Home Health Care Delivery

Reimbursement Advocate Alert for July 12, 2012

Table of Contents:

1.  Members to Start Leaving Doctor Reviews in Provider Directory
2.  Change in Specialty Designation for Physicians
3.  Make Specialty Drugs Convenient for Your Patients*
4.  It's Imperative for All Health Care Providers to File Claims on Time

1.  Members to Start Leaving Doctor Reviews in Provider Directory

The new version of Find a Doctor or Hospital allows Blue Cross Blue Shield of Michigan members to leave ratings or post a comment about their doctors. The June 2012 Record gives details about the Review a Doctor feature and the upgraded provider search function and directory. Twenty-four Blue Cross plans have this feature in place and the remaining plans are implementing the Review a Doctor feature this month.

Only BCBSM members who log in to the Member Secured Services site, agree to the Terms of Use and User Agreement, and attest they have seen the physician may leave a review. The member answers a standard set of questions on a scale of one to five. The member also has the option to leave a comment.

You can see if there are any reviews about you by visiting bcbsm.com.

• Click on the Find a Doctor or Hospital link.
• Enter your office ZIP code in the search column.
• Select your practice category in What are you looking for?
• Under What is your network?, select PPO Plans-All Other.
• Under Advanced Options, type in your name.

Before any BCBSM member comments are posted, they undergo an extensive review or moderation process. BCBSM does not allow obscenities, allegations of illegal activity, discriminatory or disparaging remarks, knowingly untrue statements, commercial solicitation, spamming, links to other sites, protected health information and harassment of health care providers or other users. Any rating or review that violates the Terms of Use and User Agreement is not posted. Comments that meet the criteria for posting are not edited.

If you feel a comment posted about you violates the Terms of Use and should be removed:

• Visit bcbsm.com.
• Click on I am a PROVIDER.
• Click on More>>.
• Scroll down toward the bottom of the Welcome Providers page.
• In the Provider Services section, click on "New" Patient Review Inquiry.
• Complete the form, and click on Submit.

You’ll receive a response within five to seven business days in writing through US mail from BCBSM.

Your provider consultant or provider inquiry representative will also direct you to fill out the Patient Review Inquiry form when you speak with them about a member comment.

Later this year, BCBSM will be adding an online feature through the Provider Secured Services portal that will allow you to leave your own comment posted next to the member’s review. Your comments will undergo the same moderation and review process as member comments. When the provider comment feature becomes available, BCBSM will explain in The Record how to post an online comment.

2.  Change in Specialty Designation for Physicians

Blue Cross Blue Shield of Michigan and Blue Care Network are changing the way they handle specialty designations for physicians.

All specialty designations will come from the CAQH UPD application
Effective this summer, the Blues will list physicians in its online provider search only under the specialties designated on the Council for Affordable Quality Healthcare^® Universal Provider Datasource^® application. That means in the Blues’ online provider search:

• Physicians previously associated with specialties that are not on their CAQH UPD applications will no longer be associated with those specialties. 
• Any specialty listed on the CAQH UPD application will be reflected in our online provider search, provided credentialing requirements are met.

Primary specialty will come from the CAQH UPD application
Beginning July 1, 2012, the BCBSM online provider search will display both primary and secondary specialties, if applicable. The specialty listed will be taken from the CAQH UPD application, regardless of board certification status, provided credentialing requirements are met.

This change occurred in the BCN online provider search in June 2012.

As a result of this change, physicians should carefully designate their primary specialties on their CAQH UPD applications, as the primary specialty:

• Determines whether the physician is designated as a primary care physician or a specialist for managed care networks (specialties eligible for participation as a primary care physician include family medicine, internal medicine, general practice, pediatrics, geriatric medicine and preventive medicine) 
• May affect the way claims are processed and paid 
• Is now reflected in the BCBSM and BCN online provider searches

Regardless of which specialty is identified as primary, when enrolling in managed care programs, such as Community Blue PPO^SM, Medicare Plus Blue^SM or Blue Care Network:

• Physicians need to be board certified or board eligible in either or both the primary or secondary specialty listed on the CAQH UPD application. 
• Physicians who are not board certified in their primary specialty must have completed the advanced training in that specialty that is required by the board. 
• Physicians who are not board certified or board eligible in any specialty will not meet credentialing requirements for managed care programs.

If you have specific questions about your situation related to these changes, we encourage you to contact your BCBSM provider consultant or BCN provider representative.

3.  Make Specialty Drugs Convenient for Your Patients*

Blue Cross Blue Shield of Michigan’s specialty drug program is designed to improve patient care and help moderate the expense of specialty medications for its members.

BCBSM identifies specialty drugs as those that require special handling, administration or monitoring. These drugs can be used to treat complex and chronic conditions, including cancer, chronic kidney failure, multiple sclerosis, organ transplants and rheumatoid arthritis.

BCBSM's Specialty Drug Program Member Guide (PDF) lists the drugs categorized as specialty medications. BCBSM updates the guide quarterly and is available at bcbsm.com for you and your patients.

If your patients request it, they can:

1. Go to bcbsm.com.
2. Click on Member and More.
3. In the left-hand navigation, click on Prescription Drugs and then Specialty Drugs.
4. Scroll down to How do I order specialty drugs? and click on specialty drug guide (PDF).

BCBSM encourages you to share the following information with your patients about filling their prescriptions for specialty drugs:

• Most Blue Cross members with specialty drug coverage can have their prescriptions filled through a participating Blues retail pharmacy or the appropriate specialty mail-order pharmacy. 
• If your patient would like to fill a specialty medication through the mail, most will have to be filled through Walgreens Specialty Pharmacy, our specialty mail-order provider. Walgreens Specialty Pharmacy can be reached at 866-515-1355. 
• Some manufacturers limit the distribution of specialty drugs. Those drugs are not available through Walgreens Specialty Pharmacy.

Limited drugs currently include: Apokyn^®, Arcalyst^®, Carbaglu^®, Orfadin^®, Remodulin^®, Sabril^®, Somavert^®, Tyvaso^®, Ventavis^® and Xenazine^®.

If a patient would like to fill a limited distribution drug through the mail, Blue Cross has secured access to these drugs through Accredo^®, Express Scripts/Medco^® specialty pharmacy. Accredo can be contacted at 800-803-2523.
For billing and reimbursement assistance, call the appropriate number on the back of the member’s ID card.

If your Blues patients have questions about their specific coverage, they should call the Customer Service number on the back of their ID cards.

* Members with Federal Employee Program insurance have a separate specialty drug program. FEP members need to check the http://www.fepblue.org/ web site or call the number on the back of their ID card for information about specialty drugs. FEP members receive a higher level of benefits when their specialty drugs are obtained through the FEP Specialty Drug Pharmacy Program.

4.  It's Imperative for All Health Care Providers to File Claims on Time

Health care providers must follow claims filing deadlines for original claims and status inquiries.

Original claims must be submitted within specified time frames from the date of service (180 days for professional providers and 12 months for facility providers), and status inquiries must be made within 24 months of the day the claim was paid or denied. If you submit a claim after the filing limit, Blue Cross Blue Shield of Michigan will not offer any special handling or filing extensions, and no payment will be due from BCBSM or the subscriber.

Check your participation agreement with Blue Cross Blue Shield of Michigan, which defines your time period for filing claims.

For more information, see the related article in the June 2012 Record.

For more information about reimbursement issues, contact Stacie Saylor, CPC, at MSMS at 517-336-5722 or ssaylor@msms.org. For more news and information, visit www.msms.org where you can read Medigram and Michigan Medicine online.