We’re making some changes to the Value-Based Reimbursement Fee Schedule, effective July 1, 2016

Value-based reimbursement is one of the ways Blue Cross Blue Shield of Michigan is working with health care professionals to create value for health care users. There have been some changes to the VBR Fee Schedule since we communicated about it in the December 2015 Record. Following is a detailed description of the VBR Fee Schedule that goes into effect July 1, 2016.

Primary care physicians

Primary care physicians in the Physician Group Incentive Program are eligible for reimbursement according to the VBR Fee Schedule. The VBR Fee Schedule sets reimbursement rates for specific codes at more than 100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules, or Standard Fee Schedules. Primary care physicians can receive value-based reimbursement at 105 percent to 140 percent of the Standard Fee Schedules for certain procedure codes,* depending on the program(s) in which they participate and the criteria they meet. Previously, primary care physicians could receive value-based reimbursement at 105 percent to 130 percent of the Standard Fee Schedules.

Effective July 1, 2016, through June 30, 2017 (based on performance in 2015), three tiers of clinical quality value-based reimbursement will be available to primary care physicians. Previously, only one tier was available.

Primary care practices without Patient-Centered Medical Home designation that:

• Rank in the 95th to 100th percentile for clinical quality performance can receive 115 percent of the Standard Fee Schedules for the following procedure codes:
• 99201-99215
• 99381-99397
• Rank in the 85th to 94.99th percentile for clinical quality performance can receive 110 percent of the Standard Fee Schedules for the procedure codes above
• Rank in the 80th to 84.99th percentile for clinical quality performance can receive 105 percent of the Standard Fee Schedules for the procedure codes above

Primary care physicians with PCMH designation receive 110 percent of the Standard Fee Schedules for the procedure codes above. Primary care physicians with PCMH designation can receive additional value-based reimbursement.

PCMH designated practices that:

• Rank in the 95th to 100th percentile for clinical quality performance can receive an additional 15 percent of the Standard Fee Schedules for the procedure codes above
• Rank in the 85th to 94.99th percentile for clinical quality performance can receive an additional 10 percent of the Standard Fee Schedules for the procedure codes above
• Rank in the 80th to 84.99th percentile for clinical quality performance can receive an additional 5 percent of the Standard Fee Schedules for the procedure codes above
• Belong to a physician organization that meets Blue Cross’ cost-benchmarking criteria can receive an additional 10 percent of the Standard Fee Schedules for the procedure codes above.
• Participate in Provider-Delivered Care Management can receive an additional 5 percent of the Standard Fee Schedules for the procedure codes above and for the following procedure codes:

• G9001-G9002
• 98961-98962
• 98966-98968
• G9007
• 99487
• 99489
• S0257

The total amount of value-based reimbursement depends upon the programs in which the primary care physicians participate and the criteria they meet. For instance, primary care physicians who are PCMH designated, are a member of a physician organization that meets Blue Cross’ cost benchmark criteria, participate in PDCM and perform in the highest tier on measures of clinical quality will receive reimbursement at 140 percent of the Standard Fee Schedules.

The table below summarizes the potential value-based reimbursement available under the VBR Fee Schedule to primary care physicians for the procedure codes indicated above.

Specialists

Specialists in PGIP are also eligible for reimbursement in accordance with the VBR Fee Schedule. Specialists will, depending on their ranking, receive value-based reimbursement at 105 percent or 110 percent of the Standard Fee Schedules for all relative value unit-based procedure codes and the time and base codes. (Relative value unit codes are most procedure codes billed by specialists, except those for ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections.)

Reimbursement for specialists treating adult members and ranked in the top third will be 110 percent of the Standard Fee Schedules for the codes described above. Those ranked in the second third will receive 105 percent of the Standard Fee Schedules for the codes described above.

Reimbursement for specialists treating primarily pediatric members and ranked in the top half of pediatric practices will be 110 percent of the Standard Fee Schedules for the codes described above. Those ranked in the second half will receive 105 percent of the Standard Fee Schedules for the codes described above.

The tables below illustrate how reimbursement works for specialists in non-pediatric practices and pediatric practices:

Specialists — non-pediatric practices

Note: If fewer than 20 percent of the Blue Cross participating specialists of a particular specialty type are in PGIP, practices ranking in the top two-fifths can receive 110 percent of the standard fee schedule, and practices ranking in the next two-fifths can receive 105 percent of the standard fee schedule.

Specialists — pediatric practices