BCBS MA Providers Guide to Quality Care and Referrals

As a BCBS MA provider, you're likely no stranger to the importance of quality care and referrals. To ensure you're providing the best possible care for your patients, it's essential to stay up-to-date on the latest guidelines and best practices.

BCBS MA has a robust network of providers, with over 90% of Massachusetts residents having access to in-network care. This means you have a wide range of resources at your fingertips to help you deliver top-notch care.

When making referrals, keep in mind that BCBS MA has a list of designated specialists and facilities that are preferred for certain procedures and conditions. For example, patients with diabetes should be referred to a BCBS MA-designated endocrinologist for optimal care.

As a BCBS MA provider, you're committed to delivering high-quality care that meets the needs of your patients. By staying informed and following best practices, you can help ensure that your patients receive the best possible care and outcomes.

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BCBS MA Coverage is quite comprehensive. They cover a wide range of therapy approaches, including Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT).

These therapies are evidence-based, which means they've been proven to be effective in treating various mental health conditions. Blue Cross Blue Shield of MA also covers Mindfulness practices and Psychodynamic therapy.

If you're looking for a specific type of therapy, you might be interested to know that they also cover Acceptance and Commitment Therapy (ACT). However, it's worth noting that Blue Cross Blue Shield of MA requires a diagnosis-based approach to therapy.

Here are some of the therapy approaches covered by BCBS MA, listed out for easy reference:

Blue Cross Blue Shield of Massachusetts (BCBS MA) has a list of exclusions and limitations that may affect the services you receive. These exclusions include services not covered by your plan, such as cosmetic surgery and fertility treatments.

If you need a referral to see a specialist, you'll need to check your plan's requirements. BCBS MA has a network of primary care physicians who can provide referrals to specialists within the network.

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With virtual primary care, you can receive dedicated support from your remote provider and care team, no matter where you are. This means you can get the care you need from the comfort of your own home.

Your provider will conduct visits virtually and can help you get devices you may need to monitor your health. This can be especially helpful if you have a chronic condition that requires regular monitoring.

For vaccines and tests, your care team will refer you to a convenient pharmacy, lab, or clinic, and connect back with you on results. This way, you can get the care you need without having to spend a lot of time searching for a location.

You can receive ongoing support from your provider and care team by text, phone, or video call. This is great for staying on top of your health and getting answers to any questions you may have.

Your care team may include some specialists, including integrated mental health support, and can help coordinate in-person specialist appointments. This means you can get a comprehensive range of care, all in one place.

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They won't cover therapy costs for services without empirical research backing their efficacy, so if a treatment modality doesn't have solid evidence, it's not covered.

Life coaching and career coaching are not covered, as they're more focused on goal-setting and achievement outcomes rather than evidence-based practices.

Holistic approaches like aromatherapy, massage therapy, acupuncture, reiki healing, and nutritional therapy are also not covered.

Ketamine and psychedelic treatments, even if used for mental health conditions, are not covered.

The Mind Body Wellness program is an exception, offering some coverage for services like massage, acupuncture, hypnosis, meditation, and Tai Chi, but it requires an additional yearly cost.

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You don't need to see your primary care doctor before starting therapy. This is because Blue Cross Blue Shield of MA is a PPO plan, which means there are no referrals necessary before seeing a specialist.

With a PPO plan, you have the flexibility to pick your providers, so you can find a great therapist near you that fits your needs, personality, and preferences.

You can begin your therapist search as soon as you're ready, without needing a referral or visiting your primary care physician first.

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The data in Exhibit 2 shows the change in average health care spending per member per quarter in the 2009 intervention cohort and control groups of the Blue Cross Blue Shield of Michigan Alternative Quality Contract (AQC).

Total quarterly spending increased from $803.98 to $863.26 in the intervention cohort, while it increased from $842.63 to $924.49 in the control groups. The between-group difference was a decrease of $22.58, with a p-value of 0.04.

The increase in spending can be broken down by category: E&M spending increased from $182.48 to $217.66, procedures increased from $168.74 to $188.91, imaging increased from $95.66 to $103.23, and tests increased from $68.35 to $78.72.

Here's a breakdown of the spending changes by category:

The savings were substantially larger in the no-prior-risk subgroup, who had an average reduction of $60.75 in quarterly spending over the first two years, which is an 8.2 percent savings.

Let's take a look at Exhibit 5, which shows the outcome quality for Alternative Quality Contract (AQC) groups and the Blue Cross Blue Shield of Massachusetts (BCBS MA) network average from 2006 to 2010.

In 2009, 80.7% of AQC group members with diabetes had HbA1c control below 9%. This is a significant improvement from 2007, when only 83.7% of BCBS MA network members with diabetes had HbA1c control below 9%.

The AQC group's LDL cholesterol control rate improved from 45.7% in 2007 to 54.7% in 2010, outpacing the BCBS MA network average.

Here's a breakdown of the AQC group's performance on various quality measures:

You have a lot of options when it comes to finding a therapist through Blue Cross Blue Shield of MA. Blue Cross Blue Shield of MA covers many different evidence-based therapy approaches and modalities, including Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), Mindfulness practices, Psychodynamic therapy, and Acceptance and Commitment Therapy (ACT).

You can choose from in-network and out-of-network therapists, and even online therapy is an option. With the Blue Cross Blue Shield of MA PPO plan, you don't need a referral or to visit your primary care physician before starting therapy. This means you can begin your therapist search as soon as you're ready.

Here are some of the mental health conditions that Blue Cross Blue Shield of MA PPO covers:

Blue Cross Blue Shield of MA PPO covers therapy services, including in-network and out-of-network mental health benefits. You'll pay less to see any therapist, even if they're not in the provider network.

The cost of therapy varies based on your therapist's fees and whether they're an in-network provider. You'll pay a coinsurance rate of 10% for an in-network provider and 30% for out-of-network providers.

Blue Cross Blue Shield of MA PPO covers many different evidence-based therapy approaches and modalities, including Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), and Eye Movement Desensitization and Reprocessing (EMDR). You can also find therapists who specialize in Mindfulness practices, Psychodynamic therapy, and Acceptance and Commitment Therapy (ACT).

Online therapy is also covered under the Blue Cross Blue Shield of MA PPO plan. You'll get the same rate of coverage for online therapy as you would for in-person visits.

The plan covers treatment for various mental health conditions, including depression, anxiety and stress, alcohol abuse, and eating disorders. Your therapist will designate a diagnosis for your condition or goals, which they'll share with Blue Cross Blue Shield of MA to ensure coverage.

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Here are some of the mental health conditions covered under the Blue Cross Blue Shield of MA PPO plan:

You don't need to see your primary care doctor before starting therapy with a Blue Cross Blue Shield of MA PPO plan. This is because it's a PPO plan, which means there are no referrals necessary before seeing a specialist.

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Improvements in ambulatory care quality measures were significant, with a notable increase in year 2.

The contract was associated with a 3.7-percentage-point increase per member per year among eligible members meeting quality performance targets for chronic care management after two years.

This increase can be broken down, with a 4.7-percentage-point increase in year 2 and a 2.6-percentage-point increase in year 1.