BlueCross BlueShield of Western New YorkChiropractic Program

Proprietary & Confidential//Overview for Educational Purposes//Additional Questions//Contact Provider Relations

Chiropractic Workshop Agenda• Chiropractic Program

• Provider Relations

• HEALTHeNET/ ASK/ Provider Website

• Quality Management

• Wellness Benefit

• Health Care Services

• Future Projects

• Questions

Changing Environment • The consumer’s role in health

care decision making is expanding

• Consumers will have more options for how, where, and from whom they purchase health insurance

• Costs continue to rise and the quality of care needs to improve

• Government regulations are dramatically changing

Beginning January 1, 2013Chiropractic Program

Providers

Provider Services

Quality Management

Pilot Programs

Health Care Services

Chiropractic Committee

Community

Employers

Members

Chiropractic Program

Chiropractic Program Goals• Leverage claims data and quality measures to

substantiate chiropractic services• Decrease spinal surgeries• Reduce pharmaceutical dependence

– Pain medications and spinal injections– Inappropriate and unnecessary imaging for spinal issues

• Optimize chiropractic provider network performance– Reduce administrative burden; less paperwork– More time with patients

• Reduce over- and under-utilization• Increase outcomes and reduce risk• Align patients and providers• Support performance management programs

Chiropractic Advisory Committee

Chiropractic Advisory Committee

• Ensure continuing access to high-quality, medically appropriate, evidence-based, cost-effective chiropractic care.

• Maintaining a consistent and clinically appropriate approach in the administration of chiropractic care, including development of its clinical practice guidelines.

• Develop clinically integrated programs and quality incentive programs.

• Aid in the development of coverage criteria, review of coverage decisions, and technology assessments.

• Review administrative rules pertaining to health care issues that may be related to the delivery of high-quality chiropractic care.

Chiropractic Advisory Committee

• Clinical practice guidelines• Chiropractic Treatment Request Form• Policies and procedures• Medical procedures• Outcome-based pilot programs• Health Care Services programs

Chiropractic Committee Commitment • Members are appointed by BlueCross BlueShield

for a two-year term beginning with attendance at their first committee meeting and may be renewed for two additional two-year terms.

• However, to ensure institutional memory of the committee, initial appointments may be extended to three- or four-year initial appointments.

• After the initial two years of the committee’s existence, one-third of the members will rotate off the committee after two years, one-third after three years and one-third after four years.

• If members do not volunteer to rotate off the committee, selection will occur via a random name selection process.

Provider Relations

Provider Relations

• The Provider Relations Specialist is your primary link with BlueCross BlueShield. – Delegated by zip code or territory– Share information and analyze practice

patterns in an effort to help you provide quality, cost-effective care

• Our commitment to partnering with our participating providers is vital to providing quality coverage for our members.

Medical Management Model• Members will have unlimited chiropractic

coverage. • Members and providers will no longer have

to complete the paperwork; therefore, access to care is easier with our model.

• A limited number of BlueCross BlueShield ASO contracts will still be managed through the preauthorization process.

• Chiropractors will now have a direct line of communication with the health plan, as well as the ability to share recommendations on quality programs and other initiatives.

Network Updates• Management of Services for chiropractors, massage

therapists, and acupuncturists.• Open network enrollment for Erie County, NY:

– January 1, 2013• Previously, participating chiropractic providers:

– Were dual contracted with the Palladian network and the BlueCross BlueShield network.

– Will not need to do anything because your participating provider agreement with BlueCross BlueShield will automatically become effective on January 1, 2013.

• To date, we have not received a single notice of termination from a chiropractor

• Therefore, the network and the access to care is not reduced

Claim Submission

• Dates of service December 31, 2012 and prior – continue to submit to Palladian Health.

• Dates of service January 1, 2013 and later– submit to BlueCross BlueShield for

processing and reimbursement – Payor ID: 00801

BlueCross BlueShield Reimbursement and Fee Schedule• Increase in BlueCross BlueShield fee

schedule for initial and established office visits by 5 percent starting January 1, 2013 – All lines of business

• Re-evaluation fee has been included• Fee schedule is available on the

provider website

Provider Credentialing Process (CAQH)

• Providers can enroll into our health plan by filling out the Universal Credentialing Application with Council for Affordable Quality Healthcare (CAQH).– Enter your CAQH Provider ID to

enter or update your information– Authorize BlueCross BlueShield to

access your information electronically

Direct Communication

• Provider Representatives• Provider Website• Provider Quarterly Newsletters• Yearly Provider Expo• Provider Customer Services• Chiropractic Advisory Committee

Quality Management

Quality Management

• Health Insurance Overview • InterQual Criteria• Chiropractic Authorization • Chiropractic Treatment Request

Form/Flow Chart• Internal Processes• Quality Department

Health Care Plans and Systems

• Managed Care Plans– Preferred Provider Organization (PPO)

• Participants care must be provided by selected health care providers, but participants can go outside the network; co-insurance, high deductibles.

– Exclusive Provider Organization (EPO)• Participants care must be provided by selected health care

providers, but participants cannot go outside the network; they are completely responsible for payment.

– Health Maintenance Organization (HMO)• Health care system assumes both the financial risk associated with

providing services and responsible for health care delivery in a particular geographic area; usually a fixed, pre-paid fee.

– Point-of-Service (POS)• HMO/PPO ‘hybrid’: resembles HMO for in-network services but

services outside of the network are usually reimbursed in a manner similar to fee schedule.

• Self-Insured Plans– Administrative Services Only (ASO)

• Employer hires a third party to deliver administrative services; claims processing and billing; employer bears the risk for claims.

Members Requiring Authorizations

• ASO/Experience Rated Groups (Self-Funded)– Fastest-growing types of employee benefit

arrangements– Employers are responsible for directly funding all

claims that their employees incur – Employers pay a fixed fee for administrative

services such as claim payment and management reporting

– An insurance company provides those administrative services, but doesn’t collect any premiums where no insurance risk has been underwritten

Chiropractic Visit Restrictions

• Three Major Limitations:

– Medical necessity prior authorization requirement

• Can vary from first visit to the twentieth visit

– Maximum dollar limit, ex: $200

– Maximum visit limit, ex: 20

Clinical Practice Guidelines

• InterQual Chiropractic Criteria– Created by actively practicing

chiropractors across the country– Promotes evidence-based standards of

care– Accepted by:

• Chiropractic Advisory Committee• Quality Management Committee

– Available on the Provider Website

Medical Review:Chiropractic Treatment Request (CTR)• Provider Office

– Checks patient contractual agreement• If no limits: treat patient• If limits: determine allowable visits

• Complete the CTR form before contractual visits have been exhausted

• For example:– If five visits are allowed without medical necessity,

complete CTR form after the fourth visit• Fax completed form BlueCross BlueShield at 1-716-887-7913• Provider and member will be notified of decision within three

days via: – mail – phone call

• If additional visits are required, submit additional CTR forms

Page 1

Page 2

Chiropractic Treatment Request

• Step 1:– Checked by staff:

• Eligible member• If required• Complete

• Step 2:– Checked by RN:

• CTR reviewed against InterQual Criteria• Additional visits given• If unable to make a determination

• Step 3:– Checked by Chiropractor:

• Combination of InterQual Criteria and clinical judgment

Provider Expectations

• Self Governance– Maintain quality medical records– Comply with HIPAA standards

• Practice Guidelines– Apply appropriate evidence-based care

to members– Ensure BlueCross BlueShield-accepted

clinical guidelines are used– Comply with regulatory agencies

Wellness Benefit

The Wellness Card • Available with the Aqua plan, Wellness Benefit

(formerly Lifestyle Rider), and Healthy Balance, effective January 1, 2013.

• All subscribers, will receive a Visa to be used with a nationwide network of health and wellness retailers based on merchant type and/or merchant category.– Fitness centers– Massage therapy– Chiropractic visits – Health food stores – And many more!

• All transactions are handled through Visa and processed through our vendor, Discovery Benefits.

The Wellness Card

• Lifestyle Rider: Effective January 1, 2013 the Lifestyle Benefit will be referred to as the Wellness Benefit.

• A wellness card will be provided to subscribers of the Aqua plan, Wellness benefit and Healthy Balance.

Senior Fitness Benefit

• The BlueCross BlueShield network will be partnering with SilverSneakers, effective January 1, 2013.

• If you are not currently part of the SilverSneakers network but would like to be, you can submit a request to begin the application process online at silversneakers.com.

• If you are already a SilverSneakers provider, no further action is required.

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Managing the Spectrum of Care

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Future Projects

Future Projects

• Educational workshops• Chiropractic continuing education• Pay for performance pilots • Interdisciplinary and chiropractic care

connections• Patient-centered medical home• College collaborations

Overview What are the benefits?

Member • Unrestricted chiropractic care*• Control over their health decisions• Improved outcomes • Improved overall satisfaction • Improved health and well-being• Reduction in member health care costs

Chiropractic • Increase reimbursement• Eliminates paperwork• Reduces administrative burden placed on the provider, staff, and

patient• Allows additional time to treat patients• Improving satisfaction and outcomes for patient• Internal direct contact with BlueCross BlueShield

Community • Musculoskeletal-specific wellness seminars• Collaborate with providers/members to drive

performance/quality • Improving customer satisfaction: providers, members,

employers, community

*Please refer to members contractual agreements for chiropractic coverage

BlueCross BlueShield of Western New York is a division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. BlueCross, BlueShield and the Cross and Shield symbols are registered trademarks of the BlueCross BlueShield Association. WNY_2477_11-10

We look forward to a long, exciting future.

Questions?

Please contact: BlueCross BlueShield of Western New York

Provider Relations Department

1-800-666-4627