Blue Physician Recognition

General Disclaimer

The Blue Physician Recognition (BPR) designation means the physician has demonstrated a commitment to delivering quality and patient-centered care by participating in local, national, and/or regional quality improvement program as determined by the local Blue Plan. The BPR Program does not serve as a measure of the quality of care provided by a physician, group and/or practice or whether the physician will meet your particular healthcare needs. Absence of a BPR icon does not mean the physician or practice is of low quality; it could simply mean that the physician or practice does not participate in a quality improvement program recognized by the local Blue Plan.

Local Program Description -

2016 Professional Provider Quality-Based Reimbursement Program

This program will offer an opportunity for eligible providers to earn Blue Physician Recognition and increased reimbursement based on a three-group approach with prerequisites for participation. This reimbursement will be in addition to the established Maximum Allowable Payments (MAPs) for 2016.

QBRP Participation Prerequisites

Providers must conduct business with BCBSKS electronically (i.e. turn off paper). Providers must submit all eligible claims electronically, accept electronic remittance advice documents, and receive all communications (newsletters, etc.) electronically.

Group A

Applies to all eligible contracting professional providers and to all eligible/ covered CPT codes.

  • Electronic Self-Service – Providers must electronically obtain BCBSKS patient eligibility, benefit information, and claims status information at least 65 percent of the time compared to the provider’s total number of queries to BCBSKS. (3 percent)

Group B

Applies to all prescribing provider types (MD, DO, DPM, OD, PA, APRN) and to all eligible/covered CPT codes (excludes Lab, Drugs, Dental).

  • KHIE inquiries –Each prescribing provider must inquire to an approved Kansas Health Information Exchange (KHIE) organization at least 60 times per quarter to earn this incentive. (1.5 percent)
  • KHIE HL7 use – Must have real-time connectivity to qualify for:
    1. Demographics, admissions, discharge, transfer – Must send all records for demographics, admissions, discharge and transfers. This includes office visits. (1 percent)
    2. Progress notes – Must send progress notes on all patient encounters. (1 percent)
    3. Diagnosis and procedure coding – Must send diagnosis and/or procedure coding on all patient encounters (1.0 percent)
    4. Must send all labs reports on all patient lab tests. (.5 percent)
    5. Medication records – Must send medication history on all patient encounters. (1 percent)
  • Use of Electronic Prescriptions – Must electronically access member benefit information for eligibility, formulary, and medication history a minimum of 90 times per quarter. (.75 percent)
  • Generic Utilization Rate – Minimum generic prescribing of 75 percent for all BCBSKS members with a prescription drug benefit. (.75 percent)
  • Cover My Meds (electronic prior authorization) – Use Cover My Meds prior authorization request for drugs requiring prior authorization. (2.5 percent)
  • Specialty Pharmacy – Prescriber must have at least five specialty pharmacy prescriptions per quarter and at least 50 percent of all specialty pharmacy prescriptions must be filled through Prime Specialty Pharmacy (3.0 percent)

Group C

Applies to primary care professionals including supervised mid-levels (FP, GP, Peds, IM, PA, APRN) and only to covered E&M codes. Group C incentives are earned at the group level (for physicians with attributed members) with the exception of NCQA Diabetes, Heart Stroke Recognition and PCMH, which are incentivized at the individual level. New providers joining a group or changing tax IDs will not be eligible for the HEDIS metrics under the new arrangement until the refresh period.

  • Diabetes Recognition Program – Provider must be recognized as participating in the NCQA Diabetes Recognition Program. (.75 percent)
  • PCMH Recognition (a or b) – a. Provider must achieve NCQA and/or URAC Patient Centered Medical Home recognition Level 1 or Level 2; OR b. Provider must achieve NCQA and/or URAC Patient Centered Medical Home recognition Level 3. (.75 percent for Level 1 or 2; OR 1.75 percent for Level 3)
  • Childhood Immunization MMR – The percentage of children 2 years of age who had one Measles, Mumps, and Rubella vaccine by their second birthday (turned age 2 in the measurement period). Must be greater than or equal to 60 percent. (.75 percent)
  • Immunization for Adolescents Tdap – The percentage of adolescents 13 years of age (turned age 13 in the measurement period) who had a Tdap vaccine by their 13th birthday. Must be greater than or equal to 70 percent. (.75 percent)
  • Breast Cancer Screening – The percentage of women 50 to 74 years of age (52 to 74 as of the end of the measurement period) who had a mammogram anytime in the past two years. Must be greater than or equal to 60 percent. (.75 percent)
  • NCQA Heart Stroke Recognition Program – Provider must be recognized as participating in the NCQA Heart/Stroke Recognition Program. (.75 percent)