Apr 1, 2023

Updates to member attribution methodology

Effective January 1, 2023, BCBSRI is updating how members in primary care provider (PCP)-required products are attributed to PCPs. The updated methodology will align with how BCBSRI attributes members in products that do not require a PCP, minimizing discrepancies among products, and will more accurately reflect actual member behavior (e.g., which PCPs a member uses) to improve care coordination, provider experience, and provider financial stability. The previous attribution method for PCP-required products relied solely on the PCP a member had proactively self-selected, either on the BCBSRI member portal, with our call center, or in person at a Your Blue Store. In practice, however, some members would then use different PCPs, sometimes in different care systems.

This discrepancy means that the clinician and system caring for the member may not receive credit for closing gaps in care; information related to their transitions, care management or utilization management needs; or shared savings, infrastructure payments, or capitation if the practice was in a value-based care arrangement – for this member. Based on provider and internal feedback, the new attribution method for PCP-required products will use the most recent “member behavior,” whether it’s the self-selected PCP or a qualifying claim with a primary care provider. We do not anticipate any changes to the member experience – members will still be able to view and update their PCP on the portal, and that PCP will not change based on their claims. The changes are expected to affect internal systems and certain provider-facing business processes, including:

  • Payment (shared savings, capitation, infrastructure, etc.),
  • Quality incentives (including Stars, PQIP, MTM, and other quality incentive programs)
  • Care coordination (transitions of care, care management, utilization management)
  • Analytics

Interim business process change: For providers who have delegated utilization management programs, BCBSRI recommends that you first check your provider group’s monthly attribution file to verify the name of the member’s PCP. If the member is not on the monthly attribution file, we recommend that you then review the member portal. BCBSRI is building reporting and automation to support this methodology change that will include solutions to ensure providers have access to the most accurate attributed PCP for utilization management purposes. Until that solution is implemented, we recommend using the interim business process described above.