Anthem’s new clinical review process may disrupt payment

Anthem Blue Cross Blue Shield (Anthem) is implementing a new prepayment clinical validation review process which could affect more than 20,000 DOs practicing in 14 states.

As noted in a June 2019 communication to network providers, Anthem stated that the new review process impacts claims submitted with modifiers 25 (significant, separately identifiable E/M service), 59 (distinct procedural service) and 57 (decision for surgery). Anatomical modifiers including left side (LT) and right side (RT) are also subject to review.

Claims billed with these modifiers will trigger a prepayment clinical validation review process within the automated claims software to evaluate their proper use, according to the insurer.

While Anthem told network physicians the process is intended to flag misuse of common modifiers, it is also likely to delay physician payment and hinder patients from receiving timely care, according to AOA President Ronald Burns, DO.

Policy likely to boost time spent on paperwork

“AOA is seeking clarification on this change because if Anthem proceeds with the new review process as described, it will impact patient care in every state where Anthem conducts business,” Dr. Burns says. “The policy would affect physicians in most specialties and increase the amount of time they spend on paperwork instead of patient care.”

Dr. Burns, writing on behalf of the nation’s 145,000 DOs and osteopathic medical students, sought clarification from Anthem in August. He and other AOA leaders are scheduled to meet with the insurer later this month.

According to Anthem, “the clinical validation review process will evaluate the proper use of these modifiers in conjunction with the edits they are bypassing, such as the National Correct Coding Initiative (NCCI). Clinical analysts who are registered nurses and coders will review claims pended for validation, along with any related services, to determine whether it is appropriate for the modifier to bypass the edit.”

DOs who document correctly may be penalized

The AOA is deeply concerned the new process will penalize physicians who code and document correctly, resulting in unjustified claims denials or delay in payments for appropriately billed services, Dr. Burns says.

“The lack of clarifying details in the policy language will lead to confusion that negatively impacts patient care,” he adds.

DOs experiencing payment issues due to the new Anthem policy are asked to submit two to three EOBs and any supporting documents with all protected health information redacted to the AOA Physician Services Team at [email protected].

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