Physicians are currently receiving three different audit letters from Anthem Blue Cross. This post summarizes the three audits in question and will help physicians understand the issues in play.
Medicare risk adjustment scoring audits
Physicians are receiving letters from Blue Cross
requesting records on a handful of Medicare Advantage (Freedom Blue) patients. This records request is part of the Medicare Risk Adjustment Scoring audits. Risk adjustment is how Medicare analyzes and adjusts the capitation amounts paid to Medicare Advantage plans.
The risk adjustment audit is designed to identify the health status and demographic characteristics of Medicare Advantage enrollees. Blue Cross is looking to identify conditions/illnesses that demonstrate patients who are at risk for being sicker, which results in higher capitation payments from CMS, or patients who are predicted to be healthier, which nets lower capitation payments from CMS.
The Blue Cross Prudent Buyer agreement requires physicians to comply with the request (see exhibit F to the Medicare Advantage PPO Participating Physician Agreement, Article VII, Reporting and Disclosure Requirements). The Blue Cross notice asks for certain patient records within a specified date range. Practices can, however, contact Blue Cross and request that they provide the specific dates of service in question. Additionally, the risk adjustment audits usually involve only a handful of patients per practice, but if the request is voluminous, practices may wish to contact Blue Cross and request that it send a copy service out to the practice.
Additional information on risk adjustment audits can be found on the Blue Cross website
. (Log in as a provider, click on Medicare Advantage Plans & Benefits, and search “risk adjustment 101.”) Physicians can also contact Blue Cross directly at (877) 489-8437.
Study of physician coding of levels 4 and 5
Physicians are being contacted by Blue Cross about a recent study of physician coding of new and established evaluation and management (E/M) visits, levels 4 and 5 (99204-99205 and 99214-99215). A letter was sent
to over 3,200 physicians who, according to Blue Cross, billed 90 percent or more of their claims to Blue Cross at E/M level 4 or 5. The data was collected during a one year period from November 1, 2009, to October 31, 2010.
The letter advises physicians that their use of these high-level codes is greater than others in their specialty and asks that they submit medical records on five specific patients so Blue Cross can provide them with feedback and education on this issue.
Approximately 600 physicians who reportedly billed 80 to 89 percent of their claims to Blue Cross at E/M level 4 or 5 received a similar letter
; however, no records were requested from this group.
Participation in the educational program is voluntary, but the notice states that future phases of the program may result in audits of E/M services.
Physicians who wish to dispute the Blue Cross findings may do so in writing via email and those who choose to participate in the voluntary program can submit records electronically (see instructions in the Blue Cross notice
). Records submitted to Blue Cross will be reviewed by a certified coder or registered nurse and written feedback will be provided within 90 days.
Questions or concerns regarding the letter can be directed to Blue Cross at (404) 842-8640.
Special Investigation Unit overpayment refund requests
CMA has heard complaints from several physicians who have received overpayment refund requests from the Anthem Blue Cross Special Investigations Unit outside the 365-day period allowed by California law. As a result, CMA has filed a formal complaint with the Department of Managed Health Care (DMHC) and asked it to quickly investigate these potential violations.
State law allows health plans to pursue recovery of any type of overpayment made to providers within 365 days of the date the claim was paid. For claims older than 365 days, plans can seek to recover overpayments only if the alleged overpayment was “caused in whole or in part by fraud or misrepresentation on the part of the provider.” CMA believes that Blue Cross is using an overly broad definition of "misrepresentation" to seek recoupment on claims older than one year.