Provider and Facility Reference Manual
PLEASE NOTE: Our website URL will be changing. On February 1, 2023 we will be redirecting this website to our Highmark Provider Resource Center (PRC) website. Click here, to visit the PRC.
Information in this manual applies only to your Highmark BCBSWNY legacy patients who have NOT moved onto Highmark’s system.
For your patients who have moved onto Highmark’s system, please visit the Highmark Provider Manual.
For more information about our affiliation with Highmark, please visit bcbswny.com/workingtogether.
Section 14 - Provider Reimbursement and Incentives
The following reimbursement methodologies are used by Blue Cross Blue Shield for the various contracts we administer. The contract language will determine which method is applicable. Contract language will also determine whether full payment or a percentage of payment is applicable.
The commercial managed care and traditional/indemnity fee schedules are based upon the Medicare Fee Schedule, which is derived from the Resource Based Relative Value System (RBRVS).
RBRVS methodology is used to price professional procedure codes based on the relative cost to provide a service. It consists of three components: relative value units, geographic adjusters and conversion factor. This reimbursement method was developed for CMS (Centers for Medicare and Medicaid Services) and implemented by Medicare in 1992. Blue Cross Blue Shield adopted a modified version of this method to establish a fee schedule and schedules of allowance. Yearly CPT code updates will be added.
The relative value unit has three components: total work of physician, practice expense such as office rent, salaries of office staff and supplies, and professional malpractice liability premiums. The geographic adjusters are applied to each of the relative value unit components to reflect how practice costs vary from locale to locale. The total of these adjusters then equals the total weighted relative value unit. The conversion factor is the dollar amount for one total relative value unit. Payments under RBRVS methodology are based on multiplying conversion factor by the total weighted relative value unit.
RBRVS is used to reimburse providers who participate with Blue Cross Blue Shield.
Exceptions to RBRVS payment under our HMO products include capitation arrangements, physical therapy services and laboratory services. Exceptions under our products include chiropractic services, laboratory services, medical pharmacy services, and Major Medical Alternative/Additional Benefits Riders.
This program is comprised of variable fee schedules that align reimbursement by encouraging lower cost but equally effective agents through proprietary Maximum Allowable Cost (MAC) and Least Cost Alternative (LCA) pricing strategies for drugs administered in the provider office and through home infusion.
Please note: outpatient medical drug fee schedules are updated every quarter on our website (requires login).
Capitation is a payment method based on a fixed dollar amount paid to a provider in advance, regardless of the number of services he or she provides. The lump sum payment is set on a per member per month basis.
Flat Rate Payment
This method of payment may be used for specific services clearly defined in certain contract language. For example, a Major Medical Rider may reimburse $50.00 for a routine physical exam.
Anesthesia Services (Surgical or Maternity)
Effective January 1, 2023, we will be changing to align with Highmark in accordance with CMS guidance and national standards in applying the use of relative value units, including base units, plus time units and eligible modifying units when appropriate, multiplied by a monetary conversion factor
Effective October 1, 2021, time will be calculated as 15 minutes equaling 1 unit. This calculation will be done by dividing the total minutes of anesthesia time reported by fifteen (15) and rounding to the nearest tenth decimal place.
Rounding down – 62 minutes divided by 15 = 4.133
- We will round down to pay 4.1 x contracted conversion factor
Rounding Up – 67 minutes divided by 15 = 4.466
- We will round up to pay 4.5 x contracted conversion factor
Please note: We will no longer round up for time greater than 8 minutes or round down for time less than 8 minutes.
The basic value for anesthesia when multiple surgical procedures are performed is the basic value for the procedure with the highest unit value. Reimbursement is not allowed for the basic unit value of a second, third, etc., procedure.
Anesthesia time begins when the anesthesiologist or CRNA is first in attendance with the patient for the purpose of creating the anesthetic state. Anesthesia time ends when the anesthesiologist or CRNA is no longer in personal attendance; that is, when the patient may be safely placed under customary postoperative supervision. This time must be documented on the anesthesia record, but not on the claim.
Time must be indicated on all anesthesia claims. Report the actual time spent administering anesthesia as minutes on the claim in the “days or units” block. The Plan will convert total minutes to time units. A “time unit” is a measure of each fifteen (15) minute interval or the actual time reported. Time units are calculated by dividing the total minutes of anesthesia time reported by fifteen (15), rounding to one decimal place (e.g., total anesthesia time of 48 minutes divided by 15 equals 3.2-time units).
Note: Report units, not minutes for moderate (conscious) sedation.
Direction of Anesthesia Services
The amount for physician anesthesia services is based on allowable base and time units multiplied by an anesthesia conversion factor.
Concurrent directed anesthesia procedures are defined with regard to the maximum number of procedures that the physician is directing within the context of a single procedure. Physicians must report the appropriate anesthesia modifier to denote whether the service was personally performed, directed, or supervised.
Specific anesthesia modifiers include:
AA - Anesthesia Services performed personally by the anesthesiologist
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures
G8 - Monitored anesthesia care (MAC) for deep complex complicated or markedly invasive surgical procedures
G9 - Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
QS - Monitored anesthesia care service
QX - CRNA service; with medical direction by a physician
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist
QZ - CRNA service: without medical direction by a physician
Note: The QS modifier is for informational purposes. Providers must report actual anesthesia time on the claim.
Physical Status Units (Commercial Only)
Patient physical status should be reported under the appropriate modifier (P1-P6).
Physical Status I - a normal, healthy patient (Modifier P1): Units allowed = 0 Ø
Physical Status II - a patient with mild systemic disease (Modifier P2): Units allowed = 0 Ø
Physical Status III - a patient with severe systemic disease (Modifier P3): Units allowed = 1 Ø
Physical Status IV - a patient with severe systemic disease that is a constant threat to life (Modifier P4): Units allowed = 2 Ø
Physical Status V- a moribund patient who is not expected to survive without the opration (Modifier P5): Units allowed = 3 Ø
Physical Status VI – a declared brain-dead patient whose organs are being removed for donor purposes (Modifier P6): Units allowed = 0
Payment for Personally Performed Anesthesia
Anesthesia payment is determined by the base unit for the anesthesia code and one-time unit per 15 minutes of anesthesia time if:
1. The physician personally performed the entire anesthesia service alone, or.
2. The physician is a teaching physician involved with one or two concurrent resident cases or in one resident case that is concurrent to another case paid under medical direction payment rules (i.e., a nurse anesthetist or anesthesiologists assistant case), or
3. The physician is continuously involved in a single case involving a student nurse anesthetist, or
4. If the physician is involved with a single case with a CRNA or an anesthesia assistant (AA), payment can be for the physician service and the CRNA (or AA) service in accordance with the medical direction payment policy, or
5. The physician and the CRNA (or AA) is involved in one anesthesia case and the services of each are found to be necessary. Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers. The physician reports the “AA” modifier and the CRNA reports the “QZ” modifier for a non-necessary case.
Payment for Directed Anesthesia
Payment for the physician’s directed service is determined on the basis of fifty (50) percent of the allowance for the service performed by the physician alone. Direction occurs if the physician directs qualified individuals in two, three, or four concurrent cases and the physician performs the following activities:
1. Performs a pre-anesthetic examination and evaluation;
2. Prescribes the anesthesia plan;
3. Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;
4. Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
5. Monitors the course of anesthesia administration at frequent intervals;
6. Remains physically present and available for immediate diagnosis and treatment of emergencies; and
7. Provides indicated-post-anesthesia care.
The physician must participate only in the most demanding procedures of the anesthesia plan, including if applicable, induction and emergence. Also, for directed services, the physician must document in the medical record he or she performed the pre-anesthetic examination and evaluation. Physicians must also document they provided indicated post-anesthesia care, were present during some portion of the anesthesia monitoring, and were present during the most demanding procedures, including induction and emergence, where indicated.
The physician can direct two, three, or four concurrent procedures involving qualified individuals, all of whom could be CRNAs, AAs, interns, residents or combinations of these individuals. The direction rules apply to cases involving student nurse anesthetists if the physician directs two concurrent cases, each of which involves a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a CRNA, AA, intern, or resident.
A physician who is concurrently directing the administration of anesthesia to not more than four surgical patients cannot ordinarily be involved in performing additional services to other patients. However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous, monitoring of an obstetrical patient does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to surgical patients. It does not constitute a separate service for the purpose of determining whether the direction criteria are met. Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.
However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature and reimbursement cannot be made.
Only three base units per procedure may be allowed when the anesthesiologist is involved in performing more than four procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit may be recognized if the physician can document that they were personally present at induction.
If anesthesiologists are in a group practice, one physician member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post-anesthesia care while another member of the group performs the other component parts of the anesthesia service. However, the patient medical record must indicate the services were performed by physicians and identify the physicians who performed them.
Anesthesia Services Provided by a Qualified Anesthetist
Reimbursement will be made for directed services when only one service is supervised. The payment amount for the physician service and the CRNA service is fifty (50) percent (for each service) of the allowance otherwise recognized had the service been furnished solely by the anesthesiologist. Modifier QX should be appended to the procedure code(s) in these cases.
Effective January 1, 2016, postoperative nerve blocks for pain management performed by the surgical anesthesiology provider will be paid in addition to the surgical anesthesia
- Preauthorization and/or medical record documentation is not required.
- Modifier 59 is required on the nerve block pain management CPT code when billed for the same date of service as the surgical anesthesia.
Post-operative Pain Management
When billing for surgical anesthesia (00 services CPT codes) and for post-operative pain management, the codes must appear on the same claim. If billed separately, the claim for the post-operative pain management will be denied due to no preauthorization being on file.
The global operative anesthesia allowance payable to the anesthesiologist includes payment for all components that are considered an integral part of the anesthesia service. The following are not eligible for separate payment and the member cannot be billed:
- Pre-anesthesia evaluation, including when surgery has been delayed and the pre-anesthesia evaluation was already done Note: A pre-anesthesia evaluation by the anesthesiologist where surgery is cancelled is eligible for coverage at the level of care rendered as hospital or office evaluation and management service
- Post-operative visits
- Anesthetic or analgesic administration including nerve blocks and continuous or single epidural, caudal, spinal, auxiliary, etc., injections for the purpose of administering the operative anesthesia
- All necessary monitoring (i.e. IV, cardiac output measurements, blood gas interpretations, oximetry)
- Intra-operative administration of drugs, IV fluids, blood, etc.
- Hypothermia and/or pump oxygenator
- Supervision of patient-controlled analgesia (PCA)
- The administration of simple infiltration local anesthetic anesthesia (this is considered part of the global surgery allowance)
Separate payment to an anesthesiologist may be available for the following procedures done in conjunction with anesthesia:
- Emergency intubation during the surgical or maternity procedure where there is supporting documentation of an emergency situation
- Swan-Ganz insertion
- Critical care services unrelated to the surgical or maternity anesthesia service that require the physician's constant attendance
- Arterial line insertion
- CVP line insertion
Other Anesthesia Services:
- Epidural During Labor (01967)
- The reimbursement for epidural pain management during labor is determined by a base unit and a time unit with associated dollar allowances for each. Payment is capped at a maximum of 20 time units.
- An epidural catheter inserted for the sole purpose of pain management in addition to the anesthesia service for the surgery or delivery is eligible for separate payment. Reimbursement on the initial day is by the allowance for the catheter insertion and injection of anesthetic substance procedure code. After that, daily management provided by the anesthesiologist or CRNA is allowed for a reasonable period of time during the post-operative period.
- Patient controlled analgesia (PCA) is monitored by the nursing staff under the physician's direction. There is no separate reimbursement as it is considered part of the post-operative care covered under the global surgical fee.
- Anesthesia attendance or monitored anesthesia care (MAC) is eligible for coverage. For a procedure to be considered attendance and not stand-by, all of the following must be true:
- The service was requested by the attending physician;
- The anesthesiologist documented that he or she was present for the entire procedure and provided all the usual services, except actual administration of anesthetic agent; and
- It was medically necessary for the patient's condition.
- For services when anesthesia isn’t recognized as appropriate in Code & Comment, preauthorization must be obtained.
- Non-routine anesthesia associated with surgery requires medical record documentation for reimbursement. Anesthesia administration is not normally required for non-surgical or dental procedures.
The following are non-covered services:
- Local anesthesia for dental services or anesthesia rendered by the dentist or other physician such as conscious or moderate sedation in his/her office
- Stand-by anesthesia
- Anesthesia by acupuncture or hypnosis
Assistance at Surgery
Payment will be made at 16 percent for physicians and 13.6 percent for physician assistants of our fee schedule. All services must warrant an assistant and be medically necessary. The member cannot be billed for denied services.
Physical and Occupational Therapy
Effective 11/1/2021, providers will be reimbursed using an all-inclusive Daily Dollar Maximum (DDM), of all modalities or procedures, for one therapy session/encounter per day.
Telehealth is a covered service, effective January 1, 2016. Preauthorization is not required. Place of service “02”, or modifiers GT or 95 are appropriate when billing for telehealth services. All services are subject to the member’s contract benefits and should be verified prior to providing services. Please visit the “code and comment” section of our website (log-in required) for code level coverage information.
Reimbursement for Mid-Level Practitioners
Physician Assistants and Nurse Practitioners
The mid-level practitioner performing the service should bill under his or her own name and provider number. No additional claims for supervision should be submitted by other providers.
Physician assistants and nurse practitioners are reimbursed 85 percent of the appropriate fee schedule minus any applicable copays and/or coinsurance for: Office, home, hospital visits, nursing home visits and periodic exams.
Payment will be made at 85 percent of the appropriate fee schedule for professional services minus any applicable copays and/or coinsurance.
Follow up days are the number of days anticipated for the recovery period for a surgical procedure. Any services provided relative to the same condition will not be covered if performed in the specified number of days. Our payment for these services is included in the initial surgical allowance. No additional benefits will be available in the follow up period. Follow-up days are the same as Medicare's, except for maternity procedures.
Health Care Provider Performance Evaluation
Blue Cross Blue Shield maintains a comprehensive Quality Management program to objectively monitor and systematically evaluate the care and service provided to members. The scope and content of the program reflects the demographic and epidemiological needs of the population served. Members and providers have opportunities to make recommendations for areas of improvement. The Quality Management program goals and outcomes are available to providers and members upon request.
The initial program development was based on a review of the needs of the population served. Systematic re-evaluation of the needs of the plan’s specific population occurs on an annual basis. This includes not only age/sex distribution but also a review of utilization data — inpatient, emergent/urgent care and office visits by type, cost and volume. This information is used to define areas that are high volume or that are problem prone. Studies are planned across the continuum of care and service, with ongoing proactive evaluation and refinement of health plan programs and initiatives.
Use of Performance Data
Practitioners and providers must allow Blue Cross Blue Shield to use performance data in cooperation with our quality improvement program and activities. Practitioner/provider performance data refers to compliance rates, reports and other information related to the appropriateness, cost, efficiency and/or quality of care delivered by an individual health care practitioner (such as a physician) or a health care organization (such as a hospital). Common examples of performance data include the HEDIS quality of care measures maintained by the National Committee for Quality Assurance (NCQA) and the comprehensive set of measures maintained by the National Quality Forum (NQF).
Quality of Care
All physicians, advanced registered nurse practitioners and physician assistants are evaluated for compliance with pre-established standards as described in our credentialing program.
Review standards are based on medical community standards, external regulatory and accrediting agencies’ requirements and contractual compliance.
Reviews are accomplished by Health Care Quality Improvement (HCQI) team and health plan professionals who strive to develop relationships with providers and hospitals that will positively impact the quality of care and services provided to our members. Results are then submitted to our HCQI department and incorporated into a data summary.
Our quality program includes review of quality of care issues identified for all care settings. HCQI staff use member complaints, reported adverse events and other information to evaluate the quality of service and care provided to our members.
Blue Cross Blue Shield uses provider-profiling methodology, rationale and processes for evaluating physician performance. The method may include the following key measures: access and availability to care, member complaints, ER utilization, compliance with quality metrics, cost efficiency.
The principal features of the methodology ensure:
- Clearly defined goals and objectives for the profiling activity have been developed, including the communication of a profiling summary to providers and the provision of provider/office manager education, based on findings and corrective action plans with time tables and measurable benchmarks of success, as indicated.
- Descriptions and rationale for each measure have been developed, and supporting clinical documentation is included, when appropriate.
- A health care plan shall develop and implement policies and procedures to ensure that health care professionals are regularly informed of information maintained by the health care plan to evaluate the performance or practice of the health care professional. The health care plan shall consult with health care professionals in developing methodologies to collect and analyze health care professional profiling data. Health care plans shall provide any such information and profiling data and analysis to health care professionals. Such information, data or analysis shall be provided on a periodic basis appropriate to the nature and amount of data and the volume and scope of services provided. Any profiling data used to evaluate the performance or practice of a health care professional shall be measured against stated criteria and an appropriate group of health care professionals using similar treatment modalities serving a comparable patient population. Upon presentation of such information or data, each health care professional shall be given the opportunity to discuss the unique nature of the health care professional's patient population which may have a bearing on the health care professional's profile and to work cooperatively with the health care plan to improve performance.
- Practice performance profiles examine a broad range of practice measures and have some adjustments for risk, and similar cohorts are analyzed across practices to fairly compare each provider.
- Profiles include data from multiple sources, including claims, HEDIS, medical record review data, utilization management and pharmacy data, member satisfaction surveys, enrollment and PCP assignment data, member complaints and provider-supplied information, such as office hours, walk-in policies, etc.
Pay for Performance Program
Blue Cross Blue Shield's Pay for Performance Program (P4P) was redesigned and implemented in 2009. It continues to encourage both quality and efficient delivery of care. The program was enhanced to improve the timeliness of reporting to physicians and address practice patterns, variations in care, and improve patient outcomes.
As the program evolves, you will receive notice of any changes occurring in 2020 when applicable.
- To reward physicians for the provision of quality care to our members
- Provide physicians timely reporting on performance
- Evaluate physicians on an individual basis
- Provide actionable reporting on P4P measures and non-compliant members
- To align with corporate strategic goals
- Clinical quality measurement score goals (targets) may vary on an annual basis. The Pay for Performance team will establish annual targets using a blended average of plan performance and HEDIS benchmarks. Clinical quality scores will be pulled from Risk Manager™ and HEDIS definitions will be used.
- Providers who do not have an office in an eligible county are excluded.
2020 Quality Metric Summary
Effective May 1, 2015, Blue Cross Blue Shield introduced an outcome-based performance opportunity to our 2015 physician performance quality initiatives. The CPT Category II codes included in the incentive can be found on the 2020 Pay for Outcomes Program (P4O) sheet on the Incentives page here (log-in required).
Provider Initiatives – Process for Supplemental Data Submission
BestPractice is an innovative payment program that rewards providers for quality and efficiency in the management of patients’ health. BestPractice is designed to improve provider reimbursement through predictable monthly payments, in addition to fee-for-service payments that encourage overall health and prevention. Providers may have an increase or decrease in their monthly payments related to how they score on quality metrics, which are primarily based on Healthcare Effectiveness Data and Information Set (HEDIS®) measures.
- BestPractice uses HEDIS specifications as guidelines for applicable time frames and appropriate ICD-10, CPT and HCPCS codes for services provided during the measurement year. This information is incorporated into our Quality Measure Guide, which is available on your secure dashboard.
Performance Adjustment Factor (PAF) is an adjustment to the monthly payment based on the BestPractice evaluation incorporating a provider’s quality (as determined by HEDIS compliance for select measures) and medical efficacy, as compared to community peers.
Pay for Performance (P4P) is an incentive program that provides additional financial incentives to providers for meeting specific quality metrics.
- Each measurement year, P4P measures are identified and communicated in writing and posted on our website.
- Primary care providers are eligible for P4P.
- P4P uses HEDIS specifications as guidelines for applicable time frames and appropriate ICD-10, CPT and HCPCS codes for services provided during the measurement year. This information is incorporated into our Quality Measure Guides, available on our secure website.
- More information on BestPractice is available here.
Risk Manager™ is an online analytical tool that assists providers in identifying quality- and cost-drivers. It provides high-level overviews and patient-level details that evaluate patient risk levels, identify gaps in care and support population management efforts. Information is refreshed monthly. Data includes but is not limited to: claims, medical enrollment, lab results, provider files, and state immunization information systems (NYSIIS).
Measurement year is the year in which the service occurs. This is usually the calendar year before the HEDIS reporting year. For example, HEDIS (reporting year) 2020 results are for measurement year 2019.
Reporting year is one year following the year reflected in the data. For example, HEDIS 2020 reporting year is for measurement year 2019.
Retrospective Measure is a measure that has a time period prior to the current measurement year. For example, the colorectal cancer screening measure has a retrospective time period for colonoscopies of 9 years including the measurement year (total of 10 years). If the current measurement year is 2020, any colonoscopy done from the beginning of 2011 through the end of 2020 would satisfy the measure.
- Retrospective measures include but are not limited to: Cervical Cancer Screening, Breast Cancer Screening, Colorectal Cancer Screening and Diabetes Care Eye Exam.
- Retrospective measures may or may not be part of any given year’s P4P program.
The standard way to close a member gap in care is to make sure that claim(s) have been submitted with the appropriate CPT and/or ICD-10 code. All claims must be submitted in a timely manner. In order to reflect accurate risk scored for your patients, please be sure that all diagnoses affecting treatment and care are thoroughly documented and coded to the highest specificity. However, there are instances where it is not possible to submit a claim (e.g., for a retrospective measure or for services where Blue Cross Blue Shield is a secondary payer.) The purpose of this policy is to describe the proper procedures to ensure that providers receive credit for following the appropriate steps to close their patients’ gaps in care.
- Primary care providers and select specialty providers are eligible for provider performance initiatives.
- BestPractice PAF will be based on submitting appropriate coding (ICD-10, CPT, HCPC, LOINC) on services performed during the current year. This process is referred to as administrative claims data.
- Medical record submission for supplemental data incentives will begin July 1 annually. In order to get credit for P4P measures, services rendered in the current year must be billed with the appropriate coding (ICD-10, CPT, HCPC, LOINC), as medical records for current year services will not be accepted for those gaps in care closures. The only exception for current year services is when Blue Cross Blue Shield is the member’s secondary insurance.
- Medical record submission for members who had services rendered within a retrospective time period (per HEDIS technical specifications) will be accepted from July 1 through the designated time period. Retrospective measures include but are not limited to: Cervical Cancer Screening, Breast Cancer Screening, Colorectal Cancer Screening and Diabetes Care Eye Exam.
- Accepted medical records will be entered into Risk Manager™. Please allow up to 60 days for these updates to appear in the member gap in care reports.
Procedure for assessing member gaps in care:
- Run a report using Risk Manager™.
- For each patient and measure, determine the following:
- If the service required by the quality measure was NOT rendered, the provider office may reach out to the patient to coordinate scheduling the service.
- If the service WAS rendered, determine if a claim has been submitted to Blue Cross Blue Shield.
- If a claim was submitted in the past 60 days, allow time for the claim to process. Do not submit any medical record documentation at this time.
- If a claim was not submitted, do so now. Use the appropriate CPT and/or ICD-10 code.
- If the service was rendered prior to the current year, such as for a retrospective P4P measure, or if Blue Cross Blue Shield is the secondary payer, submit the medical record documentation using the appropriate Quality Compliance Form (QCF). Forms are available under the Tools & Resources section of our Provider section of the website.. Medical records will not be accepted unless accompanied by the appropriate QCF. A QCF must be filled out for each measure for each individual member’s medical record. The documentation should be faxed to the Clinical Team for review at (716) 887-8640.
Physician Incentive Funds
The incentive pool will be funded by Blue Cross Blue Shield based on our annual membership numbers.
Provider Experience Team
The goal of the Provider Experience team (PE) is to work collaboratively with primary care providers/provider groups focusing on the quadruple aim. We assist practices with decreasing unnecessary medical costs while increasing provider quality and efficiency. We work to simplify practice interactions with Blue Cross Blue Shield and increase patient satisfaction. This is accomplished by providing physicians with data that pertains to their unique patient population, as well as other performance enhancement opportunities. We also provide group level data to support population health management throughout the practice.
The PE team process consists of a practice account manager and a business relationship manager visiting providers/provider groups to discuss utilization trends and gaps in care. Other resources are available as necessary, including a clinical pharmacist, medical director, coders and subject matter experts.
PE meetings with providers generally include a review of BestPractice quality and efficiency reports, discussion of quality programs and physician support. Practice account managers will offer guidance on how to succeed in our BestPractice value-based reimbursement model.
Practice account managers also review analyses for clinical population management and quality reporting using Risk Manager™ (RM). This online tool allows practices to proactively manage gaps in care. The PE team is a resource to practices that assists in navigating Blue Cross Blue Shield’s policies and procedures and maximizing opportunities to improve patient health outcomes.