We’ve amended our departicipation criteria

Effective Aug. 1, 2022, Blue Cross Blue Shield of Michigan is updating the Departicipation in the Traditional Practitioner Participation Agreement to read as follows:

Departicipation Criteria

Criteria under which a PRACTITIONER will be subject to departicipation include, but are not limited to, the following:

1. Any felony conviction or misdemeanors, guilty plea, plea of nolo contendere or placement in a diversion program for any crime related to the payment or provision of health care involving Blue Cross Blue Shield of Michigan, Medicare, Medicaid and/or any other health care insurer.
2. Termination, suspension, censure, reprimand, restriction, revocation or reduction to probationary status of licensure, certification, registration, certificate of need or accreditation or hospital related privileges.
3. PRACTITIONERs who, after at least six (6) months on Prepayment Utilization Review (PPUR), continue to be non-compliant.
4. PRACTITIONERs who, after notification, continue to bill members for amounts more than deductibles and copayments.
5. PRACTITIONERs who, upon audit, failed to document the medical necessity of 50% or more of the audited services billed to Blue Cross Blue Shield of Michigan.
6. PRACTITIONERs identified as prescribing/dispensing prescription medication for other than therapeutic reasons.
7. PRACTITIONERs demonstrating a pattern of directly/indirectly billing for services not rendered or not medically necessary.
8. PRACTITIONERs who, upon request, refuse to provide Blue Cross Blue Shield of Michigan access to records, which BCBSM requires for purposes including but not limited to claims processing, regulatory compliance, and/or for other health care operations purposes.
9. PRACTITIONERs found to be inducing patients to receive services through the use of prescriptions, money, or other items of value or financial incentive. 
10. PRACTITIONERs demonstrating a pattern of altering/entering false information on patient records and/or claims.
11. PRACTITIONERs who advertise free services, but then bill Blue Cross Blue Shield of Michigan for additional services, which are not medically necessary.
12. PRACTITIONERs who are in violation of local, state, or federal regulations, laws, codes, etc.
13. PRACTITIONERs who, after being notified, continue to demonstrate a pattern of violating or not adhering to Blue Cross Blue Shield of Michigan’s policies and procedures.
14. PRACTITIONERs who Blue Cross Blue Shield of Michigan has determined endangers a member's health and safety.
15. PRACTITIONERs who Blue Cross Blue Shield of Michigan has found to be prescribing medications for members with whom no patient-physician relationship exists.
16. PRACTITIONERs who directly/indirectly threaten the health or safety of a Blue Cross Blue Shield of Michigan  member, employee, contractor, agent or officer.