BCBS Illinois has plans to bolster its claims editing and review procedure, the insurer said March 16.
The process will change July 1 for office, inpatient and outpatient evaluation and management services. If the billed services do not align with the level of E/M services billed, BCBS Illinois will downcode. The company said it would abide by AMA guidelines while making these decisions.
If a provider disagrees with the level of service reimbursed, they can submit medical records to back up their claim.
Several insurers have made attempts to establish stricter processes around E/M billing to rein in possible fraud and mitigate costs. For example, BCBS Michigan plans to cut reimbursement in half for some services with modifier 25, a code indicator of separate services provided on the same day. Anthem Blue Cross of California pitched a prepayment review process, and Cigna rolled out its own downcoding policy, as well.
However, providers often push back. This scrutiny prompted BCBS North Carolina and Cigna to either rescind or delay similar policies in the past. The California Department of Managed Health Care has also been reviewing recent policies slated for the state.
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