Hospital and Physician Update

September – October 2020

Expansion of inpatient acute care admissions process continues

In a previous column, Steve Anderson, vice president of Hospital Contracting and Network Administration, wrote about how we were changing the way we process inpatient acute care admissions to help reduce health care costs.

Our data had revealed that some cases are billed incorrectly or that patients are admitted to a hospital when it would have been more appropriate for them to receive a less costly, lower level of care, such as hospital observation or home care.

Anderson let our physician and hospital partners know that all authorization requests for inpatient acute care admissions to select facilities for Blue Cross Blue Shield of Michigan commercial PPO members must be submitted through the e-referral system and could be subject to clinical review. Other lines of business, including Blue Care Network commercial and BCN Advantage^SM, also have full inpatient review programs at Michigan hospitals.

Now we’re expanding the list of facilities included in the current inpatient acute care admissions authorization process. As of Oct. 5, 2020, the remaining facilities not included in the first two phases of this project are required to submit authorization requests — and attach clinical records — through the e-referral system for commercial PPO. We notified them in advance of the effective date.

Blue Cross will conduct clinical reviews, as necessary, using InterQual^® criteria.

Gender reassignment and behavioral health authorizations

Gender reassignment authorization requests can also be submitted through the e-referral system, along with authorization requests for ill newborns who are already on a subscriber’s policy. If a newborn isn’t on a policy, the authorization request must be faxed.

Behavioral health authorization requests and clinical reviews will continue according to the current process with the assigned behavioral health management vendor. However, inpatient admission authorization requests processed through New Directions will be subject to full clinical review from the first day of admission and subject to non-approval.

The application of clinical criteria is required in some cases to receive authorization for Blue Cross inpatient stays. For more information, see Blue Cross’ Authorization Requirements & Criteria page.

If you’re not already using the e-referral system, you can sign up on the Sign up for e-referral or change a user page on our ereferrals.bcbsm.com website.

See the table below for dates for our Commercial Inpatient Training sessions. All sessions are one hour and virtual.

*A diagnosis-related group, or DRG, is a patient classification system that standardizes prospective payments to hospitals and encourages cost containment initiatives.

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Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.