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Anthem Extends Post-Payment Review Policy to Medicare Advantage Claims

Anthem Extends Post-Payment Review Policy to Medicare Advantage Claims

Just weeks after Anthem announced then retracted a new post-payment review policy for emergency department (ED) level 5 services for its commercial plans in some states, the payer has now announced that the policy will be implemented for Medicare Advantage plans in most states where Anthem conducts business.

According to an announcement in Anthem’s June 1, 2019, provider newsletter, beginning September 1, 2019, Anthem will initiate post-pay reviews for Medicare Advantage emergency department professional claims billed with 99285. 

“Emergency department professional claims with the highest potential for up-coding will be selected,” the payer said.

Physicians whose claims are identified will receive a request for documentation, and then the payer will evaluate the “appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Anthem guidelines.” 

Confusion over the New Policy

Providers were first made aware of the imminent post-pay reviews when Anthem sent a notice on May 1, 2019, to providers in most states announcing that the new policy would begin for commercial plans beginning August 1, 2019. A few weeks later, three states, including Indiana, Colorado, and Nevada, received a correction saying the announcement was made in error. For nine other states, however, including Connecticut, Kentucky, Maine, Missouri, New Hampshire, New York, Ohio, Virginia, and Wisconsin, the policy for commercial plans remained in effect.

Then, on June 1, 2019, all 12 states received a notice that the post-pay reviews would begin on ED level 5 Medicare Advantage claims on September 1, 2019. The same policy also will apply to Anthem’s Medicaid plans in four states: Kentucky, beginning August 1, and New York, Virginia, and Wisconsin, beginning September 1.

First Pre- Now Post-

This is not the first time Anthem has targeted level 5 Medicare Advantage claims for review. According to a 2016 article in ACEPNow, beginning in January 2016 Anthem began prepayment reviews of all level 5 claims, looking specifically for patients who were billed with a 99285 but were not admitted, “reasoning that if the patient could go home after the ED treatment, extensive treatment wasn’t required,” wrote David McKenzie, CAE, reimbursement director for the American College of Emergency Physicians (ACEP).

At that time, he worried about the effects of widespread reviews on physician practices.

“At best, this could cause a significant delay in cash flow for what is already a payment rate that is significantly discounted from usual and customary charges. At worst, if the claims are rejected or downcoded based on inappropriate ‘approved diagnosis lists,’ the payments can be reduced by as much as 40 percent or even paid at a nominal ‘screening fee’ rate,” McKenzie wrote. “There is an appeals process, but it is expensive and time-consuming, preventing timely payment for EMTALA-mandated services.”

This new post-pay review could create similar burdens. According to Anthem, reimbursement for claims will be based on the ED E/M code the submitted documentation supports. That means in addition to the administrative burden of submitting documentation for multiple claims, some 99285s could be downcoded and payment “overages” recouped.

What Should You Do?

As we explored in an earlier article, there are at least three things physicians can do right away to help mitigate the effects of these new post-pay reviews.

1. Contact Anthem and ask how claims will be identified for review and what criteria will be used to determine whether the level 5 was appropriate.

As Andrea Halpern Bryan, CIPROMS Vice President of Client Relations, said, “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.”

2. Ensure your documentation supports the codes you are submitting. 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.”

Geary encourages providers to document the rationale for all testing, recording and commenting on both abnormal and normal results, which “shows auditors the thought process behind the workup.” As well, document differential diagnosis considerations, particularly when a patient has a less severe or a non-specific condition, to support the higher acuity level of service.

3. Finally, alert all staff, at both the billing office and hospital, to be on the lookout for the anticipated documentation reviews.

“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.

Learn More

For more information about the new Anthem policy and what you should do, check out the following:

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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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