Electronic Health Record Incentives for Physicians

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1 What s Inside? Guidelines for Coding Allergy Immunotherapy Procedures... 2 Workshop Schedule... 3 New Account Groups... 3 BlueCard Tip... 3 Provider Network Relations Spotlight... 4 Quality Site Visit Results... 5 HMO Member Survey Reminder. 5 Fairness in Contracting... 6 In the Know... 6 Catch the BCBSIL Buzz on Twitter BCBSIL has recently expanded our online presence using one of the largest social media tools, Twitter. Twitter allows us to see what is being said about BCBSIL and other Blues Plans, send replies to anyone commenting on us, and broadcast information about our programs, successes and opinions for all to see. Our Twitter account will be used as a crisis communications and public affairs bulletin board, as well as a promotional and marketing communications tool. Twitter postings might include an announcement of a new major account we ve signed, health and wellness tips from Blue Care Connection, milestones in membership or provider network growth, important up-to-the-minute information during natural disasters we can also engage customers in conversation and get testimonials from our members. You can sign up to track our Twitter posts by joining the Twitter community. Go to to get started. Our site address is: Next month: BCBSIL joins Facebook June 2009 Electronic Health Record Incentives for Physicians The American Recovery and Reinvestment Act (ARRA) includes a number of provisions that will result in federal funding for health care information technology. Primarily, physicians will be able to participate in physician incentive programs designed to provide funding for electronic health record (EHR) purchases. Although many of the details will not be disclosed until the Centers for Medicare and Medicaid Services (CMS) develops policies, the following is a brief summary of certain portions of the law and how the new law may affect your practice. Through ARRA, CMS will pay physicians $44,000 to $64,000 over five years, beginning in 2011, for deploying and "meaningful use" of certified EHRs. Physicians can receive bonuses equal to an additional 75 percent of allowed charges, from $24,000 to $44,000, depending on when EHR adoption occurs. Physicians in a rural health professional shortage area can earn an additional 10 percent. Hospital-based physicians, such as pathologists, anesthesiologists, and emergency room physicians, are not eligible for the bonuses. Physicians must use a certified EHR system that meets standards that will include the ability to capture patient demographic and clinical health information, such as medical history and problem lists. System standards will also include the capacity for clinical decisions to support physician order entry, to store and query health care quality information, and to exchange electronic health information. The Department of Health and Human Services (HHS) will publish the certification criteria later this year. Physicians must demonstrate that they are meaningful EHR users to receive EHR funding. Physicians will need to demonstrate that they are using EHR for electronic prescribing, submit information on clinical quality measures and have a system capable of electronic exchange of health information. HHS will be responsible for publishing the meaningful user criteria. Beginning in 2015, physicians who are not meaningful users will receive financial penalties. If by 2018, 75 percent of physicians are not meaningful users, the penalties can increase but cannot exceed a five percent payment reduction. Physicians can apply for hardship exceptions, such as if they practice in a rural area without Internet access. Note: There are also incentives for providers servicing Medicaid recipients. Visit for more information. Physicians contemplating an EHR purchase should keep in mind that systems not certified will not be eligible for the incentive payments. The certification specifications will be published later this year. The Illinois State Medical Society (ISMS) will provide its members with timely updates as more details become available. For more information on how to choose an EHR, ISMS is hosting a webinar that is free for ISMS members and their staff on June 11, 2009, at noon. Visit to register for this webinar, and to receive more specific details. Reference: 2009 Illinois State Medical Society, Division of Health Policy Research and Advocacy U 4.09 Visit our Web site at id

2 Overpayments Regarding Direct Market Medicare Supplemental Policies Direct Market policies do not coordinate benefits with any insurance other than Medicare. If the duplicating plan is a group health plan and not a plan that the member purchased, then both policies can be maintained as primary and any overpayment would subsequently go to the member. Overpayments for the following Direct Market Medicare Supplement Group Numbers should be made to the member and should not be submitted to BCBSIL: The member s Group Number is located on the front of their I.D. Card Guidelines for Coding Allergy Immunotherapy Procedures A number of procedure codes are available for allergy immunotherapy. Use the following guidelines and criteria when billing for allergy services: CPT Codes describe the preparation of antigens. These codes do not include the administration of the antigen. Single dose vials are those vials that contain a single dose of antigen that is administered in one injection. Multiple dose vials contain a larger volume of antigen and doses are administered from the multiple dose vials at several subsequent visits. CPT Codes represent the professional service in creating the allergen extract and the number of doses (not the number of antigens) of extract used as the unit of service for reimbursement purposes. The number of vials is not reported. These codes do not include the administration of the antigen. Single dose vials are those vials that contain a single dose of antigen that is administered in one injection. Multiple dose vials contain a larger volume of antigen and doses are administered from the multiple dose vials at several subsequent visits. CPT Code describes the professional services for the supervision and preparation of antigens, whether single or multiple antigens. The number of doses/injections (not the number of antigens) of extract is used as the unit of service for reimbursement purposes. This code indicates that the physician must identify the number of doses/injections scheduled when the vial is provided. In most cases, this will be the number of doses/injections administered. In some cases, however, because of reactions or other factors, the patient will not receive the number of doses/injections intended. This code is intended to make reporting much more accurate in requiring physicians to identify the actual number of doses/injections planned to be provided no matter how many vials are used in the process. The number of vials is not reported. CPT Code does not include the injection procedure(s), per se. The physician, whether using a series of single vials or multiple dose vials, should report procedure one time and identify the number of doses/injections (not antigens) scheduled to be provided to the patient in field 24g on the claim form. When a physician prepares the allergenic extract(s), same or different antigens, and administers the extract(s) using single or multiple injections, code should be reported in addition to either or CPT Code is used to report allergen immunotherapy services including administration and appropriate documentation of an allergy injection and observation of the patient for a possible reaction. This procedure does not include providing the allergenic extract. This procedure describes a single injection. Procedure is used to report allergen immunotherapy services including administration and appropriate documentation of an allergy injection and observation of the patient for a possible reaction. This procedure does not include providing the allergenic extract. This procedure includes two or more injections. Typically only a single patient encounter is expected per date of service, therefore multiple injections are appropriately reported using code only once. Visit our Web site at 2

3 Workshop Schedule Upcoming workshops include: Workshop Date Location EFT, ERA & EPS Webinar June 10, 2009 Online esolutions June 24, 2009 St. Mary s Good Samaritan, Centralia, IL esolutions July 22, 2009 Advocate Trinity Hospital, Chicago, IL Register today! Visit our Web site at to view the agenda and sign up. We welcome your participation and value your input. us at provider_relations@bcbsil.com. New Account Groups Group Name: Fox Valley Laborers' Health and Welfare Fund Group Number: P66890 Alpha Prefix: FVL Product Type: PPO(Portable) Effective Date: June 1, 2009 BC BS Group Name: KemperSports Group Number: Alpha Prefix: KEP Product Type: PPO(Portable) Effective Date: August 1, 2009 BC BS Group Name: NTN USA Corporation Group Number: Alpha Prefix: NUC Product Type: PPO(Portable) Effective Date: June 1, 2009 BC BS Group Name: The Marmon Group-Silver King/Price Castle Group Number: Alpha Prefix: MNX Product Type: PPO(Portable) Effective Date: July 1, 2009 BC BS NOTE: The information noted above is current as of the date of publication; however, BCBSIL reserves the right to amend this information at any time without notice. The fact that a group is included on this list is not a guarantee of payment or that any individuals employed by any of the listed groups, or their dependents, will be eligible for benefits. Benefit coverage is subject to the terms and conditions set forth in the member s certificate of coverage. View Managed Care Updates Online HMO and BlueChoice Updated Policies and Procedures On a monthly basis, we post updated policies and procedures on our Web site under Updates. Go to to view the updated policies. HMO and BlueChoice Appointment/Reappointment Report On a monthly basis, we post a report of the Appointed and Reappointed providers on our Web site. To access this report, go to Select Appointed/Reappointed PCPs/PSPs under the Credentialing/Contracting section. The cumulative data is normally updated by the third Wednesday of each month. BlueChoice Updated Depart List A listing of all specialists no longer participating in the network for the BlueChoice product can be found at Note: You can find participating specialists for the BlueChoice product on our Provider Finder at BlueCard Tip: How to Identify a BlueCard Member The summer season is fast approaching and many people are traveling away from home. Unfortunately, accidents and medical emergencies never take a vacation and can happen at any time. This month s BlueCard tip will help prepare you to identify out-of-area Blue Plan members who may seek medical services in your office via our BlueCard Program. To identify BlueCard members, look for the following: an alpha prefix a blank suitcase logo the PPO in a suitcase logo for eligible PPO members The three or four character alpha prefix at the beginning of the member s identification number is critical for confirming a patient s membership and coverage so that out-of-area claims can be routed correctly. Plan-specific alpha prefixes start with X, Y, Z or Q and are assigned to every plan. Account-specific alpha prefixes start with letters other than X, Y, Z or Q and are assigned to centrally processed national accounts. A blank suitcase logo indicates that the patient has BCBS traditional, POS or HMO benefits delivered through the BlueCard Program. A PPO in a suitcase logo indicates that the patient has BCBS PPO benefits delivered through the BlueCard Program. BlueCard PPO members traveling or living outside of their Blue Plan s area receive the PPO level of benefits when they obtain services from BCBS providers. It is important to remember that not all PPO members are BlueCard PPO members. Only those whose membership card carries this special logo (noted above) can receive out-of-area benefits through the BlueCard Program. We value your input Please share your out-of-area member servicing experiences with us via at provider_relations@bcbsil.com. For additional information, refer to the BlueCard Program Manual on our Web site at: 3 June 2009

4 Ancillary Providers Are Welcome to Enroll for Electronic Transactions BCBSIL offers several electronic options to all of our independently contracted providers, including ancillary providers [Skilled Nursing Facilities (including outpatient therapy), Home Health Agencies, Hospice, Home Infusion Therapy, Durable Medical Equipment (DME) suppliers, Dialysis facilities, Orthotic/Prosthetic suppliers and Private Duty Nursing agencies]. Here is a menu of electronic solutions to consider: 1. Electronic Funds Transfer (EFT) is a safe, confidential and secure method of payment. Funds are electronically transferred directly into the bank account of your choice. This alternative to receiving paper checks can help save you time, in addition to helping reduce the frustration and the security risk of lost or misrouted payments. 2. Electronic Remittance Advice (ERA) is an electronic file that explains claim payment and remittance information. This data in the HIPAA compliant format can be automatically posted to your patient accounting system, eliminating the need for manual posting. The ERA is received in your office the day after claim finalization. 3. Electronic Payment Summary (EPS) is an electronic print image of the Provider Claim Summary (PCS). The EPS provides the same payment information you currently receive in the mail today on your paper PCS. The EPS is received in your office the same day your ERA is delivered. In addition to helping increase administrative efficiencies and reduce paper in your office, these electronic transactions present you with greater convenience, better security of information, cost reduction opportunities, faster reconciliation and easier archival access. Not only is it smart, but it s also easy to enroll! To learn more about EFT, ERA and EPS, please visit the Electronic Commerce section of our Web site at Ancillary providers may also contact our Ancillary Network Department for personalized assistance at (312) or ancillarynetworks@bcbsil.com. Provider Network Relations Spotlight Meet our Network Consultants for Ancillary Providers BCBSIL contracts with over 2,000 Ancillary providers in Illinois and Northwest Indiana. We are pleased to have an experienced and dedicated staff that deals specifically with the needs of our ancillary providers who offer the following services to members in our HMO, PPO and BlueChoice POS networks: Skilled Nursing Facility (including outpatient rehab therapy), Home Health Care, Hospice, Home Infusion Therapy, DME, Orthotics and Prosthetics, Dialysis and Private Duty Nursing. Our Ancillary Provider Relations team consists of Sherry Heise-Jaskolka, Manager, Ancillary Contracting and Elaine Williams, Ancillary Provider Network Consultant. Sherry Heise-Jaskolka, Manager, Ancillary Contracting Sherry, a registered nurse for over 25 years, began her nursing career by working in hospital critical care units leading to the position of Assisstant Director of Nursing on a busy 46 bed surgical floor. She moved into Home Care a few years later, first as a home care nurse, but assumed roles with greater responsibility leading to a position as Director of Quality Improvement/Utlization Review. Sherry has been a Certified Professional in Healthcare Quality for over 15 years and a member of the National Association for Healthcare Quality. She carried her love and knowledge of home care services to BCBSIL to become the Medicare trainer for home health care and hospice facilities and recognized early on that there was a need to advocate for and develop the ancillary provider service network. Given her extensive hospital nursing background, she also conducts on site reviews for new hospitals requesting to participate in the BCBSIL PPO network. Sherry has enjoyed over 15 years of working with the BCBSIL ancillary providers and is honored to work on their behalf in resolving issues, providing education and guidance, as well as contracting and ancillary network management. In addition to being an advocate for the ancillary providers, Sherry has become an advocate for BCBSIL staff. She identified an opportunity to provide ongoing Continuing Education (CE) program inservices for the Medical Review Unit nurses in our Springfield and Danville offices. She now coordinates and facilitates these CE programs by utilizing the BCBSIL ancillary providers as educational resources. It s a win-win situation. Both the nurses and the providers love it and it provides an opportunity for our nurses to remain clinically current without leaving the office. Sherry cherishes the relationships that she has developed with many of the ancillary providers over the years and extends her gratitude for their cooperation and superb willingness to provide the best service to our BCBSIL members. Sherry can be reached at (312) or ancillarynetworks@bcbsil.com. Elaine Williams, Ancillary Provider Network Consultant Elaine Williams has worked at BCBSIL for 23 years, with the last three as a Provider Network Consultant. Elaine s years of experience in the health care insurance industry have led her to gain a wealth of knowledge in many different departments, all contributing to her exceptional customer service skills. She has held positions in Records Management, Federal Employees Program (FEP), Illinois Comprehensive Health Insurance Plan (ICHIP) and Municipal Accounts, including the City of Chicago for nine years. After 15 years at BCBSIL, Elaine felt the need for change, and relocated to Blue Cross and Blue Shield of North Carolina in Raleigh, where she worked for four years in the FEP Department. While there she also acquired hospital experience in case and care management, and helped providers and members through customer service. Elaine thoroughly enjoys assisting providers and meeting with the diverse ancillary provider staffs to resolve their issues. Elaine says the most rewarding aspect of her job is, When I am able to get providers the information they need and they call back to say thank you. In return, Elaine wishes to thank all of the ancillary providers for allowing her to assist them and for making her job so fulfilling. Elaine can be reached at (312) or ancillarynetworks@bcbsil.com. Visit our Web site at 4

5 Quality Site Visit Results HMO Member Survey Reminder The 2009 HMO Member Survey will be mailed to randomly selected members in each Independent Practice Association (IPA) during June The primary purpose of this survey is to assess member satisfaction with various attributes at the IPA level, including access and overall service, as well as medical care and services rendered by PCPs and specialists. This survey is performed annually to analyze member satisfaction at each IPA. During 2008, Quality Site Visits were performed for Primary Care Physicians (PCPs) in the HMO Illinois, BlueAdvantage HMO, and BlueChoice networks. The site visit network results for 2008 have been compiled and, on behalf of the HMOs* of BCBSIL and BlueChoice, we are happy to report continued improvement in the following categories: Accessibility, Site Review of Physician Offices, Quality of Patient Care Documentation and Medical Record Quality for There was also a demonstrated improvement in colorectal cancer screening and influenza vaccination. Please review the Quality Site Visit standards and Site Visit Comparisons on the BCBSIL Web site at Areas of improvement identified by the 2008 site visit results include the following: Quality of Patient Care Documentation of family medical history Documentation of the assessment of physical activity Documentation of illicit drug use Documentation of adolescent smoking history Documentation of adolescent smoking cessation advice Documentation of adult smoking cessation advice The results of this survey are used to determine an IPA s Blue Ribbon Directory Indicator in the HMO Directory. The results are also used to determine an IPA s eligibility to receive the Quality Improvement (QI) Fund based on overall satisfaction, and satisfaction with the referral process for specialists. Please feel free to notify your HMO members* that the survey has been distributed. You may encourage members to promptly complete and return the survey to BCBSIL in the postage-paid envelope provided within five business days of receipt. Surveys contain instructions in Spanish for members that are primarily Spanish-speaking and/or -reading to request a survey by telephone. A bilingual postage-paid reply card is also included in the survey mailing for members who need to request a survey in Spanish. *HMO Illinois and BlueAdvantage HMO Preventive Colorectal cancer screening male and female age 50 and over Influenza vaccination male and female for diabetics, asthmatics, cardiovascular disease and age over 65 In order to improve site visit results in 2009 for the HMO and BlueChoice networks, we are requesting a review and discussion of these results. You can help us with our site visit scheduling by doing the following: If you need to cancel a site visit, please let us know five business days prior to the visit. If you use electronic medical records, please inform us when we schedule your site visit. We appreciate your continued cooperation with these quality improvement efforts. *HMO Illinois and BlueAdvantage HMO 5 June 2009

6 Fairness in Contracting In an effort to comply with Fairness in Contracting Legislation and keep our independently contracted providers informed, BCBSIL has designated a column in the Blue Review to notify you of any changes to the physician fee schedules. Be sure to review this area each month. Effective June 1, 2009, BCBSIL implemented its annual update of the Schedule of Maximum Allowances (SMA) in relation to the CMS Resource Based Relative Value Scale (RBRVS) revisions and CMS fees for DME, clinical laboratory and J codes. Reimbursement for services provided on or after June 1, 2009, will be based on the updated PPO and BlueChoice fee schedules. Providers may now request fee schedules for this update. Annual and quarterly fee schedule updates can be requested by downloading the Fee Schedule Request Form at Specific code changes that are listed above can also be obtained by downloading the Fee Schedule Request Form and specifically requesting the updates on the codes listed in the Blue Review. In the Know Did you know that the paper Provider Claim Summary (PCS) contains the same information as the Electronic Payment Summary (EPS)? In our continuing effort to help reduce paper and increase administrative efficiencies in provider offices, we encourage you to consider the advantages of the Electronic Payment Summary (EPS). The EPS is an electronic print image of the paper Provider Claim Summary (PCS) many providers receive in the mail currently. The EPS provides the same payment information as the paper PCS,* and you will receive it in your office the same day your Electronic Remittance Advice (ERA) is delivered. Here are some additional benefits of the EPS: Quicker than receiving a paper PCS Offers the option of searching by individual patients, account numbers, member IDs, etc. Space-saving capability one or multiple EPSs can be downloaded to a CD Reduced risk of unauthorized receipt of Protected Health Information (PHI) and Sensitive Personal Information (SPI) Modifier 59 Exempt Auditing and Code Auditing Upgrade Effective September 2009, BCBSIL will implement changes for Modifier 59 exempt code pairs into the claim processing system through our code auditing tool, ClaimCheck. These changes are based on the CMS National Correct Coding Initiative (NCCI) code auditing system. Additionally, BCBSIL will be upgrading to McKesson ClaimCheck Version 43 effective September 2009 for all lines of business. For further information about current bundling methodologies, or to request specific code-to-code bundling, you may utilize Clear Claim Connection (CCC or C3 ), a Web-based code auditing reference tool available to all independently contracted BCBSIL providers. To obtain access to C3, you must register with RealMed at Reduced paper storage costs Easy storage and retrieval of archived information No need to call for BCBSIL paper PCS reprints It s easy to enroll! You will automatically receive the EPS once you enroll for the ERA. The downloadable ERA Enrollment Form is available in the Electronic Commerce section of our Web site at Once you have signed up for the ERA, you will have 30 days of simultaneous paper PCS and electronic EPS delivery to make sure the new files are a good fit for your practice operations. After this 30-day transitional period, the paper PCS will be discontinued. For additional information about ERA and EPS, as well as Electronic Funds Transfer (EFT), please view the Frequently Asked Questions in the Electronic Commerce section of our Provider Web site at You may also contact our Electronic Commerce Center at (800) for assistance. *Note: The EPS is delivered by BCBSIL in a text file format. If you are utilizing a billing agent, the EPS goes to the receiver/vendor/clearinghouse. Delivery or posting specifications are determined by the vendor, not BCBSIL. Therefore, you should check with your receiver/vendor/clearinghouse to determine whether or not special software may be needed to view the EPS file. Visit our Web site at 6

7 Thinking Outside of the Mailbox Survey Examines Provider Perspective on Paperless Transactions In February and March, our Provider Network Consultants met with a number of provider offices to assess awareness and satisfaction related to electronic transactions. Specifically, providers were surveyed on their experiences with EFT, ERA and EPS. Most providers who were already enrolled at the time of the survey gave high marks to these transactions. Here are the top three reasons that survey participants cited for using EFT and ERA/EPS: 1. Decreased risk of identity theft through lost mail 2. Reduced paper handling and storage 3. Ease of use Many participants noted that these transactions have helped them save time by standardizing office processes. Providers also commented on the efficiency, convenience and environmentally friendly aspects of EFT, ERA and EPS. In addition to positive feedback from current EFT, ERA and EPS users, survey participants who were not yet enrolled at the time of the survey contributed valuable input that helped us identify opportunities for improvement. This constructive dialog resulted in a comprehensive Frequently Asked Questions document, which was posted on our Provider Web site in May. If you haven t already enrolled, we look forward to helping your office discover the benefits of participating in EFT, ERA and EPS. Please visit the Electronic Commerce section of our Web site at to access the enrollment forms and view our Provider FAQs. You also may contact our Electronic Commerce Center at (800) if you need additional assistance. Coming Soon: Discontinuance of the Paper Provider Claim Summary In previous news alerts, we notified you that, upon enrollment for ERA and EPS, you would continue to receive your paper PCS for 30 days after starting to receive your ERA and EPS files. Please be advised that, in the near future, BCBSIL will discontinue producing the paper PCS for all providers who have been receiving the ERA and EPS for at least 30 days. If you have questions or need additional information regarding this notification, please contact the Electronic Commerce Center at (800) Hospital Rate Charge Notification All BCBSIL contracting hospitals are required to notify us of any rate charge increases (including per diem room rates) at least 90 days in advance of the effective date. Hospital rate charge notification may be made by completing the Schedule of Hospital Charges form. Room rate charges received after the effective date will not be retroactive. The effective date of the new rate, if received late, will be the date of receipt of notification. The Schedule of Hospital Charges form can be found on our Web site at Just click on Forms in the Provider Library section. Completed forms may be submitted to Kendra Thompson via one of the following ways: Mail: Blue Cross and Blue Shield of Illinois ATTN: Kendra Thompson Network Management Department, 25th Floor 300 E. Randolph Street Chicago, IL Fax: (312) thompsonk@bcbsil.com Please contact your assigned Provider Network Consultant if you have any questions regarding the hospital rate charge notification process. Please note: Nothing in this article should be construed as modifying any current hospital agreements in place. In the event anything in this article conflicts with the terms of your hospital agreement, the terms of the hospital agreement shall control. 7 June 2009

8 Visit us online at Have an idea for an article? We want to hear from you! Let us know if Blue Review continues to meet your standards. Does this publication address your needs? What topics would you like to read about? BCBSIL s success is dependent on your business as a contracting provider. Blue Review has been created to communicate tools, updates and tips to support your health care practice. Think of Blue Review as a canvas for your Blue Cross and Blue Shield business information. We invite you to submit your feedback and suggestions for improvements via , to bluereview@bcbsil.com. Blue Review is a monthly newsletter published for Institutional and Professional Providers contracting with Blue Cross and Blue Shield of Illinois. We encourage you to share the content of this newsletter with your staff. Blue Review is located on our Web site at The editors and staff of Blue Review welcome letters to the editor. Address letters to: Blue Review Blue Cross and Blue Shield of Illinois 300 E. Randolph Street 25th Floor Chicago, Illinois bluereview@bcbsil.com Web site: Publisher: Stephen Hamman, VP, Network Management Editor: Gail Larsen, DVP, Provider Relations Managing Editor: Jeanne Trumbo, Sr. Manager Editorial Staff: Margaret O Toole, Marsha Tallerico and Allene Walker BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services offered by them. If you have any questions regarding any of the products or services mentioned in this periodical, you should contact the vendor directly. PRSRT STD U.S. POSTAGE PAID PERMIT NO. 581 CHICAGO, IL FSC Logo A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association