ve added two new columns — “Payment per Patient Peer Average” and “Volume Adjustment” — to compare the number of services and payments received to those of your peers. The volume adjustment is determined by taking the number of patients receiving service from a particular practitioner and dividing that number by the average number of patients for the practitioner’s peer.
• In the Procedure Code Summary, we’ll flag procedures that are designated outliers in the “Flag” column.

More details will be provided in the practice profiles.

All practitioners are expected to monitor their utilization and request their practice profiles, which are updated biannually in the spring and fall, and available upon request throughout the year. To obtain copies of your BCBSM practice profiles, you may email your signed request to the following new email address: ProviderCorrespondence@bcbsm.com.  

Note: The previous email address for requesting PRP profiles (IMPRPProfileRequest@bcbsm.com) is no longer valid.   

To report any demographic changes in your individual practice, such as a new specialty or address, you must access the Council for Affordable Quality Healthcare^® Universal Provider DataSource^® website, CAQH ProView - Sign In,** to make your changes.  Keeping your practice information current allows us to more accurately assess your utilization data. 

If you have any questions about your CAQH application, call CAQH at 1-888-599-1771.

Notifying applicants

New applicants: Following a thorough review of your application, credentialing information and practice profile, you’ll receive a letter indicating whether you’re accepted as a TRUST network practitioner. If you’re not selected, you may send a request for reconsideration to the TRUST medical director through the Network Administration mailbox, along with any additional information that would help us to better understand the nature of your practice. The Network Administration email address is provided in the letter.

Recredentialing practitioners: If you’re a TRUST practitioner undergoing recredentialing and your profile data is such that it exceeds the criteria for evaluation described in this article, you’ll receive a copy of your practice profile along with a letter identifying the type of services and procedure codes that exceed peer norms. We’ll restate the TRUST utilization standards in the letter and explain that continued affiliation in the TRUST network is contingent upon modifying your practice patterns to become more consistent with the utilization standards established by your TRUST peers.

Failure to improve utilization within the time frames set forth in your initial corrective action letter may result in your disaffiliation from the TRUST network.

As new data becomes available, there will be ongoing monitoring of your practice profile. Our Network Administration staff will contact you as needed by certified mail or email.

Network termination due to utilization concerns

A TRUST practitioner who is placed in the corrective action process and fails to bring his or her PPO profile data within established utilization standards, as described in this article, may have his or her TRUST network affiliation agreement terminated, as provided in section 6.3 b of the TRUST Practitioner Affiliation Agreement. More information about the agreement and the PPO Provider Manual are available on bcbsm.com and web-DENIS.

When a practitioner or provider is terminated, either voluntarily or involuntarily, Blue Cross will notify members affected by the termination at least 30 calendar days prior to the effective termination date.

Appeal process for termination due to utilization concerns

First-level appeal:

• Meeting with the practitioner, corporate medical director or designee and Network Administration department manager or designee
• Discuss PPO utilization standards, profile and practice patterns
• Decision communicated by certified letter or email within 14 days of the date of the appeal meeting
• If the decision to terminate is upheld, the practitioner may request a second-level appeal within 14 days of the appeal decision certified letter/email date

Second-level appeal:

• Meeting with the practitioner and a three-person, second-level appeals committee
• Attorney may attend
• Decision communicated by letter or email within 14 days of the date of the appeal meeting
• Second-level appeal decision is final

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.