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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 -

2018 Professional Provider Quality-Based Reimbursement Program

This program will offer an opportunity for eligible providers to earn Blue Physician Recognition and increased reimbursement based on a three-group approach with prerequisites for participation. This reimbursement will be in addition to the established Maximum Allowable Payments (MAPs) for 2018.

QBRP Participation Prerequisites

Providers must conduct business with BCBSKS electronically (i.e. turn off paper). Providers must submit all eligible claims electronically, accept electronic remittance advice documents (ERAs: either through receiving the ANSI 835 transaction or by downloading the RA from the BCBSKS secured website, and turn off printed RAs), and receive all communications (newsletters, etc.) electronically.

Group A

Applies to all eligible contracting professional providers and to all eligible/covered CPT and HCPCS codes (excludes Clinical Lab [using codes on Medicare clinical lab fee schedule], Pharmacy and Pharmaceuticals, and Dental services).

  • Electronic Self-Service – Providers must use Availity portal or ANSI 270/271 & 276/277 transactions to electronically obtain BCBSKS patient eligibility, benefit, and claims status information. Electronic access must meet one of the percentages at left compared to the provider’s total number of queries to BCBSKS, regardless of the mode of inquiry to receive the corresponding incentive. Providers billing under a single tax ID number will have their inquiries combined for determining the applicable percent. (86-95 percent = 1.5 percent; 96 percent or greater = 2.5 percent)
  • Provider Portal – Providers must verify provider information twice a year according to the qualifying schedule below. Each individual provider’s information within a group must be verified. Verification must be completed within the BCBSKS provider information portal. (2 percent)

Group B

Applies to all prescribing provider types (MD, DO, DPM, OD, PA, APRN, CRNA) as applicable to the measure and to all eligible/covered CPT codes (excludes Clinical Lab [using codes on the Medicare clinical lab fee schedule], Pharmacy and Pharmaceuticals, and Dental services).

  • Registry Data – Providers must send sufficient patient information to meet CMS quality measures to a CMS-approved registry. Electronic submission is preferred. Providers under a group qualify as a group. Must send report to BCBSKS demonstrating acceptance of submitting data and meeting registry requirements. Note — Although not prescribing providers, chiropractors will be eligible for this Group B measure only. (1.5 percent)
  • Well-Child visits (W15) –The percentage of members who turned 15 months old during the measurement year and who had six or more well-child visits with a PCP during their first 15 months of life. Must be greater than or equal to 80 percent to meet the metric, calculated at the provider group level having at least five attributed/eligible patients. Individual providers in the group must have at least one attributed/eligible patient to receive incentive. (.25 percent)
  • Well-Child visits (W34) –The percentage of members 3 to 6 years of age who had at least one well-child visit with a PCP during the measurement year. Must be greater than or equal to 80 percent to meet the metric, calculated at the provider group level having at least five attributed/eligible patients. Individual providers in the group must have at least one attributed/eligible patient to receive incentive. (.25 percent)
  • KHIE HL7 use – Each provider must have a user ID and real-time connectivity to qualify for:
    1. Demographics, admissions, discharge, transfer – Must send all records for demographics, admissions, discharge, and transfers. This includes office visits. (1 percent)
    2. Progress notes – Must send progress notes on all patient encounters. (1 percent)
    3. Diagnosis and procedure coding – Must send diagnosis and/or procedure coding on all patient encounters. (1 percent)
    4. Must send all labs reports on all patient lab tests. (1 percent)
    5. Medication records – Must send medication history on all patient encounters. (1 percent)
  • Access Formulary Electronically – Providers must electronically access member benefit information for eligibility, formulary, and medication history a minimum of 120 times per quarter. (1 percent)
  • Generic Utilization Rate – Minimum generic prescribing of 80 percent (for all BCBSKS members with a prescription drug benefit). (1 percent)

Group C

Applies to primary care professionals including supervised mid-levels (FP, GP, Peds, IM, PA, APRN) unless otherwise noted and only to covered E&M codes. Group C incentives are earned at the group level (for physicians with attributed members) with the exception of Level 3 PCMH Recognition, which is incentivized at the individual level. New providers joining a group or changing tax IDs will not be eligible for the HEDIS metrics under the new arrangement until the refresh period.

  • PCMH Recognition – Provider must achieve Level 3 NCQA and/or URAC Patient Centered Medical Home recognition. (2 percent)
  • Breast Cancer Screening –The percentage of women 50 to 74 years of age (52 to 74 as of the end of the measurement period) who had a mammogram anytime in the past two years. Must be greater than or equal to 70 percent to meet the metric, calculated at the provider group level having at least five attributed/eligible patients for breast cancer screening. Individual providers in the group must have at least one attributed/eligible patient to receive incentive. Note — OB-GYN and Geriatrician providers can qualify as well. (1 percent)
  • Appropriate Testing for Children with Pharyngitis – The percentage of children 2-18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e. appropriate testing). Must be greater than or equal to 80 percent to meet the metric, calculated at the provider group level having at least five attributed/eligible patients. Individual providers in the group must have at least one attributed/eligible patient to receive incentive. (1 percent)
  • Appropriate Treatment for Children with Upper Respiratory Infection – The percentage of children 2-18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e. appropriate testing). Must be greater than or equal to 80 percent to meet the metric, calculated at the provider group level having at least five attributed/eligible patients. Individual providers in the group must have at least one attributed/eligible patient to receive incentive. (1 percent)

Group D

Applies to all prescribing provider types (MD, DO, DPM, OD, PA, APRN, CRNA) as applicable to the measure and only to covered E&M codes.

  • Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis – The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Must be greater than or equal to 30 percent to meet the metric, calculated at the provider group level having at least five attributed/eligible patients. Individual providers in the group must have at least one attributed/eligible patient to receive incentive. (1 percent)
  • Monitoring Patients on Persistent Medications – The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent (ACE Inhibitors or ARB’s, Digoxin, Diuretics) and also had at least one applicable lab test in the measurement period. Must be greater than or equal to 85 percent to meet the metric, calculated at the provider group level having at least five attributed/eligible patients. Individual providers in the group must have at least one attributed/eligible patient to receive incentive. (1 percent)