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PAP108

Healthy Living Efficiency Standards


Provider Administrative Policy

Section
Information
Policy Date
March 2009
Status/Date
Revised/April 2010
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Healthy Living Efficiency Standards

Purpose:
To define Blue Cross of Idaho’s efficiency requirements for physician clinics participating in the Healthy Living product.

Definitions:

Efficiency:  A measurement of each clinic in relation to their clinic peer group that reflects both treatment cost and utilization for condition-specific episodes of care. The resulting efficiency score (calculated by Quartile) determines a clinic’s eligibility for participation in the Healthy Living product.

Clinic: An individual physician or group of physicians and practitioners collectively who is/are licensed to practice medicine in the state of Idaho and is/are jointly engaged in the provision of care through employment, partnerships or other sufficient arrangements. The term “clinic” as used within this document refers to both the singular clinic as an organization and the multiple individual clinic physicians.

Clinic Peer Group: Blue Cross of Idaho contracting physician clinics practicing within the same medical specialty field.

Quartile: Quartile 1 clinics are the most efficient at treating the market basket of condition-specific episodes as compared to their clinic peer group. Quartile 2 and Quartile 3 clinics meet the necessary efficiency requirements for treating the same market basket of condition-specific episodes. Quartile 4 Clinics are least efficient in treating the same market basket of condition-specific episodes as compared to the clinic peer group.

Policy:
In order to participate in the Healthy Living product, a clinic must meet the requirements in the Healthy Living product participation requirements policy. In order to meet the requirement for efficiency a clinic must have an efficiency score within Quartiles one, two, or three or an efficiency score in the fourth Quartile less than 1.0.

A clinic physician who does not meet the efficiency requirement may participate in the Healthy Living product if the clinic in which he/she practices is eligible to participate and the clinic physician otherwise meets the Healthy Living product participation requirements. The participating clinic shall work with the individual physician and Blue Cross of Idaho to develop an appropriate plan to address the unmet product participation requirements.

Clinic Peer Groups evaluated for Efficiency:

  • Allergy
  • Cardiology
  • Cardiothoracic Surgery
  • Dermatology
  • Endocrinology
  • ENT
  • Family and General Practitioners
  • Gastroenterology
  • General Internists
  • General Surgery
  • Nephrology
  • Neurology
  • Neurosurgery
  • OB/GYN
  • Oncology/Hematology
  • Ophthalmology
  • Orthopedics
  • Pediatrics
  • Plastic Surgery
  • Psychiatry
  • Pulmonology
  • Rheumatology
  • Sports/Physical Medicine
  • Urology
  • Vascular Surgery
We will not evaluate the Physician Peer Groups below for efficiency at this time: 
  • Anesthesia
  • Pathology
  • Emergency Medicine
  • Radiology
     

Procedure:  

  1. Blue Cross of Idaho will evaluate two years of clinic and/or a clinic physician’s Blue Cross of Idaho claim history.
  2. Blue Cross of Idaho will provide participating clinics with an annual efficiency report that includes the efficiency scores for the clinic compared to their clinic peer group for the last four complete calendar quarters.
  3. Blue Cross of Idaho will work with clinics to identify areas the clinic or clinic physician meets or exceeds the efficiency standard and areas where the clinic or clinic physician can improve their efficiency score.

Policy History

Date Action Reason
April 2010 Revised Clinical peer groups added
October 2009 Revised Removed three clinical peer groups

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