Posted in BCBS (Various States), Training, Updates

BCBS Staying compliant with after hours messaging for Behavioral health providers

Is your Behavioral Health Practice Compliant?

In the recent assessment by a third party Vendor-North American Testing Organization based in California, for the third Q of 2021, it was found that most of the Empire BlueCross BlueShield (“Empire”) plans assessed fell short of the expectation of having a live person or a directive in place after hours.

The main challenges that the third party vendor had were the following:

  • inaccurate provider information in Empire’s demographic database to allow assessment of the after-hours messaging
  • no voicemail or messaging at all
  • voicemail not reflecting the practitioner’s name
  • calls being auto forwarded with no identification, no voicemail or messaging

What does this mean for BCBS members?

In an annual member survery, BCBS members have indicated that when they needed advice, they are unable to to reach the provider office for urgent instructions.

In order to be compliant, as per Provider Manual, providers need to have the following:

  • Emergency situations : Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the practitioner.
  • Emergent / Urgent situations: Compliant responses for urgent needs after hours:
    • Live person, via a service, advises their practitioner or on call practitioner is available and connects.
    • Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
    • Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect.)

Examples of non-compliant responses include the following:

Non-compliant responses for urgent needs after hours include:

  • No provisions for after hour accessibility.
  • Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. These scenarios are non-compliant because there is no direct connection to their practitioner. This prompt can be used in addition to, but not in place of instructions.

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My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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