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May/June 2006
Prepare for avian flu
Since 2003, there have been 206 human cases of avian flu, including 114 fatalities,
according to the World Health Organization (WHO).* Birds migrating from infected
nations are expected to reach the continental United States later this year. U.S.
public health officials are concerned that a mutation in the H5N1 strain could occur,
making transmission to humans easier.
To the Physician
Better information means better outcomes for your patients The deadline for initial enrollment in the Medicare prescription drug plan is May 15. Penalties in the form of increased e-Medicine
premiums will apply to eligible Medicare beneficiaries who don’t enroll before the deadline. UF Physicians finds e-Medicine a good fit for patients, physicians
Products and Services
Medicare beneficiaries who are enrolled in Medicare Part D have two ID cards – one for their health plan and one for the New lower-cost plans address uninsured problem prescription drug program. Many members are providing the wrong card when receiving medical services. Billing and Claims
BlueOptions members can receive services from Traditional
Blue Cross and Blue Shield of Florida’s revised Insurance NetworkBlue Fast Tracker for BlueOptions updated Manual for Physicians and Manual for Ancillary Facilities are now available on our website. These comprehensive reference manuals are designed to assist office staff in Electronic Solutions
understanding our networks, products, utilization management programs, and claims filing and reimbursement BlueCard
Hospitals: Check newborn authorization and certification
requirements
Medical Notes
AHRQ: Noninvasive tests may miss breast cancer
PharmacyNews
BCBSF signs contract with new pharmacy benefit manager
Prepare for avian flu
Since 2003, there have been 206 human cases of avian flu, including 114 fatalities, according to the World Health Organization (WHO).* Birds migrating from infected nations are expected to reach the continental United States later this year. U.S. public health officials are concerned that a mutation in the H5N1 strain could occur, making transmission to humans easier. Under such a scenario, millions of U.S. cases could develop, resulting in hundreds of thousands of hospitalizations and deaths, the Centers for Disease Control and Prevention warns. The U.S. Department of Health and Human Services, through its National Institute of Allergy and Infectious Diseases (NIAID), is developing pre-pandemic vaccines based on current lethal strains of H5N1, working with industry to increase vaccine production and researching the development of new types of influenza vaccines. We’re preparing
At Blue Cross and Blue Shield of Florida we are expanding our business continuity plan to include a possible avian flu
pandemic. Given the uncertainty regarding the severity and impact of an influenza pandemic, we determined that the
most practical approach would be to define a range of scenarios and plan accordingly.
You should, too
As first responders, physicians and their office staff will be in the front lines of any possible pandemic. You may benefit
from assessing possible impacts to your practice or organization, such as increased demand for services, reduced
staffing and infrastructure breakdowns. Such an assessment can also be leveraged for other types of disasters.
In addition to what your professional associations might offer, the following websites from the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, and the World Health Organization offer excellent planning advice and checklists for health professionals and individuals. http://www.pandemicflu.gov/plan/tab6.html www.who.int/csr/disease/avian_influenza/en/ Better information means better outcomes for
your patients
Our members look to you, their physicians, for help weighing health care decisions and receiving effective care. But you don’t have to go it alone. Through our arrangement with SubimoTM 1, a leader in providing decision-support tools, we continue to broaden access to tools and resources to help members, as well as physicians, make more informed health care decisions. Help selecting a specialist or physician
Along with choosing a personal doctor, one of the most important decisions a member makes is choosing a specialist.
That’s why we offer Physician Selection AdvisorTM. With this web-based tool, you and they can evaluate options and
review relevant information about the specialist you may refer. Members can view the information along with you or on
their own. Physician Selection Advisor lets you research and compare attributes for more than 545,000 physicians,
including:
Sources of physician data
The bulk of the physician information (demographic information are included along with specialties, board certifications,
medical school, residency location, year since graduation, and any sanctions) is provided primarily by Lodestone
Solutions, a leading provider of medical databases and health care data services. Information is gathered from the
American Medical Association and other reliable sources, and every physician profile includes the date of the last
update. Inpatient procedure volumes are derived from the most recent year of Florida Agency for Health Care
Administration (AHCA) information.
Easy access
You can access the physician research tool through the Availity® 2 Gateway at www.availity.com:
z Select ‘Availity Library’ located at the top of the page z Select BCBSF – ‘Research a Physician’ and the following agreement pages There is a link to answers of frequently asked questions regarding the site, the data or any information on the site, on the bottom of every page. Verify your information
Once on the site, view and confirm the information that’s being shared about you. If you have any questions on the
information displayed, please contact your physician relations specialist.
Additional support and resources
Physician Selection Advisor is one of many online resources and personalized tools we provide our members to help
them think through health care decisions for themselves and their families. All these tools are available to our members
through MyBlueService at www.bcbsfl.com.
1 Blue Cross and Blue Shield of Florida, Inc. (BCBSF) has entered into an arrangement with SubimoTM whereby SubimoTM has agreed to provide BCBSF members with access to its Physician AdvisorTM, Hospital AdvisorTM, Healthcare AdvisorTM and Treatment Cost AdvisorTM service. BCBSF does not maintain these programs and cannot guarantee or be held responsible for the information provided by SubimoTM or these programs. Please remember that all decisions that require or pertain to independent professional medical/clinical judgment or training, or the need for medical services, are solely your responsibility. In making these programs available to members, neither BCBSF nor SubimoTM shall be deemed to be providing medical care or advice. 2 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue Cross and Blue Shield of Florida has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity’s website at www.availity.com. UF Physicians finds e-Medicine a good fit for
patients, physicians
Ninety percent of adults with Internet access want to communicate with their physicians via email.* At University of Florida Physicians they found the answer: e-Medicine offered through RelayHealth.** "Our patients and physicians have been asking for a secure way to communicate electronically with each other,” said Jane Schumaker, chief executive officer of University of Florida Physicians. “e-Medicine provides an excellent vehicle to accomplish that.” The UF College of Medicine faculty group practice, which is affiliated with the Shands HealthCare system, provides outpatient care in Gainesville. UF Physicians' patients with non-urgent health matters have easy access to staff. They can consult with participating physicians, request prescription refills and renewals, schedule appointments, receive lab results, and request referrals — all online. Benefits
Physicians benefit from increased productivity and improved patient satisfaction. e-Medicine reduces phone volume
and time spent playing "telephone tag." With the eScript™ solution, doctors can write electronic prescriptions quickly
and safely and send them to the patient's pharmacy of choice.
e-Medicine services are provided at no cost to patients with the exception of the webVisit®, an online medical review that carries the equivalent cost of a face-to-face office visit for those with coverage through Blue Cross and Blue Shield of Florida. The webVisit feature gathers key data about a patient's symptoms and relays it quickly and concisely to the doctor. Patients like it
Dr. Aida Vega, UF College of Medicine's division of internal medicine associate chief, is the medical director at Tower
Hill Internal Medicine and has been using e-Medicine to process prescription refills and referral requests and will soon
begin using the webVisit feature. "My patients have given me a lot of positive feedback about the increased level of
access to me and other clinic staff," Vega said. Messages can be securely sent and received at any time from any
computer with an Internet connection, decreasing time away from work and waiting in a doctor's office. "I think it's a
wonderful system. In fact,” Vega said, “I was on vacation the other week and used it to communicate with my nurse
and staff, so I could stay in the loop about my patients' needs."
"Online care provides a good opportunity to strengthen the doctor-patient relationship," said Kelly Kerr, Senior Director of Faculty Practice Clinics. "It can promote thoughtful questions, thorough replies and facilitate follow-up care that's convenient and effective for both patient and physician. This communication vehicle can increase access to health care without significantly increasing health care costs, thanks to support from our health plan partner." Today 150 UF providers and their offices are currently using the service. Additional providers will be joining the service as e-Medicine is rolled out across the University of Florida Physicians practices. "We are delighted that Blue Cross and Blue Shield of Florida has sponsored our introduction to e-Medicine," said Schumaker, "and, even more importantly, recognizes the value of providing coverage of webVisits® for its members."*** Learn more
e-Medicine is easy to use. And there’s nothing you need to install or purchase; you only need a high-speed Internet
connection. Your practice can use all or select those features that work best for you and your patients. To learn how e-
Medicine can help your practice become more efficient, view a four-minute demo at www.bcbsfl.com. Under Physicians
& Providers, click on Physicians, Online Services, e-Medicine-Patient Communication.
**BCBSF has entered into a vendor agreement with RelayHealth® whereby RelayHealth has agreed to provide BCBSF secure communications between BCBSF, its members and participating physicians. BCBSF has entered into this arrangement to provide a value-added service to its members and participating physicians. BCBSF cannot guarantee or be held responsible for the quality of services provided by RelayHealth.
***Not all plans cover e-Medicine. Check eligibility and benefits. New lower-cost plans address uninsured
problem
In Florida, 19 percent of the population has no health insurance. And the number continues to grow, leaving physicians and providers, particularly hospitals, rendering health care services to more patients who find it difficult to pay or don’t pay at all. The problem of the uninsured is massive, but Blue Cross and Blue Shield of Florida (BCBSF) is developing new products to help keep health insurance within reach of more people. This month, we’re adding two new products—one offering Hospital and Surgical catastrophic coverage and one offering Temporary insurance coverage—to our portfolio of lower-cost BlueOptions products. Ideal for small employers or individuals, the plans are designed for people thinking of discontinuing health insurance coverage or those who have no coverage now because of cost concerns. Priced on average 50 percent less than our most-popular conventional BlueOptions products (premiums range from 30 to 70 percent less than Health Plan 1462), the plans include benefits based on consumer research into what people really need covered. Groups and individuals purchasing these new plans will have coverage effective on or after July 1, 2006. Look for more details on these two plans and the entire portfolio next month. Lower cost, not lower value
While these plans cost less, lower cost doesn’t mean lower value. We’ve created these plans to include all existing
value-added services and capabilities that are part of our other BlueOptions plans. With this affordable coverage,
members enjoy:
z Protection in the event of major illness or hospitalization z Negotiated discounts with doctors and hospitals from the largest provider network in Florida and within the U.S.
z A wealth of value-added programs and services designed to help members take advantage of their coverage, save money and take more control of health decisions. z Access to health-related discounts on products and services through our BlueComplements® 1 program.
Benefits for small employers
We believe these plans will help expand the pool of insured workers. The launch of these lower-cost plans:
z Enables small employers to offer coverage to employees who otherwise may refuse group coverage. z Helps to control the rising cost of employee benefits. z Gives employers an affordable alternative to start or continue offering insurance coverage. Help for physicians and providers
Having so many types of plans available can make it hard to know how much to collect when a patient is standing right
there in your office or facility. We’re working on a solution to make it easier to calculate and collect a member’s
responsibility. Our new online tool will calculate the estimated amount due based on the services provided, the patient
benefits and your contractual allowances. We’re currently doing extensive testing of the tool, including testing in
physicians’ offices, with full roll-out of the tool planned for next year.
1 *The products, services and information provided through the BlueComplements program are made available as a courtesy to our members and are not a part of insurance coverage, and are not a substitute for medical advice. BCBSF does not endorse and is not responsible for the products, services or information provided by the vendors that are a part of the BlueComplements program. BlueOptions members can receive services from
Traditional physicians
BlueOptions members can choose to receive services out of network. Traditional network physicians and providers (not participating in NetworkBlue) should collect the applicable copay or coinsurance (or deductible and coinsurance) from the member. Out-of-network benefits apply. If out-of-network physician office service copayments are listed on the member’s ID card, collect the copay, as deductibles do not apply. You can also check eligibility and benefits using Availity® 1 or by calling the customer service number on the ID card. We pay the balance of the allowed amount for covered services. Under the Payment for Professional Services (PPS) and Payment for Hospital Services (PHS) contracts, participating physicians and providers are not to balance bill BlueOptions members for the difference between their charges and the BCBSF allowed amount. A Frequently Asked Questions document for Traditional network physicians and providers serving BlueOptions members is available on our website under Tips. 1 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue Cross and Blue Shield of Florida has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving the patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity's website at www.availity.com. NetworkBlue Fast Tracker for BlueOptions
updated
The English and Spanish versions of the NetworkBlue Fast Tracker for BlueOptions has been revised to reflect after-hours code updates, information on inpatient admissions notification and an additional laboratory service code eligible for payment when performed in the physician’s office. After-Hours codes eligible for reimbursement
NetworkBlue physicians are eligible for reimbursement for certain after-hours services to BlueOptions members. These
office service codes are reported in addition to the basic service code.
99050 Services provided after posted office hours or days when the office is normally closed (e.g., holidays,
Saturday, Sunday), in addition to basic service 99051 Services provided during regularly scheduled evening, weekend or holiday office hours, in addition to basic
99058 Services provided on an emergency basis in the office, which disrupts other scheduled office services, in
Notify us of inpatient admissions
Hospitals, skilled nursing facilities and psychiatric and substance abuse facilities must notify Blue Cross and Blue
Shield of Florida (BCBSF) of inpatient admissions by the end of the next business day following admission. Submit an
electronic request using Availity. If additional steps and information are required, you will receive a message to contact
BCBSF at (800) 955-5692.
Reimbursed in-office laboratory services
Only specific laboratory services are eligible for payment when performed in the physician’s office. Refer other
laboratory services to the NetworkBlue participating laboratory, Quest Diagnostics.
We have added code 82270 [Blood occult, by peroxidase activity (e.g., guaiac), qualitative; feces, 1-3 stimultaneous determinations] to the list of lab services eligible for reimbursement when performed in the physician’s office. A complete list of reimbursable office laboratory services and their descriptions are listed in the Fast Tracker. Other lab services in the participating physician’s office will be denied for payment; physicians may not bill the patient. NetworkBlueSM Fast Tracker for BlueOptionsSM (PDF): English version | Spanish version Hospitals: Check newborn authorization and
certification requirements
Effective May 1, hospitals following the process below regarding newborn services will help reduce denials and appeals related to authorizations and certifications. Situations when no authorization/certification required
Newborn services do not require authorization or certification when the newborn is discharged within the length of stay
for the mother’s normal delivery and the services group into DRG 390 or 391.
Baby going home with mother, but authorization/certification is required
Newborn services do require authorization or certification when the newborn is discharged within the length of stay for
the mother’s normal delivery and services group into sick baby DRG 385, 386, 387, 388 or 389. In other words, if the
baby goes home with the mother, but the newborn service DRGs are other than 390 or 391, contact us at (800) 955-
5692 to obtain an authorization/certification. In such cases, we will authorize services after the fact and will not apply a
penalty for late approval in these instances.
Sick baby authorization/certification is required
Newborn services require authorization/certification if the newborn is not discharged within the length of stay for the
mother’s normal delivery. As soon as you know this will be a sick baby stay or upon completing discharge paperwork
for the mother, call for an authorization or certification at (800) 955-5692. Update the electronic certification request
with the actual admission date for the newborn or provide the admission date when calling. This will ensure that the
newborn’s claim processes appropriately. Authorizations or certifications are not being waived for the sick baby DRGs
in order to monitor these cases for potential case management and/or discharge planning. In those instances when the
baby’s stay is not authorized/certified within a reasonable time period, two business days from the mother’s discharge
date, any authorization/certification denials must follow the standard appeals process.
Member enrollment
Services for a newborn cannot be authorized or paid separately from the delivery until the baby is enrolled as a Blue
Cross and Blue Shield of Florida or Health Options member. In many cases, the member or insured has up to 60 days
to enroll a dependent on the existing policy. In the event a claim is filed prior to completion of the enrollment process,
the claim may reject indicating the member is not enrolled or is ineligible. Authorization or certification approval does
not guarantee claims payment for newborn services.
If you have questions about this process, please contact your provider relations specialist. AHRQ: Noninvasive tests may miss breast cancer
Four common noninvasive tests for breast cancer are not accurate enough to routinely replace biopsies for women who receive abnormal findings from a mammogram or physical examination, according to a study, Effectiveness of Noninvasive Diagnostic Tests on Breast Abnormalities, released Feb. 9, 2006, by the Agency for Healthcare Research and Quality (AHRQ). The study compared the tests to immediate biopsy. Results showed magnetic resonance imaging, ultrasonography, positron emission tomography scanning and scintimammograph miss about 4 percent to 9 percent of cancer cases among women testing negative who have average risk for the disease, with potentially more missed cancers among women at higher risk. Only about one in five women currently getting a biopsy for an abnormal mammogram or breast examination has breast cancer. Accurate noninvasive tests could reduce the number of women needing to undergo an unnecessary biopsy. However, because early and accurate diagnosis of breast cancer is crucial, biopsies remain the most effective technique when mammography or physical examination reveals a potential problem. The AHRQ report is available at http://www.effectivehealthcare.ahrq.gov. Copies of the executive summary of the
report may be obtained by calling AHRQ's Publications Clearinghouse at (800) 358-9295 or sending an email to
[email protected].
Mammography recommendations
The U.S. Preventive Services Task Force recommends screening mammography, with or without clinical breast exam,
every 1-2 years for women aged 40 and older. The USPSTF found fair evidence that mammography screening every
12-33 months significantly reduces mortality from breast cancer. Evidence is strongest for women aged 50-69, and the
absolute probability of benefits of regular mammography increase along a continuum with age. The Task Force's
recommendations can be viewed at http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm.
Coverage
Blue Cross and Blue Shield of Florida and its HMO subsidiary, Health Options, cover baseline mammograms for
women aged 35-39, mammograms every two years for women 40-49, and annually for women 50 and older and those
who are at risk for breast cancer because of personal or family history (based on a physician's recommendation).
Generally, covered mammograms (routine and with diagnosis) are reimbursed at 100 percent for most plans, group and individual. They are not subject to deductibles or copays for BlueChoice and BlueOptions members. However, coverage varies among some plans, such as the State Employees’ PPO Plan and the new Health Investor PPO Plan. z HMO and Medicare Advantage plans (BlueCare, Medicare & More, ActivelyYou, BluePreferred—no z PPO, PPO point-of-service plans (BlueChoice, BlueOptions)—no deductible, copayment or coinsurance and does not apply toward the Adult Wellness benefit. z State Employees’ PPO and Health Investor PPO—reimburses 80 percent; subject to calendar-year deductible. When checking eligibility and benefits on the Availity Gateway® 1, choose "Diagnostic X-ray" (specialty benefit options).
1 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue Cross and Blue Shield of Florida has business arrangements with Availity with the goal of reducing costs in the Florida health care marketplace, simplifying provider workflow, improving patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity’s website at www.availity.com. BCBSF signs contract with new pharmacy benefit
manager
Blue Cross and Blue Shield of Florida (BCBSF) has purchased an equity interest in Prime Therapeutics LLC, a company owned exclusively by 10 Blue Cross and Blue Shield plans and serves approximately 8 million people nationwide. The company will serve as the pharmacy benefit manager for all BCBSF and Health Options members beginning Jan. 1, 2007. This move is designed to increase coordination between our care and wellness programs and our pharmacy initiatives. Working with Prime, we will strengthen our pharmacy programs as we integrate them with our medical management programs. Prime Therapeutics will continue to provide all the service and benefit design capabilities of our current pharmacy benefit manager, Medco. Services will include claims processing, formularies, rebates, clinical programs, reporting, national network management and Medicare Part D administration. Additionally, Prime will provide pharmacy mail service that is now offered through Walgreens. Help patients save with generics
On April 1, Blue Cross and Blue Shield of Florida expanded its Generic Copay Waiver Program to include high blood pressure, allergy and antidepressant medications in addition to heartburn medications. We will waive the first generic copay for members who switch from the prescribed brand-name medications listed below to any corresponding generic alternative. Each prescription for a brand-name drug that is changed to a generic results in savings of approximately $15 to the member. Members continue to save money as the prescription is refilled with the generic. As with other programs, members are advised to speak with their physicians before changing their medications to ensure the alternative drug is right for them. Generic Copay Waiver Program — List of Eligible
Medications
Category
Brand Name
Generic Alternative(s)
Cardiovascular
Aceon, Altace, Atacand HCT, Avalide, Avapro, Benicar Medications
HCT, Cozaar, Diovan, Diovan HCT, Hyzaar, Mavik, Micardis, Micardis HCT, Teveten, Teveten HCT, Uniretic, Univasc, Accupril, Accuretic, Capoten, Capozide, Lotensin, Lotensin HCT, Monopril, Monopril HCT, Prinivil, Prinzide, Vaseretic, Vasotec, Zestoretic, Zestril Medications
Behavioral
Paxil, Paxil CR, Wellbutrin, Wellbutrin XL, Wellbutrin SR, bupropion, bupropion ER, citalopram, Zoloft, Celexa, Desyrel, Pamelor, Prozac, Remeron, Medications
Remeron SolTab, Pexeva, Lexapro, Luvox, Serzone, Aventyl, Sarafem, Rapiflux, Prozac Weekly Heartburn
Aciphex, Prevacid, Protonix, Prilosec, Nexium Medications
Time is running out
The deadline for initial enrollment in the Medicare prescription drug plan is May 15. Penalties in the form of increased premiums will apply to eligible Medicare beneficiaries who don’t enroll before the deadline. Don’t let your eligible Medicare patients be left out. Talk to them about signing up for Medicare Part D coverage. At Blue Cross and Blue Shield of Florida, we offer z The largest list of covered drugs (largest formulary). z Few if any drugs require prior authorization. z No requirement to try an over-the-counter drug (no step therapy). Get the facts. Find out about our BlueScript® for Medicare Part D plan. Call (800) 809-8568 or visit our website at
www.bcbsfl.com.
Get the right card
Medicare beneficiaries who are enrolled in Medicare Part D have two ID cards – one for their health plan and one for the prescription drug program. Many members are providing the wrong card when receiving medical services. When asking for their ID card, make sure Medicare beneficiaries provide you with their health plan card so that services rendered by the physician are not denied for payment. Updated manuals now available
Blue Cross and Blue Shield of Florida’s revised Insurance Manual for Physicians and Manual for Ancillary Facilities are now available on our website. These comprehensive reference manuals are designed to assist office staff in understanding our networks, products, utilization management programs, and claims filing and reimbursement guidelines. Updated information available in both manuals include, but is not limited to: Insurance Manual for Physicians
In addition to the items listed above, the updated Insurance Manual for Physicians includes updated information on:
Go to the Physicians & Providers section of our website at www.bcbsfl.com and click on Physicians, Tools & Resources, Manuals & Billing Guides. Manual for Ancillary Facilities
Information in the Manual for Ancillary Facilities is designed for participating dialysis centers, home health providers,
hospice facilities, outpatient rehabilitation facilities, psychiatric and substance abuse facilities and skilled nursing
facilities. In addition to the items listed in paragraph two, the updated manual includes revised hospice information.

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