BlueCross BlueShield of Tennessee, Inc. an Independent Licensee of the BlueCross BlueShield Association

Transcription

1 BlueCross BlueShield of Tennessee, Inc. an Independent Licensee of the BlueCross BlueShield Association

2 BlueCare Tennessee

3 Promoting Quality Care

4 Our Goal Make the Lives of Our Members Better Coordinate the total physical, mental and long-term care support and services needs to Make the Lives of Our Members Better 4

5 Provider Support Key to Success Working together to deliver quality care You are the most influential element of your patients health care experience 5

6 Promoting Quality Care Program Standards Quality Program Standards Accreditation agencies Federal guidelines Mandates by State of Tennessee and Bureau of TennCare 6

7 Promoting Quality Care Clinical Data Exchange Clinical Data Exchange Securely share clinical data with BlueCross Supports collaboration Helps reduce burden of office staff Learn more about Clinical Data Exchange during our breakout session on Quality 7

8 Promoting Quality Care Prenatal/Postpartum Care $10 Bonus Each Claim Category II Codes 500F or 503F submitted with specific patient information Applies to BlueCare, TennCareSelect and CoverKids 8

9 Promoting Quality Care Quality Programs General health and wellness Women s health Child and adolescent health Senior health Coordinated behavioral and primary health services for TennCare members through Tennessee Health Link 9

10 TennCare Kids (EPSDT) Early Periodic Screening, Diagnosis and Treatment Program EPSDT Comprehensive health and developmental history Comprehensive unclothed physical exam Appropriate immunizations Laboratory tests Health education In 2015, EPSDT screening rates dropped to an average of 71% across all age groups. We can do better! 71% 10

11 TennCare Kids (EPSDT) We Need Your Help!!! Schedule Appointments and Provide Reminders for your Members Partner with us to conduct Outreach Events Document all components of the exam in the patient s medical record Bill appropriately to maximize your reimbursement 11

12 TennCare Kids (EPSDT) Missed Opportunities There are missed opportunities to capitalize on: Children with special needs require TennCare Kids services too When a patient presents with symptoms such as an ear infection and is due for a well-child exam, then both codes may be billed using the modifier 25 added to the office visit code. Sports physicals do not take the place of a annual TennCare Kids exam, so please provide both Members who have other insurance 12

13 TennCare Kids (EPSDT) Training and Coding Resources The Tennessee Chapter of the American Academy of Pediatrics offers an extensive EPSDT and Coding Program. Please visit the website at for additional information. 13

14 New CoverKids Provider Network

15 CoverKids Provider Network Same Patients, Same Providers New Network A new network is big news and usually means big changes Almost everything will stay the same for providers What stays the same: Reimbursement fees Member benefits Patients 15

16 CoverKids Provider Network Same Patients, Same Providers New Network Before Two populations: TennCareSelect Members CoverKids Members One provider network: TennCareSelect TennCareSelect Member CoverKids Member + Dr. Kimble TennCareSelect Provider 16

17 CoverKids Provider Network Same Patients, Same Providers New Network Now Two populations TennCareSelect Members CoverKids Members TennCareSelect Member + Dr. Kimble TennCareSelect Provider Two provider networks with same providers: TennCareSelect CoverKids CoverKids Member + Dr. Kimble CoverKids Provider 17

18 CoverKids Provider Network Same Patients, Same Providers New Network Only Major Change: Member ID Cards 18

19 ECF CHOICES Program

20 Employment & Community First (ECF) CHOICES Providing Help & Hope Tennessee is first in the nation to launch this type of program for people with intellectual and developmental disabilities Population People with intellectual and other developmental disabilities not currently receiving services Program Services Support for individuals and families Help to achieve employment, independent living and community goals Change lives and bring hope to individuals and their families in a way they have never known before 20

21 Claims Reminders

22 Claims Reminders Administrative Notes NICU Care Claims Accepted Only from NICU-Level Facilities Babies with life-threatening conditions born at standard birthing facilities Stabilize baby, then transfer to a NICU facility Code claim for stabilizing the baby for transfer, not for NICU care 22

23 Claims Reminders Administrative Notes Changes at Your Practice? Let us know ASAP if you have changes to: Address Phone Number Office Hours Other Key Information 23

24 Claims Reminders Administrative Notes Billing TennCare Enrollees Only collect applicable TennCare Copay Even if they have a third-party payer Even if third-party pays in full for service Note: Your office must bill the third-party payer before billing TennCare 24

25 Claims Reminders Administrative Notes Non-Covered Services Providers MUST inform TennCare enrollees that they are responsible for any charges not covered by TennCare BEFORE performing the service 25

26 Claims Reminders Administrative Notes Federal Requirements for Billing Hospital Inpatient Claims Document that care was reasonable and necessary Signed physician s certification, including the practitioner order 26

27 Provider Satisfaction Survey

28 Provider Satisfaction Survey Tell Us How We re Doing Tell us how we re doing: Quick Easy Only one page Pick-up your survey in the lobby Surveys completed TODAY are entered for a gift card drawing! 28

29 Questions?

30 Medicare Advantage

31 Risk Adjustment What is Risk Adjustment? Mechanism used by CMS to set premium levels paid to Medicare Advantage plans Each member is assigned a risk score based upon their demographics and diagnosis codes Diagnosis codes for significant conditions map to Hierarchical Condition Categories (HCCs) Approximately 80 HCCs are derived from 3,000 ICD9 and ICD10 codes Purpose is to appropriately compensate Medicare Advantage plans for the risk assumed by insuring each member 31

32 Risk Adjustment What is Risk Adjustment? Diagnosis codes are submitted to CMS from two primary sources: Claims processed by the health plan Medical record review CMS requires that diagnoses be documented every calendar year, even those for chronic conditions Appropriate documentation results in premium levels that: Cover medical expenses Maintain benefit levels Prevent member funded premiums 32

33 Risk Adjustment What is the Physician s Role? Document to the highest level of specificity given the patient s health Diagnose chronic conditions every year Include all relevant ICD9/10 codes on each claim Follow AAPC guidelines when creating medical records Remember: More diagnoses on claims = fewer medical record requests. You may also add code to your claim to report additional diagnoses. 33

34 Care and Case Management Case Management and Population Health Case Management and Population Health Management Fully Integrated Medical and Behavioral Health Case Management Team Member Education & Support Promote Quality and Cost Effective Coordination of Care Targeted Interventions Increase Member/Caregiver s Knowledge of Condition Improve Medication Adherence Reduce Gaps in Care Reduce Emergency Room visits Timely Post-Discharge Follow-up Increase Compliance with Treatment Plan Reduce Barriers to Care 34

35 Care and Case Management Case Management and Population Health Programs Available Complex Case Management Transplant Case Management Care Coordination Discharge Care Coordination Population Health Management Social Services To Make a Referral:

36 Care and Case Management Readmission Reduction Program Effective Sept. 1, 2014, BlueAdvantage (PPO) and the BlueChoice (HMO) plans implemented two readmission programs that apply to same or similar diagnosis readmissions to acute care hospitals that occur within 31 days from the index admission discharge Admission within 48 hours of discharge readmission is not reimbursed o Defined as the same or similar diagnosis from a complication of the original hospital stay or admission resulting from a modifiable cause of the both admissions must occur at the same facility or a facility operating under the same contract o BlueCross will follow for discharge planning needs only (i.e., no clinical updates) 36

37 Readmission Reduction Program What is the Readmission Reduction Program? Continued.. Admission within three to 31 days of discharge Only the higher weighted DRG pays Defined as the same or similar diagnosis from a complication of the original hospital stay or admission resulting from a modifiable cause of the original hospital stay. Both admissions must occur at the same facility or a facility operating under the same contract Reimburse a single DRG (the higher weighted of the two admissions) and all other days will be reimbursed based on DRG outlier methodology Subject to inpatient medical review based on MCG criteria Provider Appeals Standard provider appeal remedies are the same as usual for administrative service denials 37

38 Contact Us Who to Contact? Risk Adjustment/Quality Improvement and STARS Programs East Region Ashley Ward, Manager, Quality Finance Office Phone: (865) Middle/West Region Tamara Matos-Cruz, Manager, Quality Finance Office Phone: (615) Care and Case Management Jeffrey Marvel, Director of Care/Case Management Office Phone: (423)

39 Commercial

40 Preventive Visits Wellness Exams Schedule patients for regular wellness visits Proper CPT and Diagnosis Codes Code the procedure accurately and timely 40

41 Preventive Visits Wellness Exams File claims for annual wellness accurately Child Care Immunizations Health Care Screenings Colorectal cancer, breast cancer, cervical cancer, osteoporosis, HbA1c, retinal eye and urine nephropathy, etc. 41

42 Preventive Visits Proactive Health Care Initiatives Follow-up on missed appointments Gaps in care Refer to the BlueCross BlueShield of Tennessee website at for additional information. 42

43 Referring Physicians You are contractually obligated to refer to participating providers It s especially important for members referred to hospitals for lab work, DME and any other ancillary services Reference our website before scheduling appointments Visit BlueAccess SM for a list of participating providers Cost Sharing Out of pocket expenses 43

44 Service Level Improvements Multiple classes held during the year Extended service hours (8 a.m. to 6 p.m. ET) Improved Service Levels Wait Times Improved 44

45 Service Level Improvements Cross Training More efficient with less handoffs Improved first call resolution System Enhancements Benefit summary redesign Daily Intervention Meetings SWAT Teams 45

46 Provider Data Management

47 Changing Landscape Regulations, Directory Oversight and Provider Data Accuracy In early 2015, CMS released a memo related to provider directories that changes how we do business. Provider data is no longer just used to pay claims. Provider data requires a tighter maintenance protocol because of Value Based Programs (THCII/QCPI/Etc.) and the requirement for accurate directories. These are becoming more data driven and require accuracy to be effective. 47

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50 Provider Data Verification Where Are We Today? Quarterly outreach started in March. Technological industry solutions are still in development. Data verification forms to continue until industry solution is available. Regardless of the solution, cooperation and comprehensive review between the payers and providers will be critical. 50

51 Mandates Brief Overview CMS Medicare Advantage (MA) and Medicaid regulations Regularly evaluate availability of contracted providers and update directory Quarterly communications to providers to update availability and panel status Updates to online provider directory within 30 days of change notification Health and Human Services (HHS) regulations, applicable to Qualified Health Plans (QHPs) Renewed focus on network adequacy standards, reporting on provider accessibility for individuals with disabilities, network data collection Increase updates to provider directories for non-address data fields, including open panel status, medical group and institutional affiliations, specialties NCQA Accreditation Standards Provider Network Management Regularly assess the accuracy of provider directories Update provider directories at least monthly 51

52 Mandates Other External Quality Review Organization (EQRO) Bureau of TennCare Recent changes to regulatory and accreditation standards require greater emphasis and attention on directory data accuracy 52

53 Some Impacted Networks Blue Networks Commercial Blue Network P SM Blue Network S SM Blue Network E SM Medicaid BlueCare TennCare Select CoverKids CHOICES Medicare Advantage Medicare Advantage BlueAdvantage (PPO) SM DSNP BlueChoice (HMO) SM BlueCross BlueShield of Tennessee, Inc. is a PPO plan with a Medicare contract. BlueChoice Tennessee is an HMO plan with a Medicare contract. Enrollment in BlueCross BlueShield of Tennessee, Inc. and BlueChoice Tennessee depends on contract renewal. 53

54 Using Technology Vendor solutions in progress A single source of provider data verification for the industry is actively being worked through CAQH and other vendors 54

55 Data Verification Forms Quarterly outreach via Data Verification Forms continuing through 1 st quarter A single source of provider data verification for the industry is actively being worked through CAQH and other vendors. 55

56 Questions - How can we help? 56

57 Provider Reconsideration and Appeals

58 What is a Provider Reconsideration? A reconsideration allows providers dissatisfied with a claims outcome/denial to ask us questions. Reconsiderations must be requested and completed before filing a formal appeal. Provider reconsiderations may be requested in reference to numerous topics, including, but not limited to: Corrected claims Coordination of benefits Diagnoses codes Procedure or revenue codes Recoupment disputes For adjudicated claims to be reconsidered, provide adequate supporting documentation. You may initiate a reconsideration by calling us or using the Provider Reconsideration Form. If you still are dissatisfied after a reconsideration, you may file a formal appeal. 58

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60 Reconsiderations: A Case Study The kickoff point for a provider reconsideration is a denied claim and a frustrated provider. The provider determines his/her reason for reconsidering a claim and begins the process of filing the reconsideration. 60

61 Case Study (continued) Step 1: Does the provider understand why the claim was initially denied? YES: The provider understands the reason and still disagrees. NO: The provider does NOT understand the reason for denial. The remittance code is reviewed, and the provider then determines whether he/she agrees or disagrees with the ruling. 61

62 Case Study (continued) Step 2: Are ancillary services impacted by the reconsideration? YES: Durable Medical Equipment (DME), Lab and Specialty Prescription claims may only be reconsidered: If DME products were delivered or picked up in Tennessee If Lab or Specialty Rx were ordered by a provider in Tennessee FEP only: DME, Lab and Specialty Rx claims may be reconsidered if the provider filing the claim is in Tennessee NO: Providers must complete and fax a reconsideration form to (423) within 18 months of initial denial. 62

63 Submitting a Reconsideration Step 3: Submit the reconsideration form within 18 months of the initial claims denial. 63

64 What is a Provider Appeal? An appeal allows providers dissatisfied with a claim reconsideration to formally dispute the denial and provide additional documentation to BlueCross. Only one appeal is allowed per claim. Appeals must be filed and completed within a certain timeframe of receiving a reconsideration determination. (Refer to timeliness grids for each line of business.) NOTE: If the reconsideration process identified the decision was related to medical necessity, you may be directed to a separate Utilization Management appeal form. For adjudicated claims to be appealed, you must provide adequate supporting documentation. If you still are dissatisfied following an appeal, the arbitration process begins. Refer to the Provider Dispute Resolution Procedure documented in the BlueCross and BlueCare Provider Administration Manuals. 64

65 What Does the Appeals Process Look Like? 65

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67 Formal Appeals You may file an appeal if you still are not satisfied with your claims outcome after the reconsideration process is complete. Key questions: Have you filed a reconsideration, and was it denied? YES: Move forward with the appeals process NO: You will be redirected to the reconsideration process Do you agree with the reconsideration ruling? YES: Accept the denial NO: Move forward with a formal appeal 67

68 Formal Appeals (continued) Step 1: For all appeals, are ancillary services affected? YES: Claims may only be appealed: If DME products were delivered or picked up in Tennessee If Lab or Specialty Rx were ordered by a provider in Tennessee FEP only: DME, Lab and Specialty Rx claims may be appealed if the provider filing the claim is in Tennessee NO: Proceed to Step 2 68

69 Formal Appeals (continued) Step 2: Is the appeal related to an authorization request? YES: The appeal is related to an authorization request Is the authorization for a Commercial member? YES: Fax the Commercial UM Appeal Form to (423) NO: Submit the Provider Appeal Form and fax to the dedicated fax number for each line of business: BlueCare Tennessee: Medicare Advantage: BlueCare Plus: (423) CoverKids: NO: There is no pending authorization Submit the Provider Appeal Form 69

70 Formal Appeals (continued) Step 3: Complete the provider appeal form It is critical to include the member ID number (including the prefix) at the top of the appeals form. This ensures the appeal is routed appropriately. 70

71 Timeliness Timeliness standards vary between lines of business because of different regulatory requirements. The following slides provide greater clarification on the timeliness standards for each line of business. 71

72 Commercial Timeliness (Includes Federal Employee Program) Type of Dispute Reconsideration Timeliness Appeal Timeliness *Non- Compliant Arbitration Claim 18 months from Adverse Determination (Remit) Required before formal appeal 30 days from Reconsideration Determination N/A 30 days from Appeal Determination Fax: (423) Fax: (423) Authorization (TN Members) FEP Members: TN Providers Optional Before or during services but before formal appeal; Submit through normal authorization processes: phone/fax/online 180 days from Original Adverse Determination Submit through UM Appeal Form Fax: (423) *60 days from Adverse Determination (UM Letter/ Claim/ EOB) 30 days from Appeal Determination 72

73 BlueCare Timeliness Type of Dispute Reconsideration Timeliness Appeal Timeliness *Non-Compliant Arbitration Claim 18 months from Adverse Determination (Remit) Required before formal appeal 30 days from Reconsideration Determination N/A 30 days from Appeal Determination Fax: (423) Fax: (423) Authorization Optional Before or during services Submit through normal authorization processes: phone/fax/online 60 days from Original Adverse Determination Fax: *60 days from Adverse Determination (UM Letter/ Claim/ EOB) 30 days from Appeal Determination 73

74 Medicare Advantage Timeliness Type of Dispute Reconsideration Timeliness Appeal Timeliness *Non-Compliant Arbitration Claim 18 months from Adverse Determination (Remit) Required before formal appeal Fax: (423) days from Reconsideration Determination Fax: (423) N/A 30 days from Appeal Determination Pre-Service Authorization Considered Member Appeal N/A Must be filed within 60 days of the Original determination notice N/A 30 days from Appeal Determination Post-Service Authorization Optional Re-evaluation ; prior to formal appeal 60 days from most recent determination notice Fax: days from Adverse Determination (UM Letter/ Claim/ EOB) 30 days from Appeal Determination 74

75 BlueCare Plus (Dual Special Needs Plan) Timeliness Type of Dispute Reconsideration Timeliness Appeal Timeliness *Non- Compliant Arbitration Claim 18 months from adverse determination (Remit) Required prior to formal appeal 30 days from Reconsideration Determination N/A 30 days from Appeal Determination Fax: (423) Fax: (423) Pre-Service Authorization (considered a member appeal) Post-Service Authorization N/A N/A N/A N/A Optional; after initial denial but before formal appeal request Provider can submit additional clinical for re-evaluation 60 days from Original Adverse Determination Fax: (423) days from Adverse Determination (UM Letter/ Claim/ EOB) 30 days from Appeal Determination 75

76 BlueCard Host (Non-Tennessee Members) Timeliness Type of Dispute Reconsideration Timeliness Appeal Timeliness *Non- Compliant Arbitration Claim 18 months from adverse determination (Remit) Required prior to formal appeal 30 days from Reconsideration Determination N/A 30 days from Appeal Determination Fax: (423) Fax: (423) Authorization Follow normal claim reconsideration Follow normal appeal guidelines N/A N/A 76

77 Key Points to Remember Utilization management authorization appeals are handled by a medical team. Each line of business has dedicated UM appeal fax numbers. Claims appeals are handled by an administrative team. After the authorization appeals process is complete, you may not begin the claims appeal process. The next step is arbitration. Providers cover the costs associated with arbitration and independent reviews. The Provider Dispute Resolution process allows for one reconsideration, followed by one appeal per claim issue. Duplicate requests or improperly submitted forms will be returned without additional review. 77

78 Common Terms Reconsideration Allows providers dissatisfied with a claims outcome/denial to request additional information or ask us questions. Appeal Allows providers dissatisfied with a claim reconsideration to formally dispute the denial and provide BlueCross more documentation. Arbitration Allows providers dissatisfied with reconsideration and appeals process outcomes to seek resolution by a third party. Timeliness The time you have to pursue reconsideration or appeal an adverse determination. Non-Compliant When prior authorization is required, you must obtain authorization before scheduled services and within 24 hours or the next business day of emergent services. Failure to comply within specified authorization timeframes will result in a denial or reduced benefits from non-compliance, and BlueCross participating providers will not be allowed to bill members for covered services rendered, except for any applicable copayment/deductible and coinsurance amounts. 78

79 Resources Visit for updated copies of each of the required forms. Refer to the Provider Administration Manuals for each line of business: Commercial Provider Administration Manual BlueCare Tennessee Provider Administration Manual BlueCare Plus Provider Administration Manual 79

80 Breakout Session Presentations

81 ebusiness Solutions

82 Agenda BlueAccess SM Overview PCP Member Roster Electronic Claims PWK Attachments THCII Payments 82

83 Provider Webpage Providers Login Login Quality Information 83

84 Provider Webpage (Continued) Quick Links UM Resources Important Initiatives BlueAlert Newsletters Find BlueCross Contacts 84

85 BlueAccess Overview 85

86 Service Center / Authorizations Submit Initial Authorizations and Update existing Authorizations 86

87 Tennessee Health Care Innovation Initiative (THCII) Blue Access: Frequently Asked Questions Guide to Reading Your Episode of Care Report Adjustment Methodology Risk Factors Perinatal Thresholds of Episodes of Care Tennessee government website Episodes of Care: Wave 1 - In the interim phase for BlueCare/TennCare Select /CoverKids Waves 2, 3 and 4 are all in the preview phase 87

88 BlueAccess Overview (Continued) 88

89 PCP Member Roster 89

90 PCP Member Roster Report Export Report Options 90

91 100% - Electronic Claim Submission Maintenance Phase Underway Average one paper claim per provider per month across our entire provider network Monitor filing patterns for any outliers Continuing outreach efforts to any providers who exceed the normal average number of paper or paper equivalent submissions Average PAPER CLAIMS FROM PROVIDER

92 100% - Electronic Claim Submission Maintenance Phase Underway Contact ebusiness Service for help with alternative electronic filing methods such as Real Time Claims Adjudication if ever unable to file electronically New providers added to your practice are required to enroll in electronic billing as part of the Network Participation Criteria described in the Provider Administration Manual Be sure to include your EDI filing information with any new applications Notify us of any changes to ensure our records are current and you remain compliant with the network standards 92

93 PWK Attachments New Form Available To address supplemental documentation sometimes needed to process claims, BlueCross has a system support to match faxed documentation to electronic claims. Process: Submit EDI claim with PWK06 (short for paperwork ) tracking number and proper qualifiers in your 837 data. On the same day as your claim submission, fax your documents with the new PWK coversheet (one per claim). BlueCross will match your claim and document for internal processing purposes which will help streamline adjudication. 93

94 PWK Attachments New Form Available PWK IS for Submitting documents or medical records you know will be needed for processing (unlisted procedures, custom equipment, etc.) Initial claim submissions PWK IS NOT for Submitting a medical record with every claim Responding to medical record requests post-adjudication Primary EOBs/Remits for secondary claims Please visit the ebusiness resource table or the ebusiness section of for technical information and the new PWK Coversheet. 94

95 Quality Care Rewards Technology Update THCII Payments 95 The THCII Episodes of Care program will have its first round of risk and gain shares issued in September for the BlueCare lines of business. The cover page on the Wave 1 Final Performance Reports will indicate the amounts to be paid or owed by the quarterback. Financial notices will soon be available in the View/print your Remittance Advice on BlueAccess to show the impact to the quarterback s elected payee and indicate the method of payment if applicable. You will be able to match back to the Episode of Care data represented by the financial notice through the tracking numbers on the cover page of the Episodes of Care Final Performance report. If no risk or gain share is applied to your quarterback for the current Final Performance Wave(s), no financial notice will be produced. Watch for a notice on the BlueAccess landing page regarding when this data will be available.

96 ebusiness Contact Information 96

97 Quality Updates

98 Improving Health Care Quality and Outcomes What is Health Care Quality? Who Decides? Health care quality means payers, consumers and their health care team work together to ensure accessible, high quality, cost effective care A range of private, industry, professional and governmental organizations establish standards for health care quality Health Plans Centers for Medicare & Medicaid Services (CMS) i.e. ACA, Marketplaces, Medicare Advantage Bureau of TennCare America s Health Insurance Plans (AHIP) National Quality Forum (NQF) Providers Centers for Medicare & Medicaid Services (CMS) i.e. PQRS and MACRA Bureau of TennCare Professional Societies (i.e. AAP, AAFP, ACOG) National Quality Forum (NQF) Accreditation Organizations: NCQA, URAC 98

99 Improving Health Care Quality and Outcomes Why the focus on Quality? Health care spending in the U.S. is not sustainable Pay for volume, regardless of outcome High variance in care for like conditions Aging population Marked increase in chronic disease There is no correlation between high cost and high quality in the U.S. health care system Reimbursing health care based on value instead of volume aligns stakeholders (providers, patients/consumers, employers, the government) to promote the most effective, quality care at the lowest possible costs. 99

100 Improving Health Care Quality and Outcomes Future Changes in BlueCross Reimbursement Methodology 100% ---- Fee for Service ---- Pay for Gaps % of Providers*** ---- Pay for Performance ---- Total Cost of Care 0% 2015 ***% Providers figures are for demonstration purposes only and do not reflect actual performance expectations

101 BlueCross Support for Practice Quality Working Together to Ensure Optimal Care BlueCross BlueShield of Tennessee: Your Partner in Pursuit of Health 101

102 Closing Evidence-Based Gaps in Care Quality Care Rewards Tool Practice Overview Practice Name Practice Name 102

103 Closing Evidence-Based Gaps in Care Quality Care Rewards Tool Provider View Provider Name Provider Name Provider Name 103

104 Closing Evidence-Based Gaps in Care Quality Care Rewards Tool Member View Patient Name Patient Name 104

105 Closing Evidence-Based Gaps in Care Quality Care Rewards Tool Scorecard View 105

106 Closing Evidence-Based Gaps in Care Quality Care Rewards Tool Attestations Patient Name Patient Name Patient Name 106

107 Data Integrity is Key to Monitoring Performance Clinical Data Exchange [Electronic] Clinical Data Exchange accomplishes three major things: 1. Captures measurement data that cannot be obtained by claims data alone 2. Makes actionable data readily available 3. Reduces the administrative burden on offices Who You Gonna Call? Deana Hixson (423) ; Santosh Padhiari - (423) ; santosh_padhiari@bcbst.com 107

108 Data Integrity is Key to Monitoring Performance Supplemental Data Collection Supplemental Data Collection 1. BlueCross nurses review clinical records to capture measurement data not already being transmitted to BlueCross such as BP readings. 2. Ensures providers receive credit for care provided 3. Minimizes disruption to provider s practice while maximizing provider s financial opportunities 108

109 Closing Evidence-Based Gaps in Care Additional Resources Gaps In Care Events Member Scorecards Clinical Guides 109

110 Data Integrity is Key to Monitoring Performance Supplemental Data Timeframes Attestations sent to SDW every Monday QCR Tool updated every Tuesday Quality Care Rewards Tool (Electronic Scorecard) Supplemental Data Warehouse Daily 4 th of each month Claims Data, Lab Values, EMR Data Consolidated Business Data Warehouse The timeframes around the successful transfer of data may vary depending on the type of data being sent and the way in which it is submitted. 22nd h of each month 15 th of each month Central Analytics Warehouse 20th of each month Quality rules engine (Verisk) 110

111 Thank you for your time today! 111

112 Tennessee Healthcare Innovation Initiative (THCII): Episodes of Care

113 THCII Episodes of Care Agenda Episodes of Care Reporting Gain/Risk Sharing Provider Resources 113

114 THCII Episodes of Care Overview What is THCII Episodes of Care? Episode-based payment seeks to align incentives with successfully achieving a patient's desired outcome during an episode of care, a clinical situation with predictable start and end points. - See more at: The State determines the following: The quarterback for an episode The Detailed Business Requirements for each Episode The reporting parameters and requirements Sets the Acceptable Thresholds There are 74 episodes being released over the course of 5 years in 11 waves through the end of Reports are sent out quarterly, with a final report delivered in August of the year after the reporting period which shows if the provider has a payout or recoupment. It is also possible there is neither. Reports are available on BlueAccess Providers have opportunity to discuss reports and dispute results as quarterly reports are published 114

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116 THCII Episodes of Care What is it? 116

117 THCII Episodes of Care Why are we doing it? Today, most health care payment from payers to providers in Tennessee is fee for service (the provider is paid to perform a specific activity or task). Fee-for-service payments fail to reward providers who achieve higher quality, more efficient, integrated and coordinated care. Following a thorough review of outcomes-based payment strategies and with the input of stakeholders, Tennessee is implementing episodes of care to reward providers for providing high-quality and efficient care for acute medical and behavioral treatments and conditions. 117

118 THCII Episodes of Care Reporting Quarterbacks Receive Quarterly Reports: Performance summary Total number of episodes (included and excluded) Quality thresholds achieved Average non-risk adjusted and risk adjusted cost of care Cost comparison to other providers and gain and risk sharing thresholds Gain sharing and risk sharing eligibility and calculated amounts Quality detail: Scores for each quality metric with comparison to gain share standard or provider base average Cost detail: Breakdown of episode cost by care category Benchmarks against provider base average Episode detail: Cost detail by care category for each individual episode a provider treats Reason for any episode exclusions Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013 [1. Asthma] A. Episode Summary Overview Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29 Cost of care (avg. adj. episode cost) comparison YOUR GAIN/ RISK SHARE You are eligible for gain sharing Commendable Acceptable Not acceptable Less than $1,000 $1,000 to $1,750 > $4000 $1,750 +$10, x x Commendable Your avg. Number of Share cost ($) cost ($) episodes factor Your avg. cost: $ Providers base avg. cost: $1, , % Episode cost summary Your average episode cost is commendable Provider Parameters You base average Your episode cost distribution (risk adj.) # of episodes Below $ $1167- $1500 $833- $1167 $500- $833 $1833- $2167 $2167- $ Above $2500 Distribution of provider average episode cost (risk adj.) Avg. adj. episode cost ($) 1. Total cost across episodes 2. Total # of included episodes 3. Avg. episode cost (non adj.) 2,000 1,500 1, You Commendable $235, $317, $1, $1, Risk adjustment factor* (avg.) Avg. episode cost (risk adj.) $ Commendable $1, Acceptable * Risk adjustment factor calculated for select provider s patient base Percentile of providers Acceptable Not acceptable 4 Episode quality and utilization summary Quality metrics linked to gain sharing You achieved selected quality metrics 1. Follow-up visit w/ physician 2. Patient on appropriate medication Quality metrics not linked to gain sharing 1. Repeat acute exacerbation within 30 days [Period: Start/end dates of period] You Gain share standard 61% 55% 77% 70% You Provider base average 5% 8% Met standard Preliminary draft of the provider report template for State of TN (for discussion only) All content/ numbers included in this report are purely illustrative 118

119 THCII Episodes of Care Thresholds THRESHOLDS: ILLUSTRATIVE EXAMPLE 119

120 THCII Episodes of Care Reporting: Downloading This is the Quarterback report screen. The reports are based on lines of business and can be chosen by reporting period. 120

121 THCII Episodes of Care Reporting: Downloading 121

122 THCII Episodes of Care Gain/Risk Share Providers will receive a final report after the measurement period that includes a cover sheet or invoice. The invoice will be specific to the contracted entity and will inform you if you owe BlueCross a recoupment, are owed a payment or if no action is needed (along with instructions) BlueCross will distribute payment via EFT In the event of a risk share or recoupment, Providers will be given a time limit in which to respond with payment and instructions In August, providers will receive final invoices for the first time In September, Payments will be sent, and remits for recoupments and payouts will be posted on BlueAccess 122

123 THCII Episodes of Care Reporting On the first page of the Final reports which are published on BlueAccess in August, reports will have a cover letter or invoice. Depending on how the Quarterback performs, they will receive an invoice which looks similar to this example: 123

124 THCII Episodes of Care Gain/Risk Share: Check Remittance Examples 124

125 THCII Episodes of Care Gain/Risk Share Risk Share Recoupments You will be notified of your recoupment amount on the final report. However, considering the August report is the same reporting period as the May report, only with further runout, you will be notified you did not meet your target threshold for this episode. You will receive a recoupment remit in the mail as well as access to this remit in BlueAccess. You will be instructed to remit payment within 60 days. If you have not responded after 60 days, any risk share owed to BlueCross will be taken from your BlueCare/TennCareSelect claims. If you prefer we take owed payments from claims, we simply deduct from the claims after 60 days. 125

126 THCII Episodes of Care Provider Resources 126

127 THCII Episodes of Care Provider Resources The August Blue Alert contained the following language to providers: The Blue Alert is still one of our most efficient ways of communicating updates on BlueCross initiatives to our provider community. Please check them monthly! 127

128 THCII Episodes of Care Provider Resources THCII Provider Guide: The THCII Provider Guide is in our BlueCare provider manual It includes important information about the design of the program, focusing initially on the Episodes of Care strategy This guide also offers resources to help health care providers understand how the program impacts their organization You can find a link to the provider guide on our THCII web page on the BlueCare website 128

129 THCII Episodes of Care BCBST Website: 129

130 THCII Episodes of Care State Website: 130

131 THCII Episodes of Care Questions 131