U.S. physicians routinely are seeing their higher-cost claims down coded by insurers, a strategy a family physician in Cincinnati called a revenue grab, according to Medscape. This Evaluation and Management (E/M) Leveling Program (aka down coding) was announced by Anthem in its August 2020 newsletter in response to perceived over coding of level 4 and 5 visits.
In June of 2021, the Indiana State Medical Association (ISMA) started hearing from many physician practices who were seeing a sizable number of claims down coded. Anthem uses analytical tools to review E/M codes during the claims adjudication and processing process, and those physicians can dispute down coding decisions by providing a statement explaining why they disagree and documentation to support it. The E/M Leveling Program is one of Anthem’s initiatives to address provider over coding.
E/M coding represents the largest category of codes submitted by most providers and monitoring for compliance with billing remains an ongoing effort for Anthem. This is a very laborious process, and providers must submit documentation before the claims are processed or paid. This process identifies providers with a history of billing E/M services at significantly higher levels compared to their peers with similar risk-adjusted members.
When claims are submitted, Anthem’s proprietary software looks at every diagnosis on the claim. “Without medical record documentation, Anthem believes this automated process more closely represents the new 2021 coding guidelines for office and other outpatient service codes 99202-99215, because the diagnosis is the most closely related data on a claim to represent medical decision making (MDM),” said Jay DeLaRosa, Anthem’s reimbursement policy manager.
DeLaRosa stated that approximately 6% of all providers will be impacted by this new leveling program. Those who appeal 100% of their claims are seeing very few overturned; however, those who review the documentation before submitting an appeal and provide justification for the level of service have a greater chance of seeing the decision overturned. As of Oct. 19, Anthem has suspended this program until Jan. 1, 2022, based on the backlog of appeals they have received to date.
The future of healthcare is data driven. RemitOne allows for complete and accurate documentation and coding to be handled automatically with built-in compliance.
Do you want to avoid payor downcoding while reducing administrative burden? Contact our team at info@mccremitone.com to find out how you can utilize RemitOneTM to improve clinical documentation, coding, and compliance, all while providing quality patient care.
To see more about MCC and RemitOne, visit our documentary segment that aired on CNBC here: https://www.mccremitone.net/r1video/MCC_03.mp4.
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