BlueShield of Northeastern New York

BlueShield of Northeastern New York

Chiropractic Program

Chiropractic Overview• 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, 2013: Chiropractic 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


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

• Maintain a consistent and clinically appropriate approach in the administration of chiropractic care, including development of 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.


• 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 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 committees’ 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 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• Less cumbersome for the chiropractors.• A limited number of BlueShield ASO contracts will

still be managed through the preauthorization process.

• As a result, these 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.

• Furthermore, chiropractors will now have a direct line of communication with the health plan and 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:– January 1, 2013

• Previously, participating chiropractic providers:– Were dual contracted with Palladian network

and the BlueShield network.– Will not need to do anything come January 1,

2013 because your participating provider agreement with BlueShield will automatically become effective.

Claim Submission

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

• Dates of services January 1, 2013 and later:– submit to BlueShield for processing and

reimbursement – Payor ID: 00800

Reimbursement/Fee Schedule for BlueShield• Increase in 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– Allowed once every 3 months

• 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 the Council for Affordable Quality Healthcare (CAQH)– Enter your CAQH Provider ID to enter or

update your information– Authorize 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• Fraud/Abuse

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 responsibility 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 such as 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

employee claims– Employers pay a fixed fee for administrative

services like 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 forms to 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

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 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 card 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 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.

http://www.silversneakers.com/


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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• Eliminate paperwork• Reduces administrative burden placed on provider, staff, and

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

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

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

employers, and community*Please refer to members contractual agreements for chiropractic coverage

We look forward to a long, exciting future

Questions?

Please contact: BlueShield of Northeastern New York

Provider Relations Department

1-518-220-5601

BlueShield of Northeastern New York

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