DecisionHealth, DecisionHealth - 2006 Issue 6 (June)
Anthem retracts blending policy
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Article Overview
This article covers an Anthem Blue Cross and Blue Shield policy reversal affecting evaluation and management reimbursement for pediatric and other physician practices. It explains the broader context of payer review activity, physician documentation concerns, and audit preparation issues discussed by coding experts and clinicians. The piece is relevant to coders, billers, practice managers, and physicians who follow payer policy changes and audit trends.
Why This Topic Matters
Payer reimbursement policy changes can affect office visit coding patterns, payment levels, and audit exposure. Understanding the scope of the reversal and the surrounding documentation review concerns helps practices anticipate operational and compliance impacts.
Article Sections
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Policy reversal and reimbursement impact
This section summarizes the insurer’s change in approach to office visit reimbursement and the broader reaction from physicians and practice groups. It frames the issue as a payment policy matter tied to established coding levels.
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Outlier review and audit concerns
This section discusses external review activity, selection of higher-volume coding patterns, and concerns about how audits are conducted. It also touches on the role of documentation standards in payer review.
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Preparing to defend documentation
This section covers professional advice on audit preparedness and the importance of records support during a payer review. It includes commentary from coding specialists and practice representatives about defending claims and documentation.
What You Will Learn
- How a payer policy reversal can affect office visit reimbursement patterns
- What broader audit and outlier-review concerns were raised in connection with the policy change
- What kinds of documentation readiness issues practices may need to consider during payer review
- How coding professionals and physicians viewed the impact of the policy shift
Who Should Read This
- Medical coders
- Biller and reimbursement staff
- Physicians
- Practice managers
- Compliance staff
Codes Discussed
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