Transcript 2012 ALL PAYERS WORKSHOP

Blue Cross & Blue Shield of Kansas
2012
Presented by:

Denny Hartman, CPC
BCBSKS Provider Representative,
Hospitals in Southern KS

Connie Winkley
BCBSKS Institutional Relations
Education/Communication Coordinator

Cindy Garrison, CPC
BCBSKS Provider Representative,
Hospitals in Northern KS

Marie Burdiek
Electronic Data Interchange (EDI)
Account Representative
Agenda
 Connecting
 Other
with Providers
Party Liability (OPL)
 Quality
Based Reimbursement Program
(QBRP)
 Electronic
Data Interchange (EDI)
Connected to our Providers

Institutional Provider Representative

Training

eNews

BCBSKS Website (www.bcbsks.com)

Blue Access
Connected to our Providers

Availity

Webinars

KHA Convention

All Payers Workshop

BCBSKS Contact Information on the Web
Other Party Liability (OPL)

Focus on Cost Containment by
coordinating payments between carriers

Non-Duplication of Benefits Provision

Exclusions
Other Party Liability (OPL)

Duplicate Coverage

Maintenance of Benefits (MOB)

Accidents

Worker's Compensation

Auto No-Fault

The OPL Web Questionnaire
OPL -
Patient Information Form
Submit OPL Information Electronically
Other Party Liability

The Remittance Advice (RA) for secondary payers:
◦ Shows total amount paid by primary carrier
◦ Shows total amount of patient responsibility
◦ Shows the total provider write-off
◦ Eliminates the need to retrieve the primary
carrier EOB
Other Party Liability
To identify an OPL claim on the RA the CNTR column will
state OP. The OPL Adjustment Reason Code (ARC) and
Remarks on the RA for OPL claims are listed in the table below
with the code defined.
ARC
Remarks
19
MA04
This service is due to a job-related illness or injury covered by Worker's
Compensation
21
MA04
The services are Motor Vehicle relate
22
MA04
The Primary Carrier must process first and an Explanation of Benefits
from the Primary Carrier is required.
22
N48
The Explanation of Benefits (EOB) from the Primary Carrier does not
match this claim.
23
Code Definition
Paid as secondary carrier
23
MA04
The patient has accepted a financial settlement from another insurance
company for this claim.
23
M43
The Primary Carrier's payment exceeds the amount payable under the
patient's contract. No Secondary Carrier payment is available on this
claim.
227
N179
Awaiting a response to an OPL Questionnaire sent to the patient.
Explanation of Benefits

COB: Duplicate coverage secondary
payment formula

Provider's Contractual Obligation

Worker's Compensation
Quality Based Reimbursement Program
(QBRP)

Background
◦ Patient Protection and Affordable Care Act
◦ Reimbursement arrangement that incentivizes
quality
◦ Requirement for a health plan to be eligible to
participate on the Exchange
Quality Based Reimbursement Program
(QBRP)

Exchange Timeline
◦ 2014
◦ BCBSKS quality incentive programs will be
evaluated for approval in 2013.

QBRP Criteria for 2013
◦ Collaborative effort to develop our QBRP
◦ The goal: provider's quality, safety and
affordability continually improve
Quality Based Reimbursement Program
(QBRP)

Quality Measures
◦ 3 Prerequisites
1. File claims electronically
2. Accept electronic remittance advices through the
ANS1835 transaction or retrieve remittance
advices from the BCBSKS website.
3. Use the BCBSKS electronic portal for inpatient
hospital precertification and continued stay
reviews.
Quality Based Reimbursement Program
(QBRP)

7 Quality Measures
◦ 3 measures require a signed attestation form only and
4 measures require reporting.
◦ Process oriented vs. outcome based
◦ Incentive payment is not based on the scores
submitted.
Quality Based Reimbursement Program
(QBRP)

Timeline
◦ A one-time attestation form and information required
for quality measures were due December 1, 2012.
◦ Updated information must be received no later than
May 15, 2013.
◦ Failure to report information by May 15, 2013 will
result in the reduction of the incentive previously
given.
TriWest

Transition

FAQs

Web Services
2012 BCBSKS All Payers Workshop