Blue Quality Physician Program

Rewarding independent primary care practices for improving quality and lowering the cost of care

  

As we are introducing Adult primary care practices to this exciting advanced primary care model (Aledade ACO), we will not be accepting new adult practices to apply for BQPP in 2019.

We will continue to accept new pediatric practices into the BQPP program for 2019.

Aledade ACO Rollout Information

Aledade ACO FAQs

 

 

  

BQPP is not accepting OBGYN/GYN practices for 2019. OB/GYN practices can join the OBGYN Care Collaborative. Please contact OBGYN@bcbsnc.com with any questions.

What is the Blue Quality Physician Program (BQPP)?

BQPP rewards independent primary care practices for providing high-quality, low-cost, and patient-centered care for Blue Cross NC members.

We offer qualifying independent primary care practices the opportunity to participate in the BQPP. This allows your practice to improve the care you give Blue Cross NC members.

Program Benefits

Practices that successfully achieve BQPP criteria can receive a double-digit fee increase on their Evaluation and Management (E&M) and Preventive E&M codes. You can see how your practice will score in our Specialty Criteria section below:
level 2 (800 points) and level 3 (915 points).

Practices that enter the BQPP will receive:

  • Quarterly Practice Cost Efficiency reports. These show performance in relation to peer practices comparison with ER utilization, advanced imaging and specialist’s visits
  • Monthly ER Utilization, preventable admissions, and attribution reports
  • Access to online Best Practice Sharing Forums. Learn from other BQPP participants and share ideas referring to health care transformation.

The above reports are located on the DataRail portal. Only BQPP practices have access to this portal:

Should your primary care practice apply for BQPP?

BQPP accepts independent practices that are accountable for meeting a patient’s physical and mental health care needs. This includes preventive and wellness visits and acute and chronic care. Both large and small practices with a comprehensive care team are accepted.

What primary care practices can apply?

  • Family Practice
  • Internal Medicine
  • General Practice
  • Pediatrics
  • Multi-Specialty (Family Medicine/Pediatrics) only

Eligibility and Requirements

  • Must be PCMH recognized by:

    • NCQA
    • JCAHO
    • URAC

PCMH threshold requirement Mandatory Requirements

Requirement for non-PCMH locations

Expiration date is required on application

  • Electronic Health Record (EHR) is required
  • An individual practice website not associated under the patient portal or Clinically Integrated Network
  • 30 attributed Blue Cross NC members
  • All providers and practitioners must be credentialed through Blue Cross NC
  • Provider Leadership is required
  • Provider Quality Report – pulled and reviewed monthly
  • Patient Portal – free for all patients and linked on website
  • Contracting Requirements PDF MUST BE REVIEWED BY PRACTICE
  • Blue Cross NC reserves the right to audit BQPP practices from time to time

Additional PDFs:

Contracting Needs

BQPP Website Requirements

You can learn more about credentialing or email your questions, provider numbers (NPI), contract questions, and sample fee schedule inquiries to NMSpecialist@bcbsnc.com.

Program Recognitions 

All recognitions are valued at 275 points.

Patient-Centered Medical Home (PCMH)

URAC PCMH

Primary Care practices can apply for URAC PCMH.

URAC’s Achievement program promises health care reform by:

  • Increasing access to services
  • Supporting care coordination across the continuum
  • Improving patient accountability through information and decision making
  • Driving efficiency and effectiveness

URAC’s PCMH program provides a unique approach to health care and strong educational support and cost advantages.

Visit URAC online, or email or call Sheila Brunson at 202-326-3964 for more information. There is a discount for BQPP practices applying for URAC PCMH.

 

JCAHO PCMH

Primary Care practices can apply for the Joint Commission PCMH Certification.

The JCAHO PCMH certification focuses on care coordination, access to care, and how effectively a practice and team work with the patient.

To find out more about JCAHO PCMH Certification please visit www.jointcommission.org .

 

NCQA PCMH

The following practices can apply for NCQA PCMH Certification:

  • Family medicine
  • Internal medicine
  • General practice
  • Pediatrics

Both NP and PA providers can achieve PCMH recognition.

PCMH recognizes practices that function as medical homes.

If your practice has multiple locations, all sites must be PCMH recognized.

NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. BCBSNC is considered your sponsor. Please enter the NCQA code "CNCBCA" on your NCQA application to receive the discount. Visit www.ncqa.org  for more information.

Visit www.communitycarenc.org for NCQA PCMH cheat sheets and tools to assist you through the process.

Specialty Criteria

Adult Criteria

Review the Adult Points Allocation Summary (pdf) for an overview of the points allocation.

Adult Criteria Quality Measures (pdf)

Pediatric Criteria

Review Pediatric Points Allocation Summary (pdf) for an overview of the points allocation.

Pediatric Criteria Quality Measures (pdf)

HPV helpful documents for practices:

Multi-Specialty Criteria

Review the FM Multi-Specialty Peds Points Summary (pdf) for an overview of the points allocation.

Multi-Specialty Criteria Quality Measures (pdf)

 

Additional Mandatory Requirements for All Providers

Provider Quality Report (PQR) = No Points

Your PQR must be pulled monthly from Blue e (this will be audited). We ask that practices use these reports to close care gaps.

We use the PQR as our gold-standard and the first element in scoring your practice’s quality. Practices with a denominator of 30+ will be scored ONLY using the PQR.

These reports show your practice performance against nationally recognized measures.

12-Month Rolling View: allows you to see where your practice is and how you’ve performed over the last 12 months.

Prospective View: show care gaps based on HEDIS measures, gaps currently open, and how likely your practice is to closing those gaps.

We encourage practices to use these Provider Quality Reports to close care gaps. For questions concerning PQRs, contact Quality Management by email or call (919) 765-4809.

BQPP Practice Quality Scorecard

Points are awarded based on national HEDIS benchmark percentiles

  • Practices are required to download the quality scorecard below and fill it out completely.
    • Practice fills in the numerator and denominator value for all measures on the practice scorecard from your EHR.
    •  Put a “0” if your EHR cannot pull a measure.
  • 1 year lookback or calendar year (as much as your EMR allows)
  • The denominator must have at least 30 members in order to score

Complete the scorecard spreadsheet and submit it with your application. Incomplete scorecards will delay your application results.  DO NOT ADD, DELETE, OR CHANGE COLUMNS ON EXCEL FILES.

Appropriate HCC Coding Risk = 30 Points

We have partnered with Pulse8 to provide your practice with education webinars related to risk adjustment –HCC coding. The risk adjustment webinars and PDFs are located on Blue e under the Health Management section.

  • New Practices: All providers and practitioners are required to view two risk adjustment (1 hour webinar) recorded or live webinars on Blue e. You can also read two PDF documents/webinars on Blue e if more convenient. Providers must complete these prior to applying to BQPP. The Pulse8 webinar quiz is not required for BQPP.
  • Renewing practices: can view two risk adjustment webinars for additional points. ALL providers and practitioners must participate in order to receive points. New providers and practitoners added to practices are required to view two webinars or read the PDFs on Blue e. 
  • Pulse 8 BQPP Flyer

Live Webinars:

  • Email provider engagement the date and time you would like to attend. Write “Registration” in the subject line.
  • You’ll receive a WebEx invitation with login information.
  • Join the webinar when it’s time and sign in as a guest using your name and email.

Recorded Webinars:

  • Access the Risk Adjustment portal through Blue e under the Health Management tab.
  • The education section will guide you to the webinars. Click the orange arrow to access them.
  • Click the title to the right of the video to access the webinar under Archived Webinars.

Provider Feedback Loop Tool = 15 points

  • Practices will be receive optional points for accessing the tool which helps identify patients who have open coding gaps. Please review the provider feedback loop PDF below.
  • Provider Feedback Loop

Additional BQPP Elements

Knowing and Managing Your Patients = 80 points

Addressing Social Determinants - Health Opportunities

These can be Group Visits, Education, Classes (at the practice) or webinars

  • Practices will attest to these on the BQPP application
  • All applicable items must be on the practice website. Please ensure detailed class information is available for all patients. This is a class held at the practice location weekly, monthly or quarterly. It can be an educator from the practice or from outside.

Options:

We know that mental illness is associated with increased occurrence of chronic diseases such as cardiovascular disease, diabetes, obesity, asthma, epilepsy and cancer – and that it’s possible to achieve better overall health outcomes in cost and quality by providing better behavioral health care. Below is a few facts about mental health awareness.

  • Mental health disorders as a category represent one of the 5 most costly conditions in the United States, with expenditures over $60 billion. Over 8.9 million persons have co-occurring disorders — that is, they have both a mental and substance use disorder.
  • Up to one-in-four primary care patients suffer from depression; yet, primary care doctors identify less than 30% of these patients.
  • Among the 8.9 million adults with any mental illness and a substance use disorder, 44% received substance use treatment or mental health treatment in the past year, 13.5% received both mental health treatment and substance use treatment and 37.6% did not receive any treatment.
  • People with psychotic disorders and bipolar disorder are 45% and 26% less likely, respectively, to have a primary care doctor than those without mental disorders.

Patient Engagement = 20 Points

Electronic Patient Satisfaction Survey: = 10 points

  • Patient surveys can be distributed to patients through online systems such as Survey Monkey, Text, Email, Patient Portal etc.
  • Patient surveys CANNOT be distributed through any type of paper document even if it is scanned into the EMR for BQPP points.

Language Services: = 10 points

Resources or professional interpreters and translators to provide the necessary language services in the practice

Patient portal (no points) is Mandatory requirement

  • Must have link to portal on practice website
     

Team-Based Care and Practice Organization (Advanced Care Team) = 85 points

An Advanced care team model is highly encouraged. All Advanced Care team members must be listed on your practice website and be engaged with Blue Cross NC members to receive points.

Advanced Care Team members:

  • Health Coach (RN, LPN, or MA)
  • PharmD or Pharm Tech
  • Social Worker (LCSW or LPC)
  • Psychologist/Psychiatrist
  • Nutritionist/Dietician
  • RN-Triage
  • Case Manager/Care Coordinator (MA, RN, LPN or CNA)
  • Lactation Consultant - (IBCLC,/RN/LPN) focus on early childhood development

If your practice partners with a behavioral health provider to provide mental health/substance treatment, you can attest to this on the application.

Behavioral Health Co-Management Agreement (pdf)

Patient-Centered Access and Continuity = Max of 300 points

Practice After Hours:

After hours care must be listed on your practice website to receive points. Specific points for each below is listed on the score sheets under each specialty criteria section.

  • Weekday (hours after 5:00 pm and/or before 8:00 am)
    • Total four hours each weekday (lunch hour doesn’t count)
    • Seven hours on weekday
  • Weekend Hours
    • 2 hours on Saturday
    • 2 hours on Sunday
    • 4+ hours on Saturday
    • 4+ hours on Sunday
  • Co-management agreement with Urgent Care (practice with three providers or less only)

Telehealth following Blue Cross NC policy

Real Time Communication After-Hours:

  • Direct Provider Access Afterhours Phone  Access
    • Patient has direct access to Provider via phone or answering machine
      • The provider would call the patient back in real time (30 minutes to 1 hour)
      • NOT a nurse triage line or hospital line

OR

  • Direct Patient to Provider Messaging through patient portal After-Hours
    • Provider responds after-hours within reasonable timeframe outlined by practice and posted on website
    • Patient to provider directly, not nurse triage or hospital
  • Telehealth - following Blue Cross NC's policy

Cost-Driving Affordability = 275 points

The Practice Cost Report from Blue Cross NC is a report of your practice’s total cost of care compared to other peer practices in your specialty.

Relative Cost Index of:

  • .93 or below= 275 points
  • .94-1.01= 225 points
  • 1.02-1.09= 175 points
  • 1.10-1.17= 125 points
  • 1.18-1.30=75 points

View our Improving Cost FAQ for more information.

The report includes:

  • Primary Care Office Visits
  • Emergency Room Visits
  • Inappropriate ER Visits
  • Specialist Visits
  • Urgent Care Visits
  • Inpatient Hospital Admissions
  • Imaging (MRI and CAT Scans)

Application and Renewal

Application and Renewal Dates

Important Application Information and Dates

  • Practices can apply twice a year: April 1 – May 31 or August 1 – September 30
  • Practices must renew annually in order to keep BQPP reimbursement
  • It can take up to 60 days to score your application
  • Practices that do not follow instructions may have a delay in application results

Before You Begin the Application

Every practice must have at least 30 Blue Cross NC members. You need the following to complete your application:

  • The practice group NPI number
  • Address and phone numbers for all practice locations
  • Knowledge of any practice co-management agreements that are in place
  • Practice Website must be updated with all BQPP elements

 

The application works only when using the latest Google Chrome browser.

  
The NPI you entered was not found. Please check the number and try again or contact bqpp@bcbsnc.com or 919-765-1292 for help. Group NPI is required. Must be 10 characters in length.

 

Removal From Program

Reasons for Immediate Removal Include but are not Limited to:

  • Falsification of application and/or attestations approved on application, such as after hours and patient portal, or provider education.
  • Failure to maintain mandatory BQPP elements since practice's effective date with BQPP (not a part of annual renewal)
  • Joining a Health System: this program is to solely benefit and equip practices that are independent and to provide them with tools and resources for advancement.
  • Inadequate annual renewal – practices that can’t maintain program elements can be removed during application renewal
  • Failure to review the PQR monthly via Blue e
  • PCMH recognition Expiration without proof of renewal
  • Blue Cross NC matters outside of the program: credentialing, contractual obligations, provider agreement issues, SIU, etc.
  • Blue Cross NC reserves the right to audit BQPP practices from time to time

Case Management and Healthy Outcomes Program

Blue Cross NC offers Case Management of all patients. Do you need help supporting patients with chronic conditions? Refer them to our Case Management team.

Education

BQPP Practice Collaborative

The BQPP team will distribute quarterly “Best Practice Sharing Forums” online. This providers you the opportunity to share things you’ve learned and tools your practice uses for health care transformation with other BQPP practices.

Opioids Prevention

We are continuing our fight against opioid abuse. Learn more about how opioids can affect you, your practice, and your patients from our Opioid Prevention resources page. 

The opioid crisis in the United States directly affects your practice and BQPP providers. Dr. Anuradha Rao-Patel, Medical Director at Blue Cross NC, has written a letter to guide all providers. The CDC guidelines are also beneficial to all providers in your practice. Please pass these resources to your providers.

Continuing Medical Education Courses:

These courses are optional for your practice and providers: