Professional Provider Quality-Based Reimbursement Program

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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

2020 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 2020.

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 = 3 percent)
  • Provider Portal – Providers must verify and attest to 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. (3 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 — Applies only to anesthesia, pathology, radiology, urology, chiropractors, and optometrists. Although not prescribing providers, chiropractors will be eligible for this Group B measure. Quality Improvement Activity (approved by BCBSKS) for Primary Spine Providers (DC, MD, DO) may be included at a later time. (2.5 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. (1 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. (1 percent)
  • CCD or HIE use to State-approved HIO's OR Clinical Data Repository (CDR) incentive. NOTE – Providers may earn the HIE incentives or CDR incentives, but NOT both.
    • CCD or HIE use to State-approved HIO's – Each provider must have a user ID and HL7 real-time connectivity to qualify. Providers may earn either HL7 incentives or CCD incentive, but not both:

      1. HIE HL7 V2 Demographics, admissions, discharge, transfers – Must send all records for demographics, admissions, discharge, and transfers. This includes office visits. (.5 percent)
      2. HIE HL7 V2 Progress notes – Must send progress notes on all patient encounters. (.5 percent)
      3. HIE HL7 V2 Diagnosis and procedure coding – Must send diagnosis and/or procedure coding on all patient encounters. (.5 percent)
      4. HIE HL7 V2 Lab reporting – Must send all labs reports on all patient lab tests. (.5 percent)
      5. HIE HL7 V2 Medication records – Must send medication history on all patient encounters. (.5 percent)
      6. CCD complete/all data– Must send complete and comprehensive Continuity of Care Document record, HL7 V2 ADT, and HL7 V2 lab. (2.5 percent)
    • Clinical Data Repository (CDR) – Each provider must have HL7 real-time connectivity to qualify. Providers may earn either HL7 incentives or CCD incentive, but not both:
      1. CDR HL7 V2 Demographics, admissions, discharge, transfers – Must send all records for demographics, admissions, discharge, and transfers. This includes office visits. (.75 percent)
      2. CDR HL7 V2 Progress notes – Must send progress notes on all patient encounters. (.75 percent)
      3. CDR HL7 V2 Diagnosis and procedure coding – Must send diagnosis and/or procedure coding on all patient encounters. (.75 percent)
      4. CDR HL7 V2 Lab reporting – Must send all labs reports on all patient lab tests. (.75 percent)
      5. CDR HL7 V2 Medication records – Must send medication history on all patient encounters. (.75 percent)
      6. CCD complete/all data – Must send complete and comprehensive Continuity of Care Document record, HL7 V2 ADT, and HL7 V2 lab. (3.75 percent)
  • Access Formulary Electronically – Providers must electronically access member benefit information for eligibility, formulary, and medication history a minimum of 120 times per quarter. (.75 percent)
  • Generic Utilization Rate – Minimum generic prescribing of 85 percent (for all BCBSKS members with a prescription drug benefit). (.75 percent)
  • Anesthesia Performed in a Health System with a Level 1 Trauma Center – Must be dedicated onsite 24 hours a day, seven days a week, 365 days a year to a level 1 trauma center facility with a PICU and NICU and involved with teaching anesthesia residents. (5.5 percent)
  • Adolescent Well-Care Visits – The percentage of members who were 12-21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year. Must be greater than or equal to 50 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)
  • Cervical Cancer Screening – The percentage of women 21-64 years of age who were screened for cervical cancer. Must be greater than or equal to 75 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)
  • Colorectal Cancer Screening – The percentage of adults 50-75 years of age (51-75 as of December 31 of the measurement year) who had appropriate screening for colorectal cancer. Members with multiple screenings will be counted only once as appropriately screened. Must be greater than or equal to 60 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)
  • Comprehensive Diabetes Care (A1c testing) – The percentage of members 18-75 years of age with diabetes (type 1 or type 2) who had a Hemoglobin A1c test during the measurement year. Must be greater than or equal to 90 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)
  • Low-Back Pain – The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis. The percentage is reported as an inverted rate, therefore, a higher reported rate indicates appropriate treatment of low back pain (i.e. proportion for whom imaging studies did not occur). 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. Note — The member is attributed to the provider associated with the earliest date of service for an eligible encounter with a principal diagnosis of low back pain, regardless of specialty. Although not prescribing providers, chiropractors will be eligible for this Group B measure. (1 percent)
  • Statin Therapy for Patients with Cardiovascular Disease -- The percentage of males 21-75 years of age and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period. 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)
  • Statin Therapy for Patients with Diabetes -- The percentage of members 40-75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who remained on a statin medication of any intensity for at least 80 percent of the treatment period. Must be greater than or equal to 75 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)
  • Diabetes Care – Eye Exam – retinal – The percentage of members 18-75 years of age as of the end of the measurement year with diabetes (type 1 or type 2) who had an eligible screening or monitoring for diabetic retinal disease as identified by administrative data. Must be greater than or equal to 55 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)
  • Diabetes Care – Medical Attention for Nephropathy – The percentage of members 18-75 years of age as of the end of the measurement year with diabetes (type 1 or type 2) who had an eligible nephropathy screening or monitoring test, or evidence of treatment for nephropathy, as documented through administrative data. Must be greater than or equal to 90 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)
  • 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 75 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)

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)

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.

  • 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. Note — The member is attributed to the provider associated with the earliest date of service for an eligible encounter with a principle diagnosis of pharyngitis, regardless of specialty. (1.5 percent)
  • Appropriate Treatment for Children with Upper Respiratory Infection – The percentage of children 3 months to 18 years of age who were given a diagnosis of upper respiratory infection and were not dispensed an antibiotic prescription. 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. Note — The member is attributed to the provider associated with the earliest date of service for an eligible encounter with a principal diagnosis of URI, regardless of specialty. (1.5 percent)
  • 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. Note — The member is attributed to the provider associated with the earliest date of service for an eligible encounter with a principal diagnosis of acute bronchitis, regardless of specialty. (1.5 percent)