Provider Directory Data Quality Compliance Program Frequently Asked Questions February 2017 General Information 1. What is the Provider Directory Data Quality Compliance Program? In 2016, CMS mandated Medicare Advantage (MA) health plans provide complete and accurate information regarding physicians who are available to new patients/enrollees in online and printed directories. Medicare Advantage plans must verify, at least quarterly, a physician s location and availability information are accurate. A health plan s failure to maintain complete and accurate directories may be subject to compliance and or enforcement actions, including civil money penalties and STAR ratings and or enrollment sanctions. Blue Cross anticipates this approach will continue to expand to Quality Rating System (QRS) populations, among others. As a result, PGIP is launching a program to collect complete and accurate demographic information on all PGIP participating providers - the Provider Directory Data Quality Compliance Program. 2. What is practitioner demographic data? Demographic data is data that displays in the provider directory on bcbsm.com. It includes: Practice name Practice NPI Practitioner name Practitioner NPI Practice location address Primary or secondary location type Phone number (where patients call to make appointments) Whether the practice is accepting new patients 3. Will my PO be rewarded for efforts? For compliance with this program, PGIP will offer rewards to POs that submit physician demographic data electronically or can demonstrate high levels of compliance for their affiliated practitioners. Please see the PGIP Rewards section of this document. 4. Where can I find more information about the program? Information about the program can be found on the PGIP Collaboration site under Initiatives\Projects\Workgroups Provider Directory Data Quality Mandate page. In addition, Information on Blue Cross s approach will be published in future editions of The Record and Value Partnerships Update newsletters. Questions can be directed to your Field Team analyst or 1
you can submit an issue on the PGIP Collaboration site using the issue category of Provider Directory Data Compliance. 5. Why is Blue Cross Blue Shield of Michigan/Blue Care Network requiring practitioners to attest to their information so frequently? Blue Cross and BCN both have contracts with CMS to offer Medicare Advantage plans to Medicare eligible individuals. CMS has required plans to ensure their provider directories are accurate for members and their caregivers who rely on them to make informed decisions regarding their health care and health plan choices. This includes requiring a quarterly verification of key demographic information displayed in the provider directories. 6. Which system should practitioners update Council for Affordable Quality Healthcare (CAQH), Atlas PRIME-Hub, Provider Self-Service, or should I electronically submit a roster? Individual practitioners should continue to use Provider Self Service to update their information as a normal course of business. The attestation process does not replace normal provider demographic maintenance activities. Council for Affordable Quality Healthcare is a source of information for both credentialing and some demographic information. It is critical that practitioners continue to keep their ProView application current. They should continue to update CAQH as normal for both demographic and credentialing related updates. For the quarterly attestation, practice groups should continue to use the Atlas PRIME-Hub system as well as CAQH during this transition period. It is critical the CAQH contain all validation address information by July 2017. 7. I am currently enrolled in the electronic process; why am I still being contacted by phone? Generally, the groups enrolled in the electronic process will be removed from the manual process. However, sometimes the timing of the processes overlap and outreach is in error. Please contact your provider consultant if you believe you should be exempt from the quarterly vendor outreach. At times, your office will be contacted as part of an internal data quality audit. We conduct monthly audits to assess the accuracy of our provider directory. Practitioner Compliance 8. Does this program affect all types of providers? The CMS mandate focuses on physician demographic data. All Blue Cross and BCN participating physicians need to comply with this compliance program, including PGIP and non- PGIP physicians. 2
9. How will practitioner compliance be determined? Please refer to question 2 to see what practitioner demographic information is considered in the data compliance mandate. Practitioner compliance is determined through a quarterly attestation process. Each quarter, practice groups must attest to Blue Cross that practitioner demographic data is accurate. There is an electronic file submission attestation process used by POs and large health systems with 100 or more practitioners and a manual attestation used for practitioners. This attestation must be completed for each practice group location associated with the practitioner. 10. Can I update a practitioner s location in the PGIP Practitioner Alignment Tool to become compliant with this process? No. Provider groups have a tax ID and type 2 NPI numbers. Therefore, provider groups are (usually) not equivalent to a PGIP practice unit. Updating PGIP practice units in the PGIP Physician Alignment Tool will not bring a practitioner into compliance. 11. Are there penalties for non-compliance? Consistent non-compliance by individual physicians will result in successive sanctions by Blue Cross and BCN, including suppression from the bcbsm.com provider directory, suppression of value-based reimbursement (VBR) for PGIP physicians, and ultimately, termination from Blue Cross and BCN networks. 12. What is the timeline for practitioner sanctions? The following describes the timeline for sanctions by Blue Cross and BCN: 3
13. How does a PO comply with this mandate for its practitioners? Physician organizations can either: 1) Submit physician demographic data electronically to Blue Cross or 2) Demonstrate high levels of compliance for their affiliated practitioners through a quarterly attestation program For POs who chose not to submit physician demographic data electronically to Blue Cross, POs can ensure high levels of compliance by reaching out to non-compliant practitioners within their organization and having them submit provider data attestations to Blue Cross. Physician organizations will receive monthly reports detailing the compliance of aligned practitioners at each practice location. 14. How will a PO know which of its affiliated practitioner are non-compliant? Physician organizations will receive monthly PO compliance reports detailing the compliance of aligned practitioners at each practice location. These reports will be delivered to the PO s electronic direct data interface (EDDI) mailbox beginning mid-february 2017. The report will show the compliance status for practitioners during the 3rd and 4th quarters of 2016. These quarters are for given for informational purposes only. The report will also show the compliance status for practitioners during the 1st quarter of 2017 and will provide an indicator of: Compliant practitioner is currently compliant with their attestation 1st Level Risk practitioner has previously been compliant, but is non-compliant in this quarter 2nd Level Risk - practitioner has been non-compliant in the previous quarter, is currently non-compliant and at risk for directory suppression of that location 3rd Level Risk - practitioner has been non-compliant for the two previous quarters, is currently non-compliant and at risk for value-based reimbursement suppression Physician organizations are encouraged to reach out to all practitioners who are non-compliant in any practitioner location. 4
15. How will a PO determine who the solo practitioners are on the PO compliance report? POs can decipher solo practitioners versus solo practitioners that function as a group by viewing the Group NPI field. The Group NPI field will be blank on the PO compliance report for solo practitioners. 16. How does an individual practitioner comply? Practice groups should attest that practitioner demographic data is accurate and up-to-date. To become compliant, the practice group will need to attest for each practitioner s current locations. Blue Cross and Blue Care Network have a contract with a vendor, Atlas Systems, to support this attestation process. Atlas Systems has an online portal called PRIME-Hub, which lets individual practice groups log in to confirm individual practitioner location information and send it directly to Blue Cross and BCN. The PRIME-Hub portal can be found at: https://prime.atlassystems.com/frmlogin.aspx Atlas Systems has an online chat, or you can call 1-844-334-9694 if you have questions or need to speak with a PRIME-Hub customer service representative. Practice groups will use PRIME-Hub only to confirm the accuracy of current practitioner information. It doesn t replace the usual enrollment and change procedures practitioners follow with Blue Cross and BCN. Enrollment and change procedures can be found on the Blue Cross website at: http://www.bcbsm.com/providers/join-the-blues-network/enrollment.html 17. Can a PO use PRIME-Hub to attest on behalf of its practitioners? No. Attestations cannot be done by the PO through PRIME-Hub on behalf of individual practitioners or practice groups at this time. 18. What kind of notice will practitioners receive before sanctions occur? For Practitioners: Blue Cross Provider Consulting will begin reaching out to practice groups starting the first quarter of non-compliance. In addition, practice groups will receive emails/faxes from our attestation vendor, Atlas Systems, when practitioners become non-compliant for two consecutive quarters. If a practitioner is non-compliant for three consecutive quarters, he or she will receive a final warning from Blue Cross Provider Consulting, as well as a letter informing them of Blue Cross s intent to terminate the practitioner from the networks for continued non-compliance. For POs: Physician organizations will begin receiving monthly reports indicating which aligned practitioners are non-compliant in mid-february. 5
19. How and when will PGIP Value-Based Reimbursement (VBR) suppression occur? If a PGIP practitioner is non-compliant for three quarters, he or she will have their VBR suppressed beginning July 1, 2017. The practitioner may have his or her VBR reinstated starting January 2018 if they subsequently become compliant for two consecutive quarters. For 2017, the practitioner will have until October 15, 2017 to become compliant in time for a January 2018 re-instatement. If the practitioner remains non-compliant, his or her VBR will be suppressed until July 2018. Physician organizations should contact any practices that are non-compliant in their February compliance report, because these practices run the risk of having their VBR suppressed on 7/1/17 and they only have until the end of March to remedy. 20. Who will the PGIP Value-Based Reimbursement suppression apply to? The PGIP Value-Based Reimbursement suppression will apply to all PGIP primary care physicians and specialists receiving value-based reimbursement who are non-compliant for three consecutive quarters. 21. What is the difference between the PO compliance report and the roster template? The PO compliance report will be sent to POs on a monthly basis and will detail the compliance risk status of aligned practitioners for each practice location. POs should reach out to their 3 rd level risk practitioners first to prevent value-based reimbursement (VBR) suppression. These reports will be delivered to PO s EDDI mailboxes beginning in mid-february. The roster template will be used in the electronic data submission process. The roster template is the file submitted to BCBSM from the POs quarterly, per an agreed upon schedule. The roster template includes fields that are required to be validated for your aligned practitioner demographic data. 22. If a practice group submits information through PRIME-hub and the PO submits through electronic data submission, which information does BCBSM use? Practice groups should continue to attest in PRIME-hub through first quarter 2017. POs who have signed up to participate in the electronic data submission process will determine which tax IDs they will submit practitioner information for, and those practitioners will no longer need to attest through PRIME-hub beginning second quarter 2017 because the PO will be submitting updated demographic data on the practitioner s behalf. The vendor will no longer reach out to practice groups to attest in PRIME-hub if the practitioner s PO has opted to participate in electronic data submission. 23. Will the compliance report sent to POs contain all practitioners, or only PGIP aligned practitioners? The PO compliance report will contain only PGIP aligned practitioners. 6
24. We have a lot of providers with multiple locations they are credentialed through, but the providers don t practice at all of the locations. How do we handle this? Practitioners should continue using the usual enrollment and change procedures they follow with BCBSM and BCN to maintain practice locations. Any locations that the practitioner works at where a patient can schedule appointments should be listed and data submitted. 25. My PO has many practitioner locations. What can I do to maintain this information? One of the most important data elements aside from practice location is an accurate phone number that a patient can call to make an appointment. Some larger systems have established a centralized appointment phone number that is used across all practice locations. This simplifies their location maintenance. We also highly encourage the use of our Provider Self Service application which simplifies the maintenance of your practice locations. 26. Where can practitioners go to obtain information on the provider self-service system? This information is available at http://www.bcbsm.com/provider through the Web-DENIS online information system. We also have online computer based training (CBT) and a user instruction manual. Enrollment forms are included in the supplemental package. Additionally, providers can reach out to the Provider Enrollment Customer Service hotline at 800-822-2761 or contact your Provider Consultant. 27.What functionality does the Provider Self Service system offer for practitioners? Provider Self-Service allows providers to see the information that is currently in our provider systems. It allows providers to update demographic information, add group locations, terminate group locations, and make other updates. Please visit bcbsm.com/providers for additional information on our Provider Self-Service system, contact your Provider Consultant or call our Provider Enrollment Customer Service hotline at 800-822-2761. 28.Can I update my practitioners practice locations in the PGIP PA tool? Provider practice groups are not the same (usually) as PGIP practice units, and the PGIP Physician Alignment Tool only contains PGIP practice units. Provider practice groups have an NPI 2 number and a tax ID, and are used for claims processing and practitioner display in the Find a Doctor tool. PO Data Submission 29.What is the process for a PO to begin submitting demographic data electronically t\o Blue Cross? PGIP physician organizations can begin the process to submit demographic data for their aligned physicians by signing up for the electronic submission process by submitting an issue 7
on the PGIP Collaboration site by March 31, 2017. Physician organizations and Blue Cross will agree on a submission schedule and POs will be required to submit their first file by June 30, 2017. After the first successful file submission, POs will submit files each quarter thereafter per agreed upon schedule. Physician organizations should also identify the contact person for your PO for this submission process through the issue log using the category Provider Directory Data Quality. 30. What data elements are required when submitting demographic data electronically to Blue Cross? 31. Is there a deadline for when I can begin submitting data to Blue Cross? We ask that you notify us via the Collaboration site issues log using the category Provider Directory Data Quality that you d like to begin submitting electronically by March 31, 2017. This will allow for the appropriate time to set up and test the process for the year. 32. How does a PO receive the bonus for participating in the MiHIN Health Directory electronic submission process? To receive the MiHIN bonus, a PO must first sign up for and meet the conditions for the Blue Cross electronic submission. Once a PO successfully submits their first file to Blue Cross, they will copy and send the same file to MiHIN. The first file must be submitted to MiHIN by June 30, 2017. Michigan Health Information Network will match this file against data compiled from various sources including the Michigan Department of Licensing and Regulatory Affairs (LARA), the National Plan & Provider Enumeration System (NPPES), and MiHIN s Active Care Relationship Service (ACRS). Michigan Health Information Network will send POs a monthly accuracy report 8
and send practices a form asking them to resolve any discrepancies. Physician organizations that reach minimum accuracy thresholds by mid-november 2017 will receive the bonus. Physician organizations that would like to participate in the MiHIN Health Directory electronic submission process must contact Sharon Kim at skim@bcbsm.com by March 31, 2017. 33. How does a PO submit their file to MiHIN? Physician organizations that already participate in a MiHIN statewide use case may use the same method they currently employ to submit their data file directly to MiHIN. All POs also have the option of submitting their files to Blue Cross using EDDI. Files sent through EDDI will be routed to MiHIN and a message will be sent to the PO confirming receipt. 34. What is MiHIN s Health Directory? The Michigan Health Information Network (MiHIN) Shared Services is Michigan s state designated entity charged with coordinating data exchange activity at the state level. Working closely with the state of Michigan and other stakeholders, MiHIN has developed a comprehensive tool for consolidating isolated demographic and contact information on health care providers in Michigan. Use of the Health Directory is a requirement for participating in the State Innovation Model (SIM). Blue Cross is currently working with MiHIN and providers to enhance functionality and to pilot use of the Health Directory as a possible long term all-payer solution for submitting and updating provider information. PGIP Physician Organization Reward 35. What are the PGIP rewards associated with this program? Physician organizations may receive rewards for the following: 1) Submitting physician demographic data electronically to Blue Cross or 2) Demonstrating high levels of compliance (75 percent compliance rate) for their affiliated practitioners through a quarterly attestation program Physician organizations may also receive an additional reward if they submit demographic data to the MiHIN Health Directory in addition to meeting #1 or #2 above. 36. When will PGIP PO reward payments be made? For the first year, Blue Cross will provide upfront 50 percent of the baseline reward in the April 2017 PGIP payment and the remainder in January 2018 if specific deliverables are met throughout the year. Blue Cross reserves the right to adjust this schedule if necessary. 37. Are there specific deliverables a PO must meet to earn PGIP rewards? Yes. Physician organizations must meet the following: 9
1. For POs who ve signed up for the Blue Cross electronic submission process, they may earn the remaining 50 percent baseline payment in the January 2018 payment if the following conditions are met: POs must sign up for process by March 31, 2017 PO and Blue Cross agree on submission schedule; POs would have to submit first file by 6/30/17 After first successful file submission, POs submit files each quarter thereafter per agreed upon schedule For POs not currently submitting files today, the PO must meet a 75 percent attestation compliance rate in 1Q 2017 or 2Q2017 while the file submission process is being set up 2. For POs who opt out of the Blue Cross electronic submission process, they must meet an attestation compliance rate of 75 percent for practitioners aligned to their PO for 2017 (through mid-november) to receive the remaining baseline payment. Potential BONUS in addition to #1 and #2 above: 3. If POs sign up for the MiHIN electronic submission process: they may earn a bonus in January 2018 if the following conditions are met: POs must sign up and submit first file to MiHIN by March 31, 2017 POs practices/practitioners must reach a 75 percent MiHIN health directory practice compliance/attestation rate by October 31, 2017 10
The information contained herein is the proprietary information of Blue Cross. Any use or disclosure of such information without the prior written consent of Blue Cross is prohibited. 11