OBGYN Care Collaborative

Partnering with independent OBGYN practices on health care tools and resources

What is the OBGYN Care Collaborative Program?

Blue Cross NC believes that partnering with independent OBGYN practices is the best way to improve the care and quality of our members.

The OBGYN Care Collaborative Program focuses on women's  health and rewards independent practices committed to offering high-quality outcomes and low-cost, patient-centered care for our members.

OBGYN Care Collaborative Overview

How are members attributed to a practice?

Members are attributed to the primary care practice (PCP) they have visited the most for primary care utilization (based upon Wellness and E&M claims). In the new model, Blue Cross NC evaluates a member’s 15-month claims history and applies a stepwise hierarchical approach in order to attribute a member to a PCP:

The order is as follows:

  1. PCP Wellness Visit
  2. PCP E&M codes
  3. Specialty Care Provider Wellness Visit or E&M codes
  4. PCP Selection

In the case of PCP selection, a member has notified Blue Cross NC of their preferred PCP or OBGYN provider (typically during the member enrollment process).

If there is a tie, attribution is based on the most recent visit. If there is no PCP utilization during the study period, then we allow attribution to OBGYNs, Endocrinologists or Cardiovascular Disease Specialty Care Providers, taking into account the most recent visit when there is a tie.

What practices can apply?

Independent OBGYN practices that meet program criteria are eligible to apply and receive a fee increase on their Evaluation and Management (E&M) and Preventive E&M codes and specific carve outs for in-office procedures.

Practices that enter the program 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
    • The above reports are located on the DataRail portal, only OBGYN Care Collaborative practices have access to this portal
    • DataRail is a platform that will allow OBGYN Care Collaborative practices to sign in and download reports that contain member- level data.
    • DataRail link
    • DataRail User Manual and FAQs
  • Access to web-based Best Practice Sharing Forums – a collaborative environment for OBGYN Care Collaborative participants to learn from each other and share what they’ve learned in the health care transformation journey.

Program Eligibility and Requirements

There is specific criteria your practice must meet in order to apply. Criteria is based on the purpose and structure of the program. Your practice must meet ALL criteria to apply to the program. Eligibility is at the sole discretion of Blue Cross NC. Practices must reapply yearly in order to remain in the program and on the OBGYN Care Collaborative fee schedule. The program requirements will evolve yearly and practices should continue to focus their efforts on improvement.

Your practice must meet these program eligibility requirements:

  • Provider Engagement is require for your practice to participate
  • An Electronic Health Record (EHR) is required for your practice to be eligible
  • Practices must have an individual website not associated with the patient portal or Clinically Integrated Network
  • Practices must have at least 30 attributed Blue Cross NC members

Contacting Needs:

In order to be on the OBGYN Care Collaborative fee schedule, you must have:

  • Active credentialing status for all providers including NP, PA, etc.
  • Access to Blue e and EFT registration
  • A copy of your current CLIA certificate

Contact Numbers:

  • Call Blue Cross NC’s Financial Processing Department at 919-765-2293 for questions about the EFT process.
  • Call the eSolutions HelpDesk at 1-888-333-8594 for questions about Blue e.
  • You can confirm if each practitioner is Blue Cross NC credentialed by calling 800-777-1643 and choosing option 6. https://www.bcbsnc.com/content/providers/application/instructions.htm

Learn more about applying for credentialing or email your questions, provider numbers, contracts and sample fee schedules to Network Management. NMSpecialist@bcbsnc.com

Program Criteria

Please review the OBGYN Criteria (pdf) or GYN Criteria (pdf) to see an overview of the elements and points allocation for the OBGYN Care Collaborative program.

Performance Measurement and Quality Improvement

Quality measures in the OBGYN Care Collaborative Program use HEDIS quality measure standards.

Please review the Provider Quality Pocket Guide for a full explanation and specs of the measures.

Practices at the 50th percentile or below need to complete the Plan Do Study Act (PDSA)

For more information, view the How to perform a PDSA (pdf)

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

OBGYN Quality Measures

Total possible points 300

Six measures: Each measure possible points: 50

GYN Quality Measures

Total possible points 300

Five measures: Each measure possible points: 60

Appropriate HCC Coding and Provider Alert Tool = up to 50 points

ACA Webinars: 25 points

We have partnered with Pulse8 to provide you and your practice with educational resources related to risk adjustment and factor coding (HCC coding).

All new practices and providers (including NPs and PAs) are required to view two ACA risk adjustment (Pulse8) recorded or live webinars on Blue e. Any new providers that join a practice, must complete this requirement. Another option is to read two PDF documents/webinars on Blue e. You must complete these prior to applying. You must attest to completing these on the application.

Total of 25 points for 2 webinars

Review the 2019 calendar of available webinars.

Pulse 8 OBGYN Care Collaborative Flyer

Live Webinars:

  1. Visit https://pulse8.webex.com and select the Risk Adjustment Documentation and Coding Series program.
  2. Check the box to the left of any session date and time that you’re interested in attending and click Register.
  3. Fill in all required fields and click Submit.
  4. Once Pulse8 receives your request, you'll receive a WebEx invitation with personalized login information for the session(s) you requested.

Recorded Webinars:

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

Provider Alert Tool  25 points

Practices will be measured on accessing the tool which will help identify patients who have open coding gaps.

Pulse 8 PFL Alert Tool Flyer

 

Additional OBGYN Care Collaborative Elements

Team-Based Care and Practice Organization = up to 100 points

Advanced Care Team

The Advanced Care Team members must be engaged with BCNC members in order to receive points. (For example, case managers for ACO members outside of Blue Cross would not count)

Advanced Team Members Include:

  • Lactation consultant
  • Health Coach (RN, LPN, MA)
  • PharmD or Pharm Tech
  • LCSW or LPC
  • Psychologist/Psychiatrist
  • Nutritionist/Dietician
  • RN- Triage
  • MA/RN/LPN case manager/ care coordinator

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

Behavioral Health Co-Management Agreement (pdf)

Knowing and Managing Your Patients = up to 175 points

Health opportunities (Group Visits, Classes at the practice or webinars)

Electronic Patient Survey

Survey addressing patients' needs and practice assessment provided electronically which could be posted on the website, emailed, or sent by text

Patient Portal: Access to personal health records provided to all patients free of charge with link on practice website.

Patient-Centered Access and Continuity = up to 250 points 

Expanding access to patients is a critical element of patient centered care. The following four components will be scored separately but must be listed on your website in order to earn points.

  1. Practice After Hours:
  • After Hours Care Weekdays (Hours after 5 pm and/or before 8am not including lunch) *Totaling at least 1+ hour(s) per week

          *Practices can offer hours before 8 or after 5pm in half hour or hour increments.

  • For example: 7am-5 pm or 7:30-5 one day and 8-5:30 another day.  *Practices can delay opening in order to stay open later in the evening on certain days. For example: 10-7pm one day of the week.

After Hours Care Weekend (hours on Saturday and/or Sunday for any patient posted on website) *At least 2 hours on Saturday or Sunday this section is new 

  1. Same Day Appointments:  Offering Same Day Appointments as standard operating procedure on weekly basis.
  2. Telehealth: Telehealth following Blue Cross NC policy this section is new
  3. Direct Provider Communication Real Time Communication After Hours: this section is new
  • Direct Provider Access Afterhours Phone Access
    • Patient has direct access to Provider via phone
      • NOT a nurse triage line or hospital line

OR

  • Direct Patient to Provider Messaging through patient portal Afterhours
    • Provider responds after-hours within reasonable timeframe outlined by practice and posted on website
      • Patient to provider directly, not nurse triage or hospital

Driving Affordability = up to 250 points

Your practice will be measured on cost using the Practice Cost Index Report. This report measures your practice’s Total Cost of Care by comparing to determined peer groups. The report will be available quarterly for your practice to review.

Practice Cost Report FAQ

Definitions:

  • Cost Index: the score is created using practice’s attributed patients and their total cost of care. The score has a 95% confidence interval with a lower and upper bound.

            This includes:

  • Primary Care Office Visits
  • Emergency Room Visits
  • Inappropriate ER Visits
  • Specialist Visits
  • Urgent Care Visits
  • Inpatient Hospital Admissions
  • Imaging (MRI and CAT Scans)
  • Peer Group: A scientifically defined group based on similarities in:
    • Region
    • Size
    • Average Age of Patients
    • Risk Score of Patient Population

The stretch goal cost index is 1.0 or below. Practices above 1.13 will be placed on a cost-improvement plan for one year. Points are determined by your practice data divided by peer data.

Commitment to Practice Transformation and Development = 100 points

National Accreditation

  • Recognitions through NCQA, JCAHO, URAC or ACOG accrediting bodies
    • Expiration date will be required on Application

Resources

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. 

Dr. Anuradha Rao-Patel, Associate Medical Director at Blue Cross NC, has written a letter to guide all providers.

Letter from: Dr. Anuradha Rao-Patel

The CDC guidelines are also beneficial to all providers in your practice. Please pass these resources to your providers.

OBGYN Best Practice Sharing Collaborative

The OBGYN program team offers quarterly online “Best Practice Sharing Forums.” The forums provide an opportunity for practices to share lessons they’ve learned and tools they use in their journey to health care transformation. And, to create a collaborative environment for practices to learn from one another. Webinars are scheduled quarterly during the lunch hour.

PREGNANCY RESOURCES

A series of articles from moms, doctors and other professionals on important topics for new and expecting mothers.

Pregnancy and Tools

 

Important Application Information and Dates

Practices can apply once per year: August - September

  • Allow 60 days for us to score your application
  • Practices that don’t follow all the instructions outlined here may see a delay in when their application is scored.
  • Practices must reapply manually each year to remain in the program.

Application:

Please ensure you have read through all the mandatory and additional requirements before applying.

Note: You must convert the practice quality scorecard in order to upload it into your application.

Before you begin the application:

Every practice must have at least 30 Blue Cross NC members. You need to 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

Applications are currently closed.

When will a practice be removed from the program?

We may remove practices at our own discretion. Please keep in mind the goal of the program is to build a partnership with independent OBGYN practices. And, to equip you to progress in the changing health care industry.

Potential Reasons for Removal:

  • Inadequate Annual Renewal if your practice is unable to maintain program elements
  • Failure to attend required Best Practice Sharing Forums
  • Failure to review the PQR on a consistent monthly basis

Reasons for Immediate Removal

  • Falsification of application elements (like after hours care, patient portals, or provider education)
  • Joining a health system
    • This program is to solely benefit independent practices and to provide them with tools and resources.
  • Blue Cross NC matters outside the program like credentialing, contractual obligations, SIU, and provider agreements, etc.

Questions?

Email questions about the OBGYN Care Collaborative to the program manager at OBGYN@bcbsnc.com. You can learn more about credentialing or email your questions, provider numbers (NPI), contract questions, and sample fee schedule inquiries to NMSpecialist@bcbsnc.com. For questions regarding Quality contact Quality Management by email or call (919) 765-4809.