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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
Members
Providers
Provider
Services
Employers
Chiropractic
Program
Community
Chiropractic
Committee
Quality
Management
Pilot
Programs
Health Care
Services
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
BlueShield
of Northeastern New York
Chiropractic Advisory Committee
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.
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 BlueShield for a twoyear 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.
BlueShield
of Northeastern New York
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
BlueShield
of Northeastern New York
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; coinsurance, 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
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 BlueShield-accepted clinical
guidelines are used
– Comply with regulatory agencies
BlueShield
of Northeastern New York
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.
BlueShield
of Northeastern New York
HEALTHeNET Web Application
PCI HELP DESK
1-877-895-4724
HOURS OF OPERATION:
7 a.m. - 7 p.m. Monday-Friday
Administrative Transactions:
One Stop Shopping…
Security:
One User ID
and Password
EPRO
Provider File
Updates
EPRO
Claims
Adjustment
Requests
HIPAA
Membership
& Eligibility
Transaction
HEALTHeNET
30,000+ users
EPRO
Future???
HIPAA
Referrals
Transaction
HIPAA
Claims Status
Transaction
Log In
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Provider Inquiry Transaction
Provider Inquiry Summary Transaction
Available Inquiry Summaries
Provider Inquiry Detail
Provider Website
bsneny.com
Provider Website
Network Information
Help Me Find
News and Events
Resources
Policies
Payment and Operations
BlueShield
of Northeastern New York
Health Care Services
Health Care Services
Member/Provider Experience
Targeted
Interventions
Diverse
Communication
Personalized
programs
Managing the Spectrum of Care
Intervention Health Coaching
63
Disease Management
Case Management
Objectives
• Lifestyle management
• Wellness-focused
• Clinical Coaching
• Physician Involvement
• High cost
• Catastrophic illness
• Frequent ER/hospitalization
Method
• Motivational
interviewing
• Skill building
• Holistic approach
• Education/resources
• Changing behaviors
• Using latest guidelines
• Holistic approach
• Obtain medically necessary care
and support
• Member-focused care plan
Programs
• Fitness
• Nutrition
• Stress management
• Smoking cessation
• Weight management
• Asthma
• Cardiac
• COPD
• CHF
• Diabetes
• ADHD
• Depression
• Back care
• Synergy DM
• Obstructive Sleep Apnea
• General
• Maternal-child
• Transplant
• Chronic kidney
• Palliative care
• ER use/high cost
• Rare conditions
BlueShield
of Northeastern New York
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