Blue Physician Recognition

General Disclaimer

The Blue Physician Recognition (BPR) designation means the physician has demonstrated a commitment to delivering quality and patient-centered care by participating in local, national, and/or regional quality improvement program as determined by the local Blue Plan. The BPR Program does not serve as a measure of the quality of care provided by a physician, group and/or practice or whether the physician will meet your particular healthcare needs. Absence of a BPR icon does not mean the physician or practice is of low quality; it could simply mean that the physician or practice does not participate in a quality improvement program recognized by the local Blue Plan.

Local Program Description -

2014 Professional Providers Quality-Based Reimbursement Program

This program will offer an opportunity for eligible providers to earn Blue Physician Recognition and increased reimbursement based on a two-tiered approach. This reimbursement will be in addition to the established Maximum Allowable Payments (MAPs) for 2014.

Tier I will apply to all contracting professional providers.  Services excluded from the additional reimbursement program are clinical lab, pharmacies and pharmaceuticals and dentists.

Tier II will only apply to providers represented in the category of office-based “primary care physicians (PCPs)” (family practice, general practice, general internal medicine, and pediatrics). Primary care providers working collaboratively with an ARNP/APRN and/or a PA, also qualifies the ARNP/APRN and/or the PA for the additional tier II reimbursement. The components of the QBRP are largely process-based metrics rather than clinical measures.

Qualifications for any quality-based reimbursement will be on an individual provider basis, rather than a clinic basis. There are eight components to the program and an eligible provider will independently qualify for each component.  The sum of all qualified category incentive percentages will be used to calculate the total QBRP percentage to be applied to the MAPs.

Tier I  Applies to all eligible CAP contracting professional providers 

  1. Electronic Self Service: The provider must use the Availity portal or the ANSI 270/271 transaction to electronically obtain BCBSKS patient eligibility and benefit information and will obtain BCBSKS claims status information through the Availity portal or the ANSI 276/277 transaction. BCBSKS will review reports to see who is using either of these electronic self service options. Providers who meet these criteria will receive an additional 1.0 percent increase to the 2014 MAPs for all services except for clinical lab, pharmacies and pharmaceuticals, and dental services. (1.0%)

    NOTE:  The Availity portal is available now, and we encourage all providers to take advantage of these self service features.

  2. Sign up to participate in the Kansas Health Information Exchange through a Kansas Department of Health and Environment approved Health Information Network (1.25%, applies to all services except for clinical lab, pharmacies, pharmaceuticals, and dental services.)
  3. Use of Electronic Prescriptions: ((a.) & (b.) are separate, independent measures)
  4. (a.) Electronically access member benefit information for eligibility, formulary, and medication history a minimum of 45 times per quarter. (1.0%, applies to E/M CPT codes only)
    (b.) Minimum generic prescribing of 75 percent (for all BCBSKS members with a prescription drug benefit) (.50%, applies to E/M CPT codes only)

    BCBSKS will obtain reports from Prime Therapeutics to validate these metrics quarterly.

Tier II  (Applies only to office-based Primary Care Physicians and associated PAs and APRNs in the specialties of family practice, general practice, internal medicine and pediatrics)

  1. Receive recognition from National Committee for Quality Assurance (NCQA) for the Diabetes Recognition Program. (.75%, applies to E/M CPT codes only)
  2. Achieve NCQA and/or URAC Patient Centered Medical Home recognition at any level (Level 1, Level 2, or Level 3). (.75%, applies to E/M CPT codes only)
  3. MMR percentage of children who had one measles, mumps and rubella vaccine by their second birthday. MMR percentage must be equal to or greater than 60% to meet metric. (.75%, applies to E/M CPT codes only)
  4. Breast cancer screening – Adult mammogram for age 50 and above. Adult mammography percentage must be equal to or greater than 60% to meet metric. (.75%, applies to E/M CPT codes only)
  5. BCBSKS will review the NCQA Web site to validate any provider meeting the criteria in items 4. and 5. Providers who meet the criteria for items 3. and/or 4. and/or 5. and/or 6. and/or 7. above will receive the additional increase (for each item, 3., 4., 5., 6., and/or 7.) to the 2014 MAPS for all E/M CPT codes.