BlueCross BlueShield of Western New York
Chiropractic Program
Proprietary & Confidential//Overview for Educational
Purposes//Additional Questions//Contact Provider Relations
Chiropractic Workshop Agenda
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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
Chiropractic Advisory Committee
Chiropractic Advisory Committee
• Ensure continuing access to high-quality, medically
appropriate, evidence-based, cost-effective chiropractic care.
• Maintaining a consistent and clinically appropriate approach
in the administration of chiropractic care, including
development of its 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 BlueCross BlueShield
for a two-year 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 committee’s
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.
Provider Relations
Provider Relations
• The Provider Relations Specialist is
your primary link with BlueCross
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
• 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.
• A limited number of BlueCross BlueShield
ASO contracts will still be managed through
the preauthorization process.
• Chiropractors will now have a direct line of
communication with the health plan, as well
as 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 for Erie County, NY:
– January 1, 2013
• Previously, participating chiropractic providers:
– Were dual contracted with the Palladian network and the
BlueCross BlueShield network.
– Will not need to do anything because your participating
provider agreement with BlueCross BlueShield will
automatically become effective on January 1, 2013.
• To date, we have not received a single notice of
termination from a chiropractor
• Therefore, the network and the access to care is
not reduced
Claim Submission
• Dates of service December 31, 2012
and prior
– continue to submit to Palladian Health.
• Dates of service January 1, 2013 and
later
– submit to BlueCross BlueShield for
processing and reimbursement
– Payor ID: 00801
BlueCross BlueShield
Reimbursement and Fee Schedule
• Increase in BlueCross 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
• 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 Council
for Affordable Quality Healthcare
(CAQH).
– Enter your CAQH Provider ID to
enter or update your information
– Authorize BlueCross 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
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
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 responsible 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;
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
claims that their employees incur
– Employers pay a fixed fee for administrative
services such as 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 form BlueCross 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 BlueCross BlueShield-accepted
clinical guidelines are used
– Comply with regulatory agencies
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 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 BlueCross 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.
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Provider Website
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Provider Website
Network Information
Help Me Find
News & Events
Resources
Policies
Payment and Operations
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
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
• Eliminates paperwork
• Reduces administrative burden placed on the provider, staff, and
patient
• Allows additional time to treat patients
• Improving satisfaction and outcomes for patient
• Internal direct contact with BlueCross BlueShield
Community
• Musculoskeletal-specific wellness seminars
• Collaborate with providers/members to drive
performance/quality
• Improving customer satisfaction: providers, members,
employers, community
*Please refer to members contractual agreements for chiropractic coverage
We look forward to a long, exciting future.
Questions?
Please contact:
BlueCross BlueShield of Western New York
Provider Relations Department
1-800-666-4627
BlueCross BlueShield of Western New York is a division of HealthNow New York Inc. An
independent licensee of the BlueCross BlueShield Association. BlueCross, BlueShield and the
Cross and Shield symbols are registered trademarks of the BlueCross BlueShield Association.
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