Anthem Blue Cross of California is extending the pause on its upcoming evaluation and management claim downcoding policy until at least May 1, the insurer confirmed to Becker’s March 31.
The California Medical Association said the policy is pending review by the California Department of Managed Health Care. Previously, the insurer paused the policy until the beginning of March, and then the organization released another update punting it to April.
A Nov. 13 provider notice from the insurer said it would begin a pre-payment review process, which was originally set to take effect Feb. 15. In December, CMA said it “strongly” urged Anthem Blue Cross to pull back on the initiative. Under the policy, Anthem Blue Cross could evaluate whether claims coded at a higher E/M level follow industry coding standards and reimbursement policy. If the code does not align, Anthem could request for the claim to be resubmitted, suspend the claim or modify reimbursement. There would also be a dispute resolution process.
In a statement shared with Becker’s Feb. 24, Anthem Blue Cross said the policy’s aim is to combat fraud.
“Healthcare fraud costs Californians billions each year, raising premiums and draining public funds. This effort targets fraud to protect affordability,” the spokesperson said. “We welcome DMHC’s review and will continue working with providers to ensure transparency, compliance with California law and fair claims processing. Accurate billing is crucial to keeping costs down for California families, employers and taxpayers.”
CMA expressed concerns over the policy’s legality and the possibility of greater administrative burden.
“The notice provided few details about how claims would be selected, which E/M codes would be affected or how Anthem would determine the ‘appropriate’ level of service for downcoded claims,” CMA said.
This story was last updated March 31.
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