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08/23/2017

Important eviCore and Blue Cross Update

Update to the Membership: eviCore and Blue Cross!

By:       Dan Spencer, DC | Chair, MAC Legal Affairs Committee 

Many of you have heard rumors that Blue Cross is considering ending their current profiling agreement with OptumHealth by December of this year. This is accurate. Also, you may have heard that Blue Cross plans to contract with a medical benefits management company, eviCore, to provide utilization management for chiropractors, possibly as early as January 1, 2018. This is also accurate. 

Please know the MAC is very closely monitoring this situation, working daily to find out all the details of this change, and implementing extremely aggressive actions to deal with this critical situation. These actions include: Submitting a comprehensive list of questions to Blue Cross so we know all the details before the program is implemented, working to form a powerful coalition with other provider groups who share many of our concerns, researching all administrative, legal, and legislative options available to us, developing powerful grassroots plans, and reaching out to unions and buyers of insurance coverage to alert them to the effects this change could have on their employees. 

And, importantly, we will provide our members with regular updates in our emails, monthly eJournals, print Journal, at district meetings, and through twitter. Your MAC Executive Committee, Board of Directors, District Officers, and staff are all focused on this major concern. At the same time, we are working hard to provide needed strategies and assistance for our members to help them prepare for whatever changes are coming. 

Also, in order to keep you as informed as humanly possible as we take action, we are providing you with the following research on eviCore: 

What is eviCore?

eviCore is a medical benefits management company that provides utilization management services for health plans. You will want to visit their website, www.evicore.com, to read for yourself what they are selling. 

And, to access eviCore’s Clinical Guidelines for Chiropractic Services, go to: https://www.evicore.com/ReferenceGuidelines/Regence%20Chiropractic%20Guidelines.pdf 

Our Major Concerns With eviCore

  • What is/are the goal(s) that BCBSM wishes to achieve through this process?
  • What CPT codes will be subjected to a preauthorization process?
  • What studies does eviCore use to create their best practices?
  • Will providers be asked for their care recommendations?
  • The current eviCore process in other states places a large administrative burden on the provider and leaves them holding the bag for care by covering the full cost that may not be preauthorized. How will this serious concern be addressed here?
  • Are the procedures and requirements for osteopaths and other health care providers the same as those outlined for chiropractors? How are other physician-level providers affected by this change?

EviCore and Blue Care Network

Blue Care Network (BCN) currently uses eviCore for management of physical medicine services provided by BCN-contracted chiropractors for BCN HMO (commercial) members, using select *97XXX procedure codes. 

Under the Michigan BCN agreement:

  • “BCN and eviCore collaborate to establish evidence-based clinical practice standards that help ensure the best possible outcomes for members.”
  • “eviCore is responsible for authorizing therapy or physical medicine services and managing the benefit limits for physical medicine services provided by chiropractors.”
  • “eviCore monitors the compliance of each therapist and chiropractor with evidence-based practice standards and compares this performance to BCN peer performance standards. eviCore uses these data to work with … chiropractors to increase the use of efficient best practice patterns, as appropriate.” 

eviCore in the State of Washington

In Washington, eviCore is contracted with the state’s two largest insurers. The primary issues we are hearing from Washington include: 

  • Authorization timeline should be maximum of two days, according to eviCore, but in practice the process can take anywhere from three days to a week
  • eviCore uses input algorithms, an online tool in which the provider answers 22 questions and then care is authorized or not
  • eviCore places providers into categories (A, B, or C), which in turn affects authorization probability, but they do not tell providers what factors they use to place the provider into their specific category or how they are doing this
  • There is a lack of transparency in the algorithm that eviCore utilizes in its software that determines authorization
  • eviCore’s authorization process places too high an administrative burden on providers with their “OneHealthPort” system 

Moving Forward

As I said at the outset, we are working to ensure that any utilization process that Blue Cross adopts will be in the best interest of our members and their patients. We have not ruled out any tool at our disposal to ensure this is the case. 

Stay tuned to the MAC communication channels – Journal, eJournal, Action Report, Facebook, Twitter, our “Factual Fridays,” etc. – for more information as it becomes available.

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