BCBS and Orthonet – October 2013 Update

Other Available Articles

Tiering Survey – For all doctors

Appeal Information (Members Only)

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Patient Advocacy

According to BCBS, providers should be receiving their tier letters over the next few days. Additionally, they are making the announcement in the October 2013 BlueReview. As always, we continue to advocate for our doctors during this transition, and we are weighing all of our options for further action. Here are the key points:

Tiering:

• Tier I will have no pre-authorization requirements;
• Tier II will require pre-authorization following the 8th physical medicine visit;
• Tier III will require pre-authorization following the 1st physical medicine visit;
• The key contributor to determine tier levels was the average number of physical medicine visits per patient – risk-adjusted for a number of factors; and
• Providers will have until October 31, 2013, to appeal their tiering assignment.

Timetable:

• January 1, 2014 – City of Chicago will implement the new Orthonet program. This applies to the following group numbers: P16705, P16602, P16632, P17600, P18600, P18601, P20600, P16628, P16642, P16643 and P35955;
• No sooner than March 1, 2014 – The fully insured plans will implement the new Orthonet program; and
• Other self-funded plans will be approached after the fully insured plans are fully implemented.

Tier Breakdown for Chiropractic Physicians:

• Tier I – 77.2% (thus 77.2% of chiropractic physicians will have no pre-authorization requirements)
• Tier II – 6.7%
• Tier III – 16.1%

BCBS indicated they will be offering training webinars in December to educate providers on how to navigate the new requirements. The Illinois Chiropractic Society will also gather information and provide members with relevant educational materials.

As mentioned above the ICS will continue to advocate for chiropractic physicians in Illinois. As an example, here are just a few of the steps the ICS has taken regarding these changes:

• Filed a letter of inquiry with the Illinois Department of Insurance regarding the Orthonet’s utilization review program functions being performed out of state.
• Filed a letter requesting an advisory opinion from the Illinois Department of Insurance regarding whether this program will violate the Affordable Care Act’s provider non-discrimination clause, which will become law January 2014.
• Filed a letter requesting an advisory opinion from the US Department of Health and Human Services’ (HHS) Secretary Sibelius regarding whether this program will violate the Affordable Care Act’s provider non-discrimination clause, which will become law January 2014.
• Launched a patient information campaign to ensure patients are aware of how this proposed program may affect their coverage of chiropractic services, physical therapy, and occupational therapy from BCBS-IL.