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 -

2013 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 2013.

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. Clinical measures as well as an expansion of other quality components will be considered for inclusion for 2014.

Qualifications for any quality-based reimbursement will be on an individual provider basis, rather than a clinic basis. There are four 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

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 monthly reports to determine eligible providers for this incentive category. Services excluded from this incentive category are; clinical lab, pharmacies and pharmaceuticals, and dental services.

Tier II Applies only to office-based Primary Care Physicians in the specialties of family practice, general practice, general internal medicine, and pediatrics. Primary care providers working collaboratively with an ARNP/APRN and/or PA, also qualifies the ARNP/APRN and/or PA for additional reimbursement.

Use of Electronic Prescriptions: ((a.) & (b.) are separate, independent measures)
(a.) Electronically access member benefit information for eligibility, formulary, and medication history a minimum of 15 times per quarter

(b.) Minimum generic prescribing of 70 percent (for all BCBSKS members with a prescription drug benefit)

BCBSKS will obtain reports from Prime Therapeutics to validate these metrics quarterly.
Receive recognition from NCQA for the Diabetes Recognition Program.
Achieve NCQA Patient Centered Medical Home recognition at any level (Level 1, Level 2, or Level 3).
BCBSKS will review the NCQA Web site monthly to validate any provider meeting the criteria in items 3. and 4.