Download Chiropractic Program

BlueShield
of Northeastern New York
Chiropractic Program
Chiropractic Overview
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Chiropractic Program
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Provider Relations
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HEALTHeNET/ ASK/ Provider Website
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Quality Management
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Wellness Benefit
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Health Care Services
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Future Projects
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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
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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
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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
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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
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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.
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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
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News and Events
Resources
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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
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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
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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
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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