PROVIDER SEMINAR
BlueCross of Northeastern Pennsylvania
October 5, 2011
WELCOME
Jeanne Wisnewski
Director, Provider Relations
HEALTH PLAN UPDATES
Odette Ashby
Provider Relations Consultant
Updates
BlueCross of Northeastern
Pennsylvania
BCNEPA Updates
Radiology Management Program
• Effective with date of service November 1, 2011, prior
authorization through NIA is required for select nonemergent, advanced outpatient radiology services
• All professional offices or free-standing radiology
providers who perform these select studies must be
privileged by NIA for BCNEPA
• Excludes services performed in emergency room,
observation, inpatient and qualified contracted urgent
care centers
BCNEPA Updates
Radiology Management Program
• Applies to FPLIC and FPH Group Products and CHIP
• Does NOT apply to self-funded groups or individual
products
• In Luzerne County, the existing capitated radiology
program still applies for FPH members
BCNEPA Updates
Radiology Management Program
• Ordering physician is responsible for OBTAINING
authorization
• Luzerne County members whose PCP is part of the
Cap Rad program must still be directed to the capitated
provider for CT, CTA, CCTA
• Rendering providers should VERIFY that authorization
has been obtained
BCNEPA Updates
Radiology Management Program
• Applies to the following studies:
• Nuclear Cardiology
• Stress Echo Cardiology Procedures
• CT/CTA/CCTA*
• MRI/MRA*
• PET Scans*
*
Continue to call BCNEPA to request authorization for select
services for individual members and self-funded accounts
BCNEPA Updates
Radiology Management Program-Privileging
• Establishes consistent standards for all diagnostic
imaging services
• Establishes minimum participation guidelines
– Facility accreditation
– Equipment capabilities
– Physician and technologist education, training and certification
– Procedures for handling emergencies
– Radiation safety guidelines
BCNEPA Updates
Radiology Management Program
Training will be offered via webinar on the following dates:
• October 18, 2011
• October 19, 2011
• October 20, 2011
• October 25, 2011
• October 27, 2011
There will be 2 hour-long webinars each day – 8:00 am and 12:00 pm
To register, contact NIA at 1-800-327-0641 at least one week prior to the
session you wish to attend
BCNEPA Updates
Radiology Management Program

Complete information is available at the BCNEPA
Provider Center

Select “Resources and Tools”

Select “BCNEPA NIA Radiology Management
Program”
Quick Reference Guide for Facilities
Quick Reference Guide for Ordering Physicians
FAQ’s
BCNEPA Updates
New Products
– Offered August 1, 2011
• AffordaBlue
• BlueCare QHD EPO
– Developed to:
Provide new products with reduced premiums
Significantly reduce out of network utilization to keep
healthcare $$ and services in our service area
Position our portfolio for healthcare reform
BCNEPA Updates
AffordaBlue
– Alpha Prefix - QFZ
– 3 Levels (Tiers) of Benefits
1. Custom PPO Network (FPLIC PPO network plus
Lehigh Valley, Berwick, Bloomsburg providers
and Bon Secours Hospital
2. Hospitals that charge a facility fee for an
outpatient visit with a hospital based physician
and whose costs exceed specific thresholds
3. BlueCard PPO Network
BCNEPA Updates
AffordaBlue
• Member Cost Sharing
–$
Tier 1 Provider = lowest cost
– $$ Tier 2 Provider = median out-of-pocket cost
– $$$ Tier 3 Provider = highest out-of-pocket cost
• Separate deductible and co-insurance applies to each tier
• Services rendered by non-network providers are covered
for emergency services only
BCNEPA Updates
AffordaBlue Key Benefit Features
• No PCP selection is required
• No Referrals
• Deductible/co-insurance plan design – no co-pays
• Prescription coverage is offered as a rider
 Multi-tiered
 Generic-based
BCNEPA Updates
AffordaBlue Key Benefit Features
•
Benefits are applied based on the provider’s network
participation
•
Preventive services are covered without cost-sharing
at the Tier 1 and Tier 2 providers
•
Member will be liable for costs associated with
services provided by Tier 2, Tier 3, and nonparticipating providers even if the service is not
available from a Tier 1 provider.
•
No coverage is provided for non-emergency services
rendered by a non-network provider
BCNEPA Updates
BlueCare QHD EPO
• Alpha Prefix – QFI
• Two Tiers of Benefits
1. Current FPLIC EPO Network (FPLIC PPO Network
plus Lehigh Valley, Berwick, Bloomsburg providers
and Bon Secours Hospital)
2. BlueCard PPO Network
BCNEPA Updates
BlueCare QHD EPO
• Member Cost Sharing
– $ Tier 1 Provider = lowest cost
– $$ Tier 2 Provider = highest out-of-pocket cost
• Separate deductible and co-insurance applies to each tier
• Deductible and out-of-pocket maximums must differ in
each tier
• Services rendered by non-network providers are covered
for emergency services only
BCNEPA Updates
BlueCare QHD EPO
• No PCP selection is required
• No Referrals
• Deductible/co-insurance plan design – (no co-pays
except for prescriptions)
• Integrated Prescription Drug Benefit
BCNEPA Updates
BlueCare QHD EPO
• Benefits are applied based on the provider’s network
participation
• Preventive services are covered without cost-sharing
at Tier 1 providers
• Member will be liable for costs associated with services
provided by Tier 2 and non-participating providers even
if the service is not available from a Tier 1 provider.
• No coverage is provided for non-emergency services
rendered by a non-network provider
BCNEPA Updates
Security 65 Processing After Medicare Exhausts
• Claim must be submitted on an original red and white
UB-04 claim form
• Report the applicable occurrence codes and dates in
locator #31
– A3
Benefits Exhausted, Payer A
– B3
Benefits Exhausted, Payer B
– 24
Date Insurance Denied
See October, 2011 Provider Bulletin
BCNEPA Updates
• Medicare Part B claim must be billed to Medicare prior
to submitting the Medicare exhaust claim to BCNEPA
 Include the Medicare EOMB with the paper claim
• Written documentation of the Medicare allowed
amounts must be attached to the form (i.e. a screen
print from the Medicare system showing the amount
they would allow)
• Submit claims to:
BCNEPA Claims
P.O. Box 890179
Camp Hill, PA 17089-0179
BCNEPA Updates
Home Health Precertification Requests
• The Home Health Initial Precertification Worksheet has
been updated and now requires an explanation of
member’s homebound status. The worksheet is located
on our Provider Center
• Precert must be requested prior to assessing the patient
or rendering services
• Retro requests must be submitted within 5 days of the
start of services
BCNEPA Updates
Utilization Management Department
• Complete ALL fields on request forms
• Check the monthly Provider Bulletin for updates to
processes throughout 2011
• Precertification requests may now be e-mailed directly
to our Utilization Management Department through a
secure, confidential e-mail address:
umreviews@bcnepa.com
• Current Focus PAC listings for FPLIC, EPO and BC
(Non-FPLIC) lines of business are available on our
Provider Center
BCNEPA Updates
Provider Claim Issues
For providers without NaviNet access, ALL claim inquiries,
reconsiderations and research requests must be initiated
through the appropriate Blue Cross of Northeastern
Pennsylvania (BCNEPA) address or by contacting the
appropriate customer service department
* Claim issues directed to any other area may result in
a delay in responding to your request
BCNEPA Updates
• All written Blue Cross/FPLIC claim issue requests must
be sent to:
Claims
PO Box 890179
Camp Hill, PA 17089-0179
• Continue to use the Claims Research Request Form and
send FPH claim issue requests to:
BlueCare HMO
19 N. Main St.
Wilkes-Barre, PA 18711
BCNEPA Updates
Provider Bulletins
• Be sure to review/print the monthly provider bulletin
from the BCNEPA Provider Center; this can be
accessed via NaviNet or www.bcnepa.com
• For those providers with NaviNet access, there is a
monthly Blue Alert message indicating the current
bulletin is now available
BCNEPA Updates
Provider Center
Our Re-designed BCNEPA Provider Center is your
resource for important information and updates.
Please check the Provider Center site via NaviNet or
www.bcnepa.com prior to contacting us for bulletins,
forms, policies, manuals, etc.
BCNEPA Updates
BCNEPA Updates
BCNEPA Updates
BCNEPA Updates
BCNEPA Updates
BCNEPA Updates
Highmark Blue Shield Updates
Highmark Blue Shield Updates
Authorization Requirement Update
• 15 new codes added to authorization list effective
October 3, 2011
• Applies to Direct Blue (group only) and Freedom Blue
PPO
• Highmark-sponsored NaviNet should be used to
request authorization for services
See Special Bulletin dated June 23, 2011 for a complete list of codes
Highmark Blue Shield Updates
Reimbursement Changes Approved
• Increases to specific services effective 7/1/11
• Minimal number of codes decreased effective 9/26/11
• Payment differential updated for E&M services
performed in a facility vs. non-facility effective 9/26/11.
Highmark Blue Shield Updates
Reimbursement Changes
• Fee information is available via Highmark’s NaviNet
 From the Plan Central Menu, select Allowance, then
select Allowance Inquiry to view pricing for specific
procedure codes by plan or product type
OR
 Use “Provider Center/Medical and Claims Payment
Guidelines/ Fee Modification” to view the complete
list of adjustments
Highmark Blue Shield Updates
Technical Component Multiple Procedure
Payment Reductions
• Two or more services on contiguous body parts, same
patient, same day
• Effective 9/26/11, the highest priced procedure is paid in
full
• Payment reduction of 50% will be applied to the technical
component allowance of each additional procedure
• See PRN dated June, 2011 for list of affected procedure
codes
Highmark Blue Shield Updates
Elimination of Paper Initiative
• Phase I: Effective 10/01/10, all new assignment accounts and new
practitioners are automatically enrolled in Highmark’s NaviNet,
paperless EOB’s, and EFT
• Phase II: By 6/30/11, all current NaviNet-enabled practitioners will
be required to enroll in paperless EOB’s and EFT
• Phase III: By 12/31/11, all practitioners doing business with
Highmark will be required to enroll in NaviNet, paperless EOB’s
and EFT
IMPORTANT NOTE: Change in banking information or authorized
person requires completion of a new form.
Highmark Blue Shield Updates
Reminder:
Paper versions of the Policy Review and News (PRN)
and Behind the Shield publications have been
eliminated. Each issue of the newsletters is posted
online in the Provider Resource Center
• PRN contains medical policies
• Behind the Shield is bimonthly newsletter
• Special Bulletins are a companion to the above regularly
scheduled periodicals and will still be issued
• Consider enrolling in E-subscribe
Highmark Blue Shield Updates
Credentialing & Recredentialing
• Effective October 17, 2011, CAQH will be the sole
credentialing/recredentialing system for Highmark
• Paper will be accepted until 10/16/11
• If no internet access, contact CAQH Help Desk at
1-888-599-1771 for other options
Highmark Blue Shield Updates
Prescription Drug Formulary
• Updated quarterly via Special eBulletin
• eBulletins are available on-line at:
 Highmark’s Provider Resource Center
 NaviNet Plan Central
• Walgreen’s Specialty Pharmacy (formerly MedMark)
exclusive provider for self-administered injectables or
oral biotechnology drugs
Highmark Blue Shield Updates
Medicare Advantage Updates
Global Surgery Period
• Highmark adopted CMS global surgery values of 0
(zero) and 90 (ninety) days in 1999
• 10-day post-op was not recognized due to system
limitations and 0 (zero) was used
• Effective 7/22/11, Highmark recognizes a 10-day
post-op period for Freedom Blue Members only
Medicare Advantage Updates
Medicare Advantage PPO Network Sharing
•
A reminder that all “Blue” Medicare Advantage PPO
Plans are participating in reciprocal network sharing
•
The “MA” in the suitcase on the member’s card will
help you identify these members
•
Providers should always check the out-of-area
member’s benefits via the Blue Exchange transaction
on NaviNet, or by calling the BlueCard eligibility line –
1-800-676-BLUE
Medicare Advantage Updates
Medicare Advantage PPO Claim Submission
• Submit all Medicare Advantage claims to Highmark.
– Electronic claims are to be submitted directly to Highmark via trading
partner agreement (TPA) with 378 plan code / NAIC # 54771C
– To establish a TPA, visit Highmark’s Provider Resource Center,
Electronic Data Interchange (EDI) Services and complete the request
on-line
– Paper Claims:
FreedomBlue PPO Claims
PO Box 890062
Camp Hill, PA 17089-0062
Medicare Advantage Updates
National Correct Coding Initiative (NCCI)
• Developed by CMS to prevent improper payment when
incorrect code combinations are reported
• NCCI edits will be applied to all Freedom Blue claims
received on or after 10/15/11
Medicare Advantage Updates
• CMS rates Medicare Advantage plans annually
• Results are posted using a “star”
hotels, cars, and other services
score similar to
• Allows Medicare beneficiaries to compare plan
options when choosing a Medicare Advantage plan
• Highmark Freedom Blue received a four star rating!
Medicare Advantage Updates
Annual Wellness Visit Covered
• Extends the Initial Preventive Personal Examination
(IPPE), also known as the “Welcome to Medicare Visit”
• AWV is NOT covered during the first 12 months of
beneficiary’s initial enrollment in Medicare
• Medicare has provided a physician quick reference for
the AWV
Medicare Advantage Updates
Advanced Illness Services Program
• Provides 100% coverage for 10 comprehensive,
interdisciplinary visits by appropriately
accredited hospice providers
• This benefit is in addition to the hospice benefit
Medicare Advantage Updates
Advanced Illness Services Program
• Members may receive services in their home or in a
healthcare facility
• Members are not required to be homebound or meet a
skilled level of care to be eligible for services
• “AIS” page has been added to Provider Resource
Center
Medicare Advantage Updates
Wheelchair Van Transportation Benefit
•
Covers trips to medical appointments if provided by a
wheelchair van when:
 Medicare’s medical necessity criteria are met, and
 Billed with the appropriate HCPCS modifiers
indicating a medically acceptable origin and
destination
Medicare Advantage Updates
Wheelchair Van Transportation Benefit
• Wheelchair van transportation is not separately
reimbursable when the member is in a covered
Part A inpatient stay in an acute care hospital,
LTAC or SNF.
Medicare Advantage Updates
NaviNet Enhancements
Home Health and Hospice Providers:
New NaviNet enhancement will permit home health
agencies and hospice providers to submit authorization
requests electronically
A template for the clinical information has been
developed which replaces the free text field
See August, 2011 BCNEPA Provider Bulletin for complete
information
Medicare Advantage Updates
NaviNet Enhancements
Acute Care Hospitals:
Effective 4/18/11, authorizations for transfers from
acute care to post-acute care facility should be
completed on NaviNet
A template for the clinical information has been
developed which replaces the free text field
See August, 2011 BCNEPA Provider Bulletin for complete
information
Medicare Advantage Updates
Important Changes for Freedom Blue PPO Plans effective Jan 1, 2012
•
Annual deductible and out-of-pocket limits decreased for
PPO-HD Plan
•
Member cost-sharing amounts increased for certain
services
•
Quarterly cap on Medicare Part B covered medications
eliminated
•
Determination of refractive state not a covered benefit
For additional information see the Special Bulletins
dated September, 2011.
Questions?
HIPAA 5010 / ICD-10
UPDATES
Dawn Reece
Project Manager, Claims
5010 Updates
All HIPAA mandated EDI transactions sent to BCNEPA
after December 31, 2011 must be version 5010a1
All HIPAA mandated EDI transactions sent by BCNEPA
after December 31, 2011 must be version 5010a1
The following are HIPAA mandated EDI transactions:
 Professional Claims (837P)
 Institutional Claims (837I)
 Remittance Advice (835)
 Claim Status Inquires & Responses (276/277)
 Benefit Inquires & Responses (270/271)
 Request for Authorization (278)
What Does This Mean For My Office?
• BCNEPA will reject all 4010 transactions received after
December 31, 2011
• NaviNet was converted to 5010a1 in July. All
transactions conducted through NaviNet are 5010a1
compliant
• Emdeon clearinghouse transactions converted to
5010a1 in May
• You must be prepared to send your electronic claims in
5010a1 and to receive your Electronic Remittance
Advices (ERA/835) in version 5010a1 by 12/31/2011
Conversion Issues
• Many practice management and software vendors are sending
4010 claims data to clearinghouses who made the cut over to
5010a1 with BCNEPA, such as Emdeon
• The clearinghouse converts the 4010 data received into 5010a1
and then sends it to the payer (BCNEPA)
• Significant data gaps between 4010 and 5010a1 cause this
conversion to result in claims rejected by the payer (BCNEPA) for
missing or invalid data
Example:
5010a1 requires the related surgical procedure for all anesthesia
services. This data element does not exist in 4010; therefore, can
not be sent when 4010 data is converted to 5010a1. The end
result is the claim is rejected by BCNEPA for the missing data
Data Flow
Your
Office
5010a1
Claim File
Claims
Data
Transfer
Clearing
House 2
Clearing
House 1
4010
Claim File
BCNEPA
4010 to 5010a1
4010 to 5010a1
Conversion
Conversion
Who Is The Weakest Link?
• Everyone in the chain must be using a format that
fulfills the 5010a1 data requirements
• Many offices do not know that their data is passed to
multiple vendors before it gets to its final stop, the
payer
• Please contact all your vendors to be sure all parties
are conducting business in manner that fulfills the
5010a1 data requirements
• Do not wait until December 31, 2011 to convert to
5010a1. Your data may pass through several vendors
and have many stops before it gets to BCNEPA. It’s
possible that 4010 data released prior to 12/31/2011
will not get to BCNEPA in time
ICD-10
ICD-9 will no longer be used as of October 1, 2013
• The government mandated the usage of ICD-10 DM
and ICD-10 CM effective with dates of service
October 1, 2013
• ICD-10 CM replaces both the ICD-9 DM code set used
for reporting diagnosis and ICD-9 CM code set used
for inpatient procedure code reporting
Submission Requirements
• The conversion to ICD-10 is based on service date
• Please look for further details on ICD-10 billing
requirements in future bulletins
• Medicare issued MLN Matters bulletin MM7492 on
8/29/2011, which contains ICD-10 submission
requirements for Medicare claims
How Are ICD-10 Diagnosis Codes Different?
The Humorous Side Of ICD-10
The Wall Street Journal recently published an article on ICD-10 that illustrates
the complexity of ICD-10 in a humorous way.
“Walked Into a Lamppost? Hurt While Crocheting? Help’s on the Way”
The full article can be found at http://online.wsj.com/article/SB100014240531119041034045765607427
46021106.html
A medical coding company, Find A Code, published a series of YouTube
videos which also show the funny side of the level of detail found in
ICD-10.
The video suite can be found at - www.youtube.com/user/findacode
•
Example Of Fracture Diagnosis
ICD-10:
S52 – Fracture of forearm
S52.5 – Fracture of lower end of radius
S52.52 – Torus fracture of lower end of radius
S52.521 – Torus fracture of lower end of right radius
S52.521A - Torus fracture of lower end of right radius, initial
encounter closed fracture
ICD-9:
813.5 – Fracture of radius
813.45 - closed; torus fracture of radius (alone)
How Are ICD-10 Procedure Codes Different?
ICD-10 PCS Coding Structure
1. Section = The broad procedure category or section where the code is found.
2. Body System = The general physiological system or anatomical region involved.
3. Root Operation = The objective of the procedure, such as bypass, excision, etc.
4. Body Part = The specific anatomical site where the procedure was performed.
5. Approach = The technique used to reach the procedure site, such as open or
percutaneous (through the skin) endoscopic.
6. Device = Any device (whether biological, synthetic, therapeutic or mechanical)
left in place after the procedure is completed.
7. Qualifier = An additional attribute of the procedure.
ICD-10 Impact To Providers
• Clinical and administrative system changes
• Impacts most of the processes in your practice
 Pre-patient visit activities such as eligibility checks and prior
authorizations
 Patient visit activities such as documenting the patient’s
condition requires more detail for the coder to choose an
ICD-10 diagnosis code
 Post visit activities such as claim form changes and coding
ICD-10 Impact To Providers
• The change in code sets requires a major change in clinical
documentation requirements
• Significant training and changes in procedures would be necessary to
support this change
• Continuing to code the “unspecified” versions of a diagnosis will at best
delay reimbursement
• The ICD-10 documentation requirements increase the amount of time
and effort that practices spend on each patient encounter
• This is not a temporary decrease in productivity due to learning a new
code set and does not just impact the coding staff. This increase is
permanent and may warrant additional staff
• The points above are based on the Nachimson Advisor’s report on
IC9-10 impact to providers
• The full report can be found at:
http://nachimsonadvisors.com/Documents/ICD-0%20Impacts%20on%20Providers.pdf
Learning The ICD-10-CM System
• It is important to become aware of the various coding
concepts related to ICD-10-CM and to recognize the
differences from ICD-9-CM
• Clinical AND coding professionals should review the ICD10-CM information Center for Disease Control (CDC)
/National Center for Health Statistics Web site (NCHS)
http://www.cdc.gov/nchs/icd/icd10cm.htm
• Training for all staff, including physicians and other
clinicians is necessary
What Can I Do To Prepare?
• Begin talking to your vendors
• Raise awareness of ICD-10 in your clinical office
• Train clinical staff on ICD-10 coding so they fully
understand how to change their clinical documentation
for the billing staff to correctly report the
service/diagnosis
• Take a sample of your existing charts and try to find an
ICD-10 diagnosis for them. You will quickly see the
gaps
Discussion and Comments
NAVINET UPDATES
Becky Krasson
EDI Specialist
NaviNet Enhancements for HIPAA 5010
In July 2011, the HIPAA 5010 mandates were
implemented in NaviNet by BCNEPA. With this
implementation, most of the transactions were
updated to accommodate these changes. NaviNet
is no longer maintaining transactions utilizing the
4010A1 format
The following slides are intended to show the new
features and functionality when accessing the
transactions
On the Patient Search screen, the “Subscriber/Dependent”
labels have been renamed “Patient”
A description is now required for Not Otherwise Classified, Not
Elsewhere Specified or Unlisted procedure codes
Blue Exchange
Authorization Submission Updates
Prior Authorization Submission
New Feature: Patient Event Information
One of these sections is required in order to
submit a Blue Exchange Prior Authorization
Transactions to enhance your office output
Facility Report Options
Professional Report Options
Claim Submission Reports –
Display on NaviNet the next day
Customer Support is the source to locate all
BCNEPA updates recently added to NaviNet
Transactions Updated on July 1, 2011
BCNEPA NAVINET
EXPANSION
Kevin Quaglia
Project Manager, Provider Relations
BCNEPA NaviNet Expansion
NaviNet Expansion Split Into Two Phases:
•
Phase I - BCNEPA NaviNet granted to all providers currently NaviNet
enabled through another Health Plan
•
Phase II - BCNEPA NaviNet available to remainder of BCNEPA Provider
Network
As of June, 2011:
•
20% of BCNEPA’s provider network (573 provider entities) had access
•
80% of BCNEPA’s provider network (2295 provider entities) did NOT have
access
As of September, 2011:
•
53% of BCNEPA’s provider network (1522 provider entities) have access
•
47% of BCNEPA’s provider network (1346 provider entities) do NOT have
access
BCNEPA NaviNet Expansion
Phase I: July-August 2011
– BCNEPA NaviNet granted to any provider who was
NaviNet enabled through another Health Plan
 Impacted providers notified via a message on their NaviNet
Home Page
 All NaviNet “users” for each provider were notified of
BCNEPA NaviNet expansion via email
– Any Provider who currently has NaviNet access
through another Health Plan who did not receive
notification of BCNEPA NaviNet access should
contact BCNEPA Provider Relations
BCNEPA NaviNet Expansion
Phase II: September-December 2011
• BCNEPA NaviNet now available to ALL providers who
do not have NaviNet through any other Health Plan
• NaviNet training opportunities (on-site, webinars)
available by BCNEPA Provider Relations once NaviNet
set-up is complete
BCNEPA NaviNet Expansion
Providers must provide the following information to
BCNEPA via e-mail: BCNEPANavi@bcnepa.com to
finalize NaviNet set up:
 Provider/Group/Facility Name, Tax Id Number, and Type II NPI
 FPH/FPLIC Legacy Number(s)
 Security Officer contact name, phone number, and e-mail address
 For professional groups, list all physicians within the group and
provide their NPI and FPH/FPLIC legacy numbers
Refer to August and September Provider Bulletins
THE MEDICAL HOME
NEIGHBORHOOD
BCNEPA Medical Director, Quality Improvement,
Disease/Case Management, Behavioral Health
MEDICAL HOME
CONCEPT
Thomas Curry, MD
Medical Director, Network Management
and Provider Operations
Health Care System Realities
• Rising Health Care Costs
• Rising Cost of Insurance
• Questionable Quality
• Poorly Coordinated Care
• Burden of Uninsured
• Cost Shifting
• General Dissatisfaction
• Primary Care in Crisis
Chronic Care Model
• Concept formulated and advanced by Edward H.
Wagner, M.D.
• Focus on delivery of primary care to patients with
chronic illness
– Comprehensive
– Coordinated
– Continuous
Chronic Care Model
The six key components include:
1. Self-Management Support
2. Delivery System Design
3. Decision Support
4. Clinical Information Systems
5. Community Partnerships
6. Quality Improvement Incentives
Medical Home
• Personal Physician
• Physician-Directed Teams
• Whole Person Orientation
• Coordinated/Integrated Care
• Enhanced Access
• Quality and Safety
• Appropriate Reimbursement
Medical Home
Quality and Safety
– Care Planning involves medical team, patients, and
patient’s family
– Evidence-based clinical decision support tools
– Use of Information Technology
– Practice redesign
– Performance measurement
– Continuous Quality Improvement
Core Concepts
Team building
Improve care management
Self-management support at every encounter
Planned visits
Improved coordination with specialty and
inpatient care
Patient-Centered Medical Home
Neighborhood
 Recognizes the importance of collaboration
with specialty and subspecialty practices
 Ensures effective communication with PCMH
practices
 Ensures appropriate and timely consultations
and referrals
PROCESS
IMPROVEMENT
Cathy Gorski, BS, MSHA, RN, CCM
Manager, Quality Management and
Quality Improvement
Transitions In Care
"Care transitions is a team sport, and yet all too often we don't know
who our teammates are, or how they can help.”
~ Eric A. Coleman, MD, MPH
• Actions designed to ensure the coordination and
continuity of health care as patients transfer between
different locations or different levels of care
• Consider:
– Post inpatient and ER telephonic outreach and in-office visit
– Bi-directional communication with specialty providers on
patient plan of care
– Coordination with specialty and ancillary providers to ensure
medication reconciliation and adherence to follow-up
recommendations
Planned Visits & Care Coordination
• Planned Visits:
– Pre-visit plan to ensure labs/testing results available
– Patient screening prior to each visit for medication changes
and other health providers seen
– Patient dashboard
• Care Coordination:
– Develop feedback loop with IP/OP providers to get timely
status on patient
– Community Resources
– Payor processes/contacts to ensure appropriate utilization of
benefits/services
Care Management
Center for Health Care Strategies:
• The goal of care management is to achieve an optimal
level of wellness and improve coordination of care
while providing cost effective, non-duplicative services.
• Engage the patient and their support system in a
collaborative process to manage their
medical/social/mental health conditions effectively
Components:
– Identification and prioritization
– Intervention
– Evaluation
– Payment/Financing
Self-Management Support
• Self-management support is what health care
practitioners provide to assist a person with their selfmanagement practices, and to support their self
efficacy and ability to effectively self-manage
• AAFP recommendations for offices:
– Motivational Interviewing
– Address goal setting and problem solving in each visit
– Provide self-management education
– Refer patient to community or health plan support programs
– Follow-up plan/tracking using telephone/e-mail or other contact
with nurse as a way to improve blood sugar control and weight
loss in patients with diabetes
Continual Process Improvement
• Small Steps, Big Concepts
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Transitions in Care
Medication Reconciliation
Planned Visits
Coordination of Care
Care Management
Chronic Care Self-Management
• Team approach to improved patient outcomes and
satisfaction
CPI: Model For Improvement
Three Questions:
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in an
improvement?
Plan-Do-Study-Act
DISEASE MANAGEMENT
CASE MANAGEMENT
Donna Koepfler, RN, BS, CCM
Manager, Case Management
Blue Health Solutions
We help individuals at every level of need
Healthy
Acute
Chronic
Catastrophic
Nurse Call Line; On-line Portal; Health Care Reminders; Education; Advocacy
Wellness Programs
HIGH RISK
LOW RISK
Health Coaching/
Intermediate Care
Disease Management
Case Management/Transition of Care
Clinical Intensity
Wellness & Lifestyle Management Programs
• Designed for members interested
in making changes to their
current lifestyle or in getting
support or information to continue
making healthy choices
Wellness & Lifestyles
Management
Blood Pressure
Cholesterol Management
Diet
Exercise
GERD
Healthy Back
Metabolic Syndrome
• Provides individualized education
and support, self-management
tools and phone access to Health
Coaches
Nutrition
Maternity Management
Stress Management
Tobacco Cessation
Weight Management
Disease Management
• Integrated management of comorbidities, use of evidence-based
guidelines, individualized care plans
• Supports the physician’s plan of care
including registry with gaps-in-care,
alerts and feedback on progress to
goals
• Focus on prevention and early
detection of complications, education
and development of care plans
Diseases and Conditions
Asthma
Chronic Obstructive Pulmonary
Disease (COPD)
Cardio-Vascular Disease (CVD)
Depression
Diabetes
Heart Failure
Case Management
Catastrophic Case Management
• Require high-tech or extensive home care
• Are terminally ill
• Have sustained traumatic injury
• Require frequent hospital admissions
• Have chronic illnesses with complications
• Require extensive discharge planning
• Require coordination of benefits and/or services
• Have an extended LOS
Intermediate Care Management
• Chronic, long-term illness that may include multiple sclerosis,
rheumatoid arthritis, renal disease, migraines
Transition of Care
• Planning for an elective surgery
• Recovery from surgery
24/7 Nurse Now
• Access to medical information 24 hours a day 7
days a week
• Members are referred to Blue Health Solutions
programs from Nurse Now
Blue Health Solutions Is Here To Help!
• We are here to act as an extension of your office when
self-management assistance, patient education, and
support navigating the health care system will make a
difference.
• Just call….
Triage Nurse
Health Management 1-866-262-4764
Case Management 1-800-346-6149
BEHAVIORAL HEALTH
Susan Ferry, LCSW
Clinical Care Manager, CBHNP
Behavioral Health Care
• Mental illness…a scary thought
• The reality & prevalence of mental illness
• Statistics
• Help is available
Mental Illness…A Scary Thought
Mental illness refers collectively to all of the
diagnosable mental disorders. When the average
person hears the phrase mental illness, they conjure
up images of a person being tortured by demons only
he sees or by voices no one else hears.
This, of course, comes from the TV & movie versions
of mental illness which often rely on the
extraordinary symptoms of psychotic
illnesses like schizophrenia.
“ There is someone in my head but it’s not me”. Pink Floyd
The Reality & Prevalence Of Mental Illness
• Few mental illnesses have hallucinations as symptoms. The
reality is that the most prevalent mental health illnesses are
anxiety disorders, depression and substance abuse. The
good news is that they are among the most treatable of the
psychiatric illnesses.
• Anyone, no matter what age, economic status or race can
develop mental illness. During any one year, more than 22%
of the adult population suffers from a clearly diagnosable
mental disorder.
The Reality & Prevalence Of Mental Illness
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Isaac Newton
Beethoven
Abe Lincoln
Winston Churchill
Jane Pauley
Betty Ford
Carrie Fisher
Vivien Leigh
Bette Midler
Patty Duke
Ernest Hemingway
Marlon Brando
Howie Mandel
Jim Carrey
Charles Dickens
Statistics
• Some 8 to 14 million Americans suffer from depression each
year
• As many as 1 in 5 Americans will suffer at least one episode
of major depression during their lifetime
• 6% - 9% of older Americans in the primary care setting
suffer from major depression
• Women are 70% more likely than men to
experience depression during their lifetime
• Depression very often co-occurs with other
medical illnesses and conditions such as
cancer, stroke, heart attack and diabetes
Statistics
Almost any medical condition can trigger a mental health
issue (i.e. celiac disease can lead to depression &
symptoms of an eating disorder).
Vincent Van Gogh, a Dutch post–impressionist painter, suffered from a
lifetime of mental illness, anxiety, depression (possibly bi-polar disorder)
and ultimately committed suicide at age 37.
Statistics
• Suicide is the 3rd leading cause of death for people
between the ages of 15 and 24
• Male physicians have a 40% higher rate of suicide
than the general population, and a whopping 130%
for female physicians
• 15.4 million American adults and 4.6 million
adolescents experience serious
alcohol-related problems
• 12.5 million Americans suffer from drug abuse
or dependence
Statistics
• 20% of the ailments for which Americans seek a doctor’s
care are related to anxiety disorders, such as panic
attacks, that interfere with the ability to live normal lives
• Women are 60% more likely than men to experience an
anxiety disorder
• Nearly ¼ of the elderly who are labeled as senile
actually suffer some form of mental illness
that can be effectively treated
Statistics
• Only a small fraction of those who suffer from
mental illness ever receive mental health
treatment
• Of those patients who do receive treatment,
80%-90% of them will respond
positively
Help Is Available
Community Behavioral Network of Pennsylvania
1-800-599-2428
CBHNP is a managed care company who Blue Cross
has contracted with to provide triage, referral and
utilization management for behavioral health. We
have licensed behavioral health clinicians available 24
hours a day and 7 days a week to help with referrals to
behavioral health specialists.
MEDICAL HOME
NEIGHBORHOOD
Thomas Curry, MD
Medical Director, Network Management
and Provider Operations
Specialists
•Transition of care
information
• Behavioral health
integration
PCMH
•Problems list
•Medication list
BCNEPA
•Office Transformation
•Reports
•Treatment
•Care Coordination
•Tracking
•Education
•Care Coordination
(Onsite & Telephonic)
•Admission & Discharge Info
(Inpatient & ER)
•Onsite UM
•Discharge
Information &
•Follow-up Plan
Patient
•Discharge
Information &
•Follow-up Plan
•CM
•DM
•Wellness
•Member Portal
•24-hour Nurse Line
HMS-BHS
Hospitals
•Discharge Planning
THANK YOU
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