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Industry Insights

Maximizing revenue under the BCBSM incentive program

Did you know? Blue Cross Blue Shield of MI withholds 5 percent of all commercial payments. That means even if you’re earning 100% of the standard fee schedule, you’re still losing 5 percent!

Pathology value-based reimbursement

For years, BCBSM has operated a quality incentive program to realign provider reimbursement with quality-of-care standards in an effort to control health care costs. Bonus reimbursement earned through the program is referred to as value-based reimbursement (VBR).

Pathologists who participate in the Physician Group Incentive Program (PGIP) and meet defined criteria are eligible for reimbursement using the VBR Fee Schedule. The VBR Fee Schedule sets reimbursement rates for specific procedure codes to allow you to earn more than 100 percent of the standard fee schedules. From March 1, 2018 to February 28, 2019, 153 pathologists are receiving a VBR bonus, according to BCBS of MI.


Why are population metrics used?

  • According to BCBS, these metrics:
    • Promote the PGIP principle of a community of caregivers’ shared responsibility for a population of patients.
    • Encourage communication and collaboration between primary care and specialty practitioners.
    • Encourage a focus on system performance, accountability and improvement.
    • Promote optimal quality, efficiency and health care utilization in the population of patients.


How to participate:

  • Pathologists must be nominated by their member physician organization and must have been in PGIP for one year.
  • The top two-thirds of non-pediatric specialist practices are based on the pathologist weighted composite score and are reimbursed in accordance with the VBR Fee Schedule
  • Practices that serve a small number of Blue Cross patients cannot be evaluated and ranked.


VBR bonuses:

  • Practices in the top third of non-pediatric practices are reimbursed at 110 percent of the Standard Fee Schedules.
  • Practices in the second third of non-pediatric practices are reimbursed at 105 percent of the Standard Fee Schedules
  • Practices in the bottom third of non-pediatric practices are reimbursed at 100 percent of the Standard Fee Schedules.
  • The VBR Fee Schedule is applied to the relative value unit-based procedure codes and the time and base codes.
  • The VBR Fee Schedule is applied only to Blue Cross commercial PPO.


Keep in mind:

  • Charges less than the BCBSM allowed amount will not receive the fee schedule uplift. Your practice’s charges may need to be increased to receive the full reimbursement.
  • Just because you’re getting paid 100 percent of the BCBSM fee schedule does not mean there is not additional money you can earn if you achieve the top or second third of performers under this program.

Interested in learning more about the benefits of auditing or overall revenue cycle management? Contact us today for a free consultation.


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