2015 Horizon BCBSNJ Physician Quality Recognition Program (QRP)

2015 Horizon BCBSNJ Physician Quality Recognition Program (QRP)

Frequently Asked Questions (FAQ)

Frequently Asked Questions (FAQ)

Q1. What is the Blue Physician Recognition (BPR) Program?

A1. Blue Physician Recognition (BPR) is a national program that identifies those physicians who have demonstrated a commitment to delivering quality, patient-centered care through participation in national, regional and/or local quality improvement or recognition programs. Each Blue Cross and/or Blue Shield Plan throughout the country administers its own quality improvement or recognition program. The BPR indicator is used to identify those physicians recognized by each Blue Cross and/or Blue Shield Plan.

Information regarding BPR is located on HorizonBlue.com/QRP.

Q2. What is the Horizon BCBSNJ Quality Recognition Program?

A2. As an independent licensee of the Blue Cross and Blue Shield Association (BCBSA), Horizon Blue Cross Blue Shield of New Jersey has developed its own criteria for the BPR program. The criteria for another BCBS plan may differ from Horizon BCBSNJ criteria.

Q3. What are the criteria?

A3. The criteria for each eligible specialty are listed on HorizonBlue.com/QRP.

Q4. Who is eligible to participate in BPR?

A4. Participating physician practices in the following specialties are eligible to participate in BPR:

- Cardiology.

- Endocrinology.

- ENT.

- Family Practice.

- Gastroenterology.

- Internal Medicine.

- Nephrology.

- Ob/Gyn.

- Orthopedic Surgery.

- Pediatrics.

Q5. Are there any exclusions to participating in BPR?

A5. Nonparticipating physician practices and participating physician practices with specialties other than the specialties noted in Q4 are excluded from participation.

Q6. What is the measurement year?

A6. The measurement year is the year that Horizon BCBSNJ reviews for the current BPR program. For example, BPR 2015 reviews claims from dates of services in the measurement year 2015 (January 1, 2015 through December 31, 2015)

Q7. What is the recognition or reward year?

A7. The recognition or reward year is the year that Horizon BCBSNJ will recognize the eligible physician practices that have met the BPR criteria. For example, BPR 2013 recognizes the physician practices in 2015.

Q8. How is the physician practice recognized?

A8. Our online Provider Directory and the BCBSA National Hospital and Doctor Finder will include the BPR icon in the physician profile of those physicians affiliated with the eligible practice. The eligible physician practice will receive an enhanced reimbursement of 15 percent above the Horizon BCBSNJ standard fee schedule for at least one year.

Exclusions to enhanced reimbursement:

·  Services including but not limited to: HCPCS codes, immunizations, CMS clinical laboratories, CMS durable medical equipment and radiology codes.

·  Medicare primary or income based (service benefits) member health plans.

·  Physician practices that participate in other Horizon BCBSNJ nonstandard reimbursement arrangements and Horizon BCBSNJ value-based programs are not eligible for financial recognition. This includes practices that participate in Horizon BCBSNJ’s patient-centered programs, such as Patient-Centered Medical Home, Accountable Care Organization and Episode of Care programs.

·  Physician practices whose specialty is ENT, Gastroenterology, General Surgery, Nephrology, Orthopedic Surgery, or Urology.

Q9. What is the BPR icon?

Q9. The BPR icon is the symbol that is placed in the physician profile on our online Provider Directory and the BCBSA National Hospital and Doctor Finder. It indicates that the physician is affiliated with a physician practice that has met the Horizon BCBSNJ Quality Recognition program criteria.

Q10. How does my practice become eligible?

A10. A physician practice is eligible if the physician practice is:

o Affiliated with a tax identification that is listed as participating in the measurement and recognition year.

o The physician practice is one of the eligible specialties.

o The physician practice must have at least 30 eligible Horizon BCBSNJ patients attributed to their practice.

o The physician practice must have at least 10 Horizon BCBSNJ members in a minimum of one metric to compare against specialty peer.

Q11. Are there limitations to the data?

Q11. The data is limited to our claim system and administrative sources. To have the most accurate and comprehensive information about your practice and patients, it is important that you submit all claims for your Horizon BCBSNJ patients for consideration and refer your patients to other in-network or participating providers. Every claim should include the most appropriate CPT® and/or HCPC codes, as well as all of the applicable diagnoses for your patients including their presenting and underlying diagnoses.

Q12. When is my practice evaluated?

A12. Eligible practices are evaluated according to the current criteria for the measurement year. For example, in the BPR 2015 program eligible practices were evaluated at year end for 2015.

Q13. Why is Horizon BCBSNJ evaluating my practice?

A13. In the insurance marketplace, patients and employer groups are asking for more information to help them make choices in using their health plan including but not limited to quality and cost information.

Q14. How often are scores generated?

A14. Scores are generated after the final review for the measurement year.

Q15. How are scores determined?

A15. The physician practice group compliance rate is compared to the peer specialty compliance rate.

The physician practice eligible member population for clinical quality is weighted per measure based on the number of standard deviations that the physician practice (group) compliance rate is above the peer compliance rate per measure.

EXAMPLE:

Measure / Compliant
Members / Eligible
Members / Group
Compliance
Rate / Peer
Compliance
Rate / Standard
Deviation / Weight
A / 8 / 60 / .13 / .30 / 0 / 0
B / 25 / 40 / .63 / .40 / 2 / 80
C / 20 / 20 / 1.00 / .50 / 3 / 60
Subtotal / 120 / 140

Clinical Quality Subtotal = Weight (140) / Eligible (120) = 1.167

The physician practice pharmacy dispensing behavior.

Pharmacy / Rx Prescribed / Total Rx Prescribed / Group
Compliance
Rate / Peer Compliance Rate / Standard Deviation
Preferred / 10 / 20 / .50 / .35 / 2
Generic / 5 / 20 / .25 / .10 / 1

The physician practice’s final score or ranking is equal to

Clinical Quality 90% of final score

Pharmacy Dispensing Behavior 10% of final score

For the example above the final score is 1.19.

Category / Subtotal / Final Score Weight / Final Score Calculation
Clinical Quality / 1.167 / .90 / 1.04
Pharmacy- Preferred / 2 / .05 / .10
Pharmacy- Generic / 1 / .05 / .05
Total / 1.19

The total final score for this group (1.19) is ranked against peers (1-100) to identify percentile.

Category / Percentile
Clinical Quality- 1.04 / 75th
Pharmacy- .15 / 90th
Total- 1.19 / 86th (overall ranking)

In the example above the physician practice receives nonfinancial and financial recognition because their final score is 85% or higher.

Q16. Why don’t we have scores?

A16. A physician practice may not have scores if:

- The physician practice does not participate with Horizon BCBSNJ.

- The physician practice specialty is excluded from the program.

- The physician practice does not meet the member threshold of 30 Horizon BCBSNJ

members in their panel.

Q17. How can I appeal my score?

A17. You can appeal your score by sending an email request to . Please include your name, telephone number, practice name and practice tax identification number.

Q18. How is my score calculated?

A18. Your practice’s score is calculated by the number of compliant patients divided by the number of eligible patients for each measure. These percentages are then compared to your specialty peer.

Q19. What is the reward for meeting the criteria?

A19. For eligible practices, the reward is enhanced reimbursement of 15 percent above the Horizon BCBSNJ standard fee schedule for at least one year.

Exclusions to enhanced reimbursement:

·  Services including but not limited to: HCPCS codes, immunizations, CMS clinical laboratories, CMS durable medical equipment and radiology codes.

·  Medicare primary or income based (service benefits) member health plans.

·  Physician practices that participate in other Horizon BCBSNJ nonstandard reimbursement arrangements and Horizon BCBSNJ value-based programs are not eligible for financial recognition. This includes practices that participate in Horizon BCBSNJ’s patient-centered programs, such as Patient-Centered Medical Home, Accountable Care Organization and Episode of Care programs.

·  Physician practices whose specialty is ENT, Gastroenterology, General Surgery, Nephrology, Orthopedic Surgery, or Urology.

Q20. How can I improve my score?

A20. You can improve your scores by:

- Ensuring patients receive the recommended preventive care services and tests by December 31st of every

year.

- Ensuring patients are compliant with medication adherence.

- Submitting claims to Horizon BCBSNJ with the presenting and underlying diagnosis codes on every claim.

- Submitting claims to Horizon BCBSNJ even though Horizon BCBSNJ may be the secondary or tertiary carrier.

- Ensuring your practice demographics is current with Horizon BCBSNJ.

Q22. Are there resources to help members comply with preventive screenings or medication adherence?

A22. Yes, Horizon BCBSNJ offers programs, services, and tools to help physicians and members manage the member’s health. Information about these resources can be found online at our website, HorizonBlue.com, Patient Health Support (Providers tab) and Health & Wellness (Members tab).

Q23. Will members be able to view BPR information?

A23. Yes, members who view our online Provider Directory or the BCBSA Hospital and Doctor Finder will be able to see the BPR icon in the physician profile.

Q24. Why is Horizon BCBSNJ making this information available to members?

A24. We are making this information available to members to help them make choices in using their health plan including but not limited to quality and cost information.

Q23. How can I submit questions or comments about the program?

A23. You may submit questions or comments about the program to .

CPT® is a registered mark of the American Medical Association.

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