Count on Quality at Blue KC
Blue Cross and Blue Shield of Kansas City (Blue KC) continues its efforts to improve member health by expanding its value-based care models. The value-based strategy focuses on quality improvement programs that drive improved health outcomes, lower costs for everyone and enhances member experience. Blue KC leverages a Population Health approach through care coordination, data-driven decision making and advanced analytics, practitioner and member engagement, and improved access to care networks.
The quality improvement (QI) program includes, but is not limited to, measuring, monitoring and improving:
- Clinical care and preventive services using the Healthcare Effectiveness Data and Information Set (HEDIS®) to evaluate health plan performance
- Care transitions including continuity and coordination of medical care and behavioral health
- Member and provider Experience with Blue KC.
- Network analysis and availability
- Member quality of care concerns
- Clinical programs (Case, Disease and Utilization Management)
Achievements — Blue KC currently has 2 commercial products accredited by the National Committee for Quality Assurance (NCQA). Blue Care (HMO) and Preferred-Care Blue (PPO) attained “Commendable” accreditation status in 2019 which, under the new accreditation scoring system, is now listed as “Accredited” as of 2022.
Annual Evaluation — Each year, the QI Program is evaluated to see how much we’ve improved the quality and safety of clinical care along with a review of Blue KC’s services, including claims, customer service and our website. This evaluation is used to identify opportunities to make improvements.
Current Goals and Initiatives — The goals and objectives of the QI Program include:
- Continue to improve our NCQA accreditation status for our healthcare products – HMO and PPO.
- Attain NCQA accreditation for our ACA product in 2022.
- Continue to improve member’s health as measured through the Healthcare Effectiveness Data and Information Set (HEDIS®) scores.
- Improving both the member and provider experience with Blue KC.
- Expand the Blue Distinction Total Care (BDTC) /Advanced Primary Care (APC) program as well as other value-based care models.
- Quality workgroups with interventions for chronic disease, women’s and children’s care, and alternative care options.
- Restructuring our quality of care process for monitoring and tracking adverse cases in identifying trends.
Learn More:
If you would like more information about Blue KC’s QI Program, goals, processes or outcomes, please contact the Quality Management Department by email: _Quality_Management@BlueKC.com or by mail: c/o Blue KC Accreditation & Quality Improvement, 1400 Baltimore Avenue, Room 1544, Kansas City, MO 64105.
Population Health Management Programs
Are you aware Blue KC provides care management programs for all eligible members? We are a highly-trained team consisting of Registered Nurses (RN) and licensed clinical social workers (LCSW) who are ready to assist you with managing your health.
Discharge Programs target members recently discharged from hospital, skilled nursing, or rehabilitation settings to home. Studies have shown nearly 11.6% of patients will readmit to the hospital within 30 days of discharge. Our Clinician will contact you within seven days of your discharge and provide follow up within 10-14 days and at the end of the program to decrease your risk for readmission. Your dedicated RN will review and provide education on discharge instructions and medications; assist with scheduling follow up appointments, and provide assistance with other post-discharge needs (i.e. home health, equipment).
- Transition 2 Home (T2H) & Discharge Follow up
- Readmission Program Reduction for CHF Members
Preventive Program reminders are mailed to eligible members. Our team is available to provide educational resources, clinical support and assist with locating service providers.
- Breast Cancer Screening
- Flu Shot Reminders
- Medication Adherence Program
- Asthma
- Diabetes (AIC testing and control, Diabetic Eye Exam)
Other programs include:
- Emergency Department Visit Reduction
- Complex Case Management
- Advance Illness Program
Blue KC Case Management clinicians provide personalized, support by phone as needed to help:
- Develop individualized treatment plans that optimize the health benefits allowed in a member’s Blue KC plan.
- Advocate for patient health by coordinating with the member, and/or their family, family physician and healthcare providers, finding and reviewing treatment alternatives, and helping with discharge planning (if hospitalized).
For more information, please contact our Clinicians at (816) 395-2060 or toll free at (866) 859-3813 Monday-Friday from 8 a.m. to 5 p.m., Central Time. You will be prompted to leave your name and phone number and your call will be returned.
Or, if you would like to opt out of our programs or be removed from mailing list, please contact us.
You can also find health support at your fingertips with the Blue KC Care Management app. The app puts you in control of your health by connecting you to your care team right from your smartphone or tablet. You can securely message your care team about your health, and they can provide wellness support and inspiration. Our app is with you every step of your care journey, making it easier to manage your health and chronic conditions such as diabetes, asthma, cancer, maternal health and more. Click here to learn how you can download the app.
Blue KC Care Management Services
Are you aware Blue KC provides case management services for all eligible members? We are a highly-trained team consisting of Registered Nurses, a Registered Dietician (CDE certified), and a licensed Social Worker who are ready to assist your patients. Below is an example of the various member conditions you can refer to our programs.
- Chronic Disease
- Catastrophic Accident
- Pre- and Post-Transplant
- High-Risk Pregnancy/Premature Birth
- Life-Threatening Illness
- Post-Discharge Follow Up
- Stroke
- Care Coordination while away from home/DME/Medication
- Advanced Illness Program (end-of-life care guidance)
- Integrated Care Management (Behavioral and medical diagnosis)
- Other medical conditions requiring case management support
Blue KC Case Management clinicians provide personalized, support by phone as needed to help:
- Develop individualized treatment plans that optimize the health benefits allowed in a member’s Blue KC plan.
- Understand the medical costs associated with treatment and find available care resources.
- Advocate for patients health by coordinating with the member, and or their family, family physician and healthcare providers, finding and reviewing treatment alternatives, and helping with discharge planning (if hospitalized).
To refer a member to a care management program, please contact us at (816) 395-2060 or toll free at (866) 859-3813 Monday-Friday from 8 a.m. to 5 p.m., central time. You will be prompted to leave your name, phone number and your call will be returned by one of our clinicians.
You can also find health support at your fingertips with the Blue KC Care Management app. The app puts you in control of your health by connecting you to your care team right from your smartphone or tablet. You can securely message your care team about your health, and they can provide wellness support and inspiration. Our app is with you every step of your care journey, making it easier to manage your health and chronic conditions such as diabetes, asthma, cancer, maternal health and more. Click here to learn how you can download the app.
How Prior Authorization Works
Blue KC requires participating network physicians and providers to receive prior authorization for certain services and medications. Complete lists of items requiring prior authorization are below:
- Services, Durable Medical Equipment (DME) and Prostheses requiring Prior Authorization
- Medications requiring Prior Authorization
- Prior Authorization for Medications – High-Performance Formulary Plans Only
- Federal Employee Advance Medical Review
Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in this list may occur. Physicians and pharmacy providers will be notified of any such changes via newsletters and direct mailings.
Member Satisfaction Survey Results
According to the 2024 Member Satisfaction Survey, most Blue KC members are satisfied with their health plan, their doctors and their healthcare. Following are the complete results:
Member Rights & Responsibilities
You have the right to:
- Receive considerate and courteous care with respect and recognition of personal privacy, dignity and confidentiality.
- Have a candid discussion of medically necessary and appropriate treatment options or services for your condition from any participating physician, regardless of cost or benefit.
- Receive medically necessary and appropriate care or services from any participating physician or other participating healthcare provider from those available as listed in your managed care plan directory or from any nonparticipating physician or other healthcare provider.
- Receive information and diagnosis in clear and understandable terms, and ask questions to ensure you understand what you are told by your physician and other medical personnel.
- Participate with Providers and practitioners in making decisions about your healthcare, including accepting and refusing medical or surgical treatments.
- Give informed consent to treatment and make advance treatment directives, including the right to name a surrogate decision maker in the event you cannot participate in decision making.
- Discuss your medical records with your physician and have health records kept confidential, except when disclosure is required by law or to further your treatment.
- Be provided with information about your managed healthcare plan, its services and the practitioners and providers providing care, as well as have the opportunity to make recommendations about your rights and responsibilities.
- Communicate any concerns with your managed healthcare plan regarding care or services you received, receive an answer to those concerns within a reasonable time, and initiate the complaint and grievance procedure if you are not satisfied.
You have the responsibility to:
- Respect the dignity of other members and those who provide care and services through your managed healthcare plan.
- Ask questions of your treatment physician or treatment provider until you fully understand the care you are receiving and participate in developing mutually agreed upon treatment goals to the degree possible.
- Follow the mutually agreed upon plans and instructions for care that you have discussed with your healthcare practitioner, including those regarding medications. Comply with all treatment follow-up plans, and be aware of the medical consequences of not following instructions.
- Communicate openly and honestly with your treatment provider regarding your medical history, health conditions, and the care you receive.
- Keep all scheduled healthcare appointments and provide advance notification to the appropriate provider if it is necessary to cancel an appointment.
- Know how to use the services of your managed healthcare plan properly.
- Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.