BlueCompare 2009 Reviews and Inquiries
If you are not satisfied with your BlueCompare Evidence Based Measures (EBM) information, you have the right to request a review.

The Review Process For Physicians Who Did Not Meet the Threshold for Recognition

Response Required:
You must submit a written response regarding your performance by May 1, 2009.  Include supporting patient documentation and/or a Performance Improvement Plan as described below.  Please understand that physicians participating in BCBSTX networks must cooperate with peer review activities.  We will refer physicians who fail to cooperate to a BCBSTX peer review committee for consideration of sanctions, which may include termination of the physician’s network participation contract.

Physicians Submitting Supporting Patient Documentation:
Initial Review:  If the physician sends documentation that demonstrates or indicates that services were provided to the patient(s), or that services do not apply to the patient(s), it is reviewed by a BCBSTX nurse.  The information is entered into a database that re-scores the data and the information is retained for future evaluations.  If this results in a score change that meets the threshold for expected performance, the online Provider Finder will be updated with a blue ribbon. We send a letter to the physician about the review outcome.

If the initial review does not result in a score change, the case is reviewed by the Evidence Based Measures Internal Review Committee (EBMIRC) which is a committee comprised of representatives from BCBSTX.  If the EBMIRC determines that the case warrants a change in the physician’s results, Provider Finder will be updated with a blue ribbon. A letter is sent to the physician informing them of the review outcome. 

If the review does not result in a change, the physician is given the option to request a second-level review by a panel of participating physicians, either the Texas Medical Advisory Committee (TMAC) or the Texas Peer Review Committee (TPRC) of BCBSTX.  Both committees’ members are practicing physicians and other health care providers who also participate in networks serving members of BCBSTX health programs.

Second-level Review: If a second-level review is requested by a physician, the documentation provided by the physician is presented to either the TMAC or TPRC. If the committee determines that the case warrants a change in the physician’s results, Provider Finder will be updated with a blue ribbon.  We send a letter to the physician about the review outcome.

If the review does not result in a change, the second-level review is the final step in the review process and there are no other options for additional reviews.

Please note: For the 2009 BlueCompare update, we will complete both the initial and second level reviews on all BlueCompare review requests received on or before May 1, 2009 prior to updating the individual physician’s BlueCompare information on the Web site.

Submitting a Performance Improvement Plan (PIP) in Lieu of Patient Documentation:
If a PIP is submitted, it is presented to the EBMIRC which is a committee comprised of BCBSTX representatives.  If the EBMIRC recommends a change in the physician’s results, Provider Finder will be updated with a blue ribbon. We send a letter to the physician about the review outcome.

If the review does not result in a change, the physician is given the option to request a second-level review by a panel of participating physicians, either the Texas Medical Advisory Committee (TMAC) or the Texas Peer Review Committee (TPRC) BCBSTX.  Both committees’ members are practicing physicians and other health care providers who also participate in networks serving members of BCBSTX health programs.

Second-level Review: If a physician requests a second-level review, all documentation provided by the physician is presented to either the TMAC or TPRC. If the committee recommends a change in the physician’s results, Provider Finder will be updated with a blue ribbon. We send a letter to the physician about the review outcome.

If the review does not result in a change, the second-level review is the final step in the review process and there are no other options for additional reviews.

Please note: For the 2009 BlueCompare update, we will complete both the initial and second level reviews on all BlueCompare review requests received on or before May 1, 2009 prior to updating the individual physician’s BlueCompare information on the Web site.

Information to Submit for a Review and Where to Send the Review Request:
Send your written response and/or performance improvement plan to:

Kathleen Leifker, R.N.
901 S. Central Expressway, North Building – D
Richardson, Texas 75080-7302

Requests should include:

• the date of the request
• your name and address
• your Practice Evaluation ID Number (found on the BlueCompare letter and reports)
• a statement of the reason(s) for requesting a review
• supporting documentation for patients on the EBM Member List that indicates services were completed or that a measure did not apply to the patient. 

If you are unable to provide this supporting documentation you must submit a  Performance Improvement Plan as described below.          

Submitting a Performance Improvement Plan (PIP):
If you submit a Performance Improvement Plan, it must clearly state the actions you will take to improve your performance. Your plan must include at least one of the following:

• Reports from an Electronic Medical Record system or Quality Improvement Program demonstrating the performance in your practice on the measures shown on your EBM Summary Report; or
• Completed documents from the AAFP METRIC or ACP PIM or AMA PCPI modules for these measures.

All the information submitted will be evaluated. You will be notified of the results.  If you submit a PIP by May 1, 2009, the results of that review will be reflected in the 2009 BlueCompare online update.

The Review Process For Physicians Who Received a Blue Ribbon

If the physician sends documentation showing services were provided to the patient(s), or that services do not apply to the patient(s), the information is reviewed by a BCBSTX nurse.  The information is entered into a database and retained for future EBM evaluations. We send a letter to the physician about the review outcome.

Information to Submit for a Review and Where to Send the Review Request:
If you do not feel that your EBM reports accurately represent your practice’s performance for the selected measures, you may request a review of your updated BlueCompare EBM information by sending a written request to your local Professional Provider Network office. Requests should include:

• the date of the request
• your name and address
• your Practice Evaluation ID Number (found on the BlueCompare letter and reports)
• a statement of the reason(s) for requesting a review
• supporting documentation for patients on the EBM Member List that indicates services were completed or that a measure did not apply to the patient. 

If you submit additional documentation, the information submitted will be evaluated. If changes are necessary, we will update our system and the information will be retained for future evaluations.

Where to Direct Other BlueCompare Inquiries

All other inquiries regarding BlueCompare methodology, interpretation of scores, your tax ID number or specialty designation should be directed to your local Professional Provider Network office. You should receive a response within 30 days of our receipt of the inquiry.

General inquiries and requests for reports are not considered by BCBSTX as formal requests for review. Requests for review must follow the procedure outlined above. You do not have to order any reports prior to requesting a review.
View information on BlueCompare and BlueCompare Evidence Based Measures (EBM).

Frequently Asked Questions

1. How can I get a copy of the EBM report(s) from the BlueCompare mailer? 
   You can request copies of BlueCompare EBM reports by contacting your local Professional Provider Network office.
2. If I ordered reports, will I also get a review?
   General inquiries and requests for reports are not considered by BCBSTX as formal requests for review. You do not have to order any reports prior to requesting a review. To ensure your status is reviewed, you must send a written request to your local Professional Provider Network office.
3. Do I need to send a written request for review or can I call my local PPN representative to request a review?
   We request that reviews be in writing because a written request enables us to track and forward the case to the correct staff members for a response. They can be mailed, faxed or sent via email to the local Professional Provider Network office.
   
4. What is the Deadline for Requesting a Review?
   You may request a review at anytime. Results of review requests received prior to May 1, 2009 will be reflected in the upcoming 2009 BlueCompare update.  Review requests received after that date will be reflected in BlueCompare as quickly as possible; updates are typically made on a daily basis.
5. How does my BlueCompare information affect my participation status in the networks? 
   For those physicians who did not reach the threshold for recognition, the EBM evaluation results may have an impact on their network participation. Those physicians will receive a letter explaining this process.

If you have questions regarding your participation, please contact your local Professional Provider Network office.