Tiered Network Product

Overview:

The Blue Cross NC Tiered Network uses administrative claims data to identify high-quality, low-cost providers so consumers can make informed choices about their care. The methodology shows providers how their performance compares to their peers based on nationally accepted quality measures, local cost measures and efficiency benchmarks.

Providers: We compare providers within a geographic region and across like specialty groups. Non-tiered specialties do not have a tier rating.

Practices: We classify practices by area of specialty, then measure them against a quality rating and then by cost. Practices that exceed both the quality and cost thresholds are Preferred Care (Tier 1) practices; all others are Standard Care (Tier 2).

These ratings will help consumers choose a physician, practice or medical group. Because all ratings have a risk of error, patients are urged to base their choices on more than one factor and to talk with their provider before making a decision.

Rated Specialties:

  • Cardiology
  • Endrocrinology
  • Gastroenterology
  • General Surgery
  • Neurology
  • Obstetrics and Gynecology
  • Orthopedic

Quality Measurement:

Physician practices are evaluated for quality using data based on these aspects of care:

  • Preventative Care: cancer and other screening interventions
  • Appropriateness of Care: (delivering the right care) appropriate use of medications, diagnostic tests and procedures, treatment and monitoring
  • Appropriate Health Outcomes: avoiding potential complications
  • Use of Registries: GI, General Surgery and Neurology specialties

 

Measures Evaluated for Each Specialty: 

Cardiology OB/GYN Orthopedics General Surgery Gastroenterology Neurology Endocrinology
NCQA Recognition: HSRP or PCSP NCQA Recognition: PCSP or BQPP NCQA Recognition: PCSP NCQA Recognition: PCSP NCQA Recognition: PCSP NCQA Recognition: PCSP NCQA Recognition: DRP or PCSP
Beta blockers prescribed after most recent MI Mammography screening Imaging studies more than 28 days after initial visit for low back pain Cholecystectomy: Potentially Avoidable Complications Colonoscopy: Potentially Avoidable Complications Diabenzazepine annual monitoring. Hemoglobin A1C testing
ACEI or ARBs therapy for those with Heart Failure and LVSD Cervical cancer screening Knee replacement surgery:  Potentially Avoidable Complications Colonoscopy: Potentially Avoidable Complications GERD: Potentially Avoidable Complications Barbiturate  annual monitoring Eye exam (retinal) performed
Beta-blocker therapy for those with Heart Failure and LVSD Chlamydia Screening Hip replacement surgery:  Potentially Avoidable Complications Colon Resection: Potentially Avoidable Complications Attestation for use of registry (practice based-100% bonus if participates) Misc. anticonvulsants    (Valproic acid) annual monitoring Low-density lipoprotein: Cholesterol (LDL-C Screening)
Measurement of LV function for those with Heart Failure Childbirth: Potentially Avoidable Complications Knee Arthroscopy: Potentially Avoidable Complications Attestation for use of registry (facility based-100% bonus, e.g., NSQIP)   Hydantoin  annual monitoring Medical attention for nephropathy
Lipid-lowering therapy for those with CAD Hysterectomy: Potentially Avoidable Complications       Migraines: active prescription for preventive medications, and narcotic analgesics Proportion of patients 18 years or older with diagnosis of hyperlipidemia and CAD diagnosis and no diabetes, who were prescribed lipid-lowering therapy
Lipid profile for those with CAD         Migraine and CAD: do not have active prescription for triptans or ergot derivatives Proportion of patients 18 years or older with a diagnosis of hyperlipidemia and diagnosis of diabetes and No CAD, who were prescribed lipid lowering therapy
Warfarin prescription for those with heart failure and atrial fibrillation         Migraines: frequent and severe with an active prescription  
Angioplasty: Potentially Avoidable Complications         Attestation for use of registry (practice based- 100% bonus if participates, e.g., AXON)  
 

Methodology:

Improving the quality of health care while ensuring patients get the right care is important to everyone. Blue Cross NC rates its network of providers and facilities using a program designed to help practitioners achieve the best ratings by understanding how they compare to others in their market.

Our ratings are based on:

  1. Specific quality measures adopted from those endorsed by the National Quality Forum (NQF), National Committee for Quality Assurance (NCQA) and the Ambulatory Quality Alliance (AQA), and then
  2. Cost (local, North Carolina claims data)
  3. Efficiency (appropriateness of care or delivering the right care) as shown by national claims data

Methodologies may not be the same each year, so check below to read about specific ratings used. All methodologies are provided for information purposes only.

 

    Tiered Network Criteria for 2018

      Tiered Network Criteria for 2019 & 2020

      Historical Criteria 

       

      Reconsideration

      We understand there may be conditions that demand reconsideration of your quality rating. You can request reconsideration by sharing new data that may add to the accuracy of the measurement process.

      Most reconsiderations are processed within 45 days, once all data is received. We’ll send your results by letter or email (as noted on your request) and let you know of any changes to the rating we display publicly.

      Request Forms:

      Submit completed forms to:

      Fax: (919) 287-5491

      Email:TieredNetwork@bcbsnc.com or

      Postal Mail: Quality-Based Networks/Reconsiderations, Blue Cross NC, P.O. Box 2291, Durham NC 27702-2291

       

      Questions about Quality-Based Networks?

      Provider Ratings: (919) 765-7040 or  TieredNetwork@bcbsnc.com.

      Facility Ratings: TieredFacilities@bcbsnc.com