Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Anthem to Implement Post-Pay Reviews for ED Level 5 Claims in Some States; Indiana Currently Excluded

Anthem Implements New Policy of Post-Pay Reviews for ED Level 5 Claims

Anthem Blue Cross and Blue Shield recently announced a new policy of post payment reviews of professional ER claims billed with level 5 E/M codes. The new policy is being implemented to “ensure documentation meets or exceeds the components necessary to support its billing,” according to Anthem, and will begin August 1.

Originally, providers in most states that Anthem services, excluding California and Georgia, received the May 1 update notifying them of the policy change. Andrea Halpern Bryan, CIPROMS Vice President of Client Relations, reached out to several Anthem representatives asking for clarification on the new policy, and on May 29, she was informed that the policy was published in error for Indiana. Anthem sent a correction to Indiana providers today, May 30. Similar corrections were sent to providers in Colorado and Nevada back on May 16. However, no such corrections appear to have been sent to providers in the following states for whom the policy seems to be moving forward: Connecticut, Kentucky, Maine, Missouri, New Hampshire, New York, Ohio, Virginia, and Wisconsin.

More Complicated Than Meets the Eye

This latest directive from Anthem is one in a string of payer policies attempting to address the high costs of emergency medicine. To be sure, emergency department costs are going up, but so is emergency department use. A recent study by the CDC showed a continue uptick of ER visits (a 7 percent increase between 2015 and 2016, the most recent two years of data). But what accounts for both the increased use and the increased spending?

Based on the implementation of recent policies, Anthem seems to be addressing two possible problems: misuse by patients and upcoding by physicians. For instance, in 2018, Anthem introduced a policy aimed at reducing ED visits for “non-emergency” conditions. In Indiana and several other states, Anthem now performs a pre-payment review of claims, looking for any “non-emergency” conditions and requiring patients to pay out of pocket for those “non-emergency” services. But that recent CDC study mentioned above shows that patients generally aren’t misusing the ED. On the contrary, the study showed that very few ED visits (4.3 percent) are for “nonurgent medical symptoms.”

On the other hand, Anthem explains their most recent policy of post-payment reviews of level 5 services by pointing to “an increasing trend in the billing of emergency room level 5 Evaluation and Management codes.” Rather than point to upcoding, this trend in ED coding likely reflects the new reality of emergency medicine. The CDC study showed that more and more patients are presenting to the ED with serious illnesses and injuries, with 12.5 million patients presenting with stomach pain in one year and 7.5 million with chest pain, two of the top reasons patients seek emergency care.

“Emergency care is growing more complex,” said Vidor Friedman, MD, FACEP, president of the American College of Emergency Physicians (ACEP), in a prepared statement about the CDC study, “and some of the larger trends that will impact emergency department planning and resource discussions include the rising number of elderly patients, preventing and treating opioid abuse and the role of the emergency department in treating and managing patients with mental illness.”

Halpern Bryan agrees, especially as it relates to Anthem’s pair of policies.

“There is an increase in the percentage of higher acuity care in the ED because of the decrease in patients seeking care for non-emergent conditions,” Halpern Bryan said. “Payers need to acknowledge that lower acuity care has been shifted away from the hospital emergency department to more appropriate settings for non-emergent care such as a primary care clinic, urgent care, or retail clinic.”

More Administrative Burdens

While Anthem providers in Indiana, Colorado, and Nevada have avoided this additional level of scrutiny for now, Halpern Bryan believes providers in states that are affected need more information about the policy before it is implemented, such as Anthem’s criteria for determining which level 5 claims will be subject to the review, as well as Anthem’s current policy for determining the level of coding for E/M services 99281-99285.

“Anthem has the right to perform a post payment audit; however, there needs to be some transparency on how they intend to determine which claims to audit and limit these to a reasonable amount of claims per provider,” Halpern Bryan said.

As well, she would like to ensure that Anthem’s medical records requests are sent to the appropriate address so providers don’t miss an opportunity to defend their claims.

“All too often requests for records for emergency services are sent to the service location and do not get into the hands of the coding and billing staff that can facilitate pulling and sending the requested records appropriate for the services billed,” Halpern Bryan said.

In addition to making her own concerns known to Anthem, Halpern Bryan also is urging emergency physicians and other industry advocates to reach out to Anthem representatives about the administrative burdens of this policy and for clarification about its implementation.

Better Documentation

But advocacy isn’t the only way forward for emergency physicians. Being sure documentation in the medical record passes muster in an Anthem review is just as, if not more, important, according to Cara Geary, CIPROMS Client Liaison and Coding Auditor. A properly documented history and exam are just the beginning; documenting medical decision making has become the real gem of the medical record.

“Explicit medical decision making documentation is becoming one of the most important elements that payers and auditors are looking at to support the level of service,” Geary said. “Pulling lab or radiology results into the chart without context is no longer sufficient with many auditors.”

Documenting the rationale for all testing is essential. Geary also urges providers to record and comment on both abnormal and normal results, which “shows auditors the thought process behind the workup.” As well, documenting differential diagnosis considerations, particularly when a patient has a less severe or a non-specific condition, will support the higher acuity level of service.

More of the Same

Of note, post payment reviews, like the ones codified in this latest Anthem policy for some states, are not new for the payer. According to Geary, Anthem already performs post payment reviews for some level 5 Anthem Medicare Advantage claims through medical records requests.

Based on their review, Anthem either agrees with the original level of service as it was coded and reimbursed, or they “downcode” the claim and make a recoupment for the difference in payment. When a post payment review results in a downcoded claim for CIPROMS’ clients, Geary gets involved by sending an additional written appeal to Anthem showing how the level of service is supported by the medical record.

“So far, I have been fairly successful in getting the ‘downcodes’ overturned on appeal,” she said.

Whether providers in the commercial plans affected by the new policy will be as successful is yet to be seen.

Find out More

Learn more about Anthem’s new post payment review of professional ER claims billed with level 5 E/M codes by visiting the provider news page of Anthem’s website and searching by state for the new policies and/or the corrections Anthem has issued. Anthem updates for Indiana can be found here.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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