Anthem Blue Cross has announced that beginning January 2016, the plan will begin a prepayment review of selected ED visits billed with Current Procedural Terminology (CPT) code 99285 (professional service) or HCPCS code G0384 (ED facility service) under the Blue Cross Medicare Advantage Program. In other words, certain claims from these plans will not be paid until the medical record from the encounter has been reviewed by auditing the chart documentation to verify it meets, or exceeds, the requirements listed in the American Medical Association CPT book.

Anthem is targeting level 5 services that were not admitted to the hospital following the ED visit, reasoning that if the patient could go home after the ED treatment, extensive treatment wasn’t required. Anthem is concerned that ED visit frequency distributions do not reflect a normal bell curve distribution, suggesting overuse of the higher-level codes.

Challenge This Practice

ACEP advises that this practice be challenged and that you should insist that frequency distribution comparisons be “apples to apples.” In particular, Anthem should be comparing emergency physicians against other emergency physicians in similar practice locations rather than against claims from a different medical specialty or provider. Importantly, there are meaningful differences between high-acuity urban tertiary trauma centers and more rural emergency departments that often go unrecognized.

The increase in lower-cost alternative sites of service, ranging from “minute clinics” to urgent care clinics, has siphoned some of the lower-acuity volume away from emergency departments, which has likely resulted in the appearance, to payers, that a higher percentage of higher-level services in emergency departments are being claimed when compared to the frequency of lower codes. In fact, the acuity of the average ED patient is increasing regardless of whether they require admission.

Anthem has stated that it has implemented this process for its Medicare Advantage plans at this time, but we are watching to see if the policy spreads to Anthem commercial products as well.

Routine prepayment audits will create a significant financial hardship on practices with high Anthem exposure because the ED group will not be paid until after the reviews are complete. 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. There is an appeals process, but it is expensive and time-consuming, preventing timely payment for EMTALA-mandated services.