Blue Cross Blue Shield of Massachusetts to downcode high level E/M codes for outlier providers

By Brian Murphy

We’ve got another blanket E/M downcoding policy set to take place on Monday, just after Halloween.

Not a treat. Not a totally unexpected trick, either.

A large insurer in my home state of Massachusetts, Blue Cross Blue Shield of MA, will review E/M claims from providers who consistently bill at levels 4 and 5. BCBS of MA will then auto-reduce reimbursement if the insurer decides that overcoding has occurred.

It estimates that just 1-2% of primary care physicians and 3-4% of specialists in its network will be subject to the expanded process.

Clinicians can submit additional documentation and appeal to have claims reinstated as originally billed, per Becker’s (see article below).

You might remember that Cigna was poised to implement a very similar policy starting Oct. 1 (see article below), but ultimately relented following pressure from physician groups in its network.

BCBS of MA appears to be moving ahead despite getting similar pressure from the likes of the American Osteopathic Association, who wrote a strongly worded letter of opposition.

Blanket downcoding of outliers is now of course entirely possible due to advanced analytics and AI. Insurers have full transparency into how individual providers bill, and outliers in the E/M bell curve will draw an AI equipped auditor’s bullseye.

Technology companies promising AI as a billing panacea should take pause. Just because a note is auto-populated via generative AI with supporting documentation does not make a provider immune to scrutiny.

It’s part of an escalating, AI fueled arms race.

I have zero doubts that some providers overcode, either out of ignorance of coding guidelines (among those who self-code) or due to ill-trained office staff. Some truly believe their patients have a higher acuity than their peers.

In some cases it’s just simple fraud.

But I understand the need for provider organizations to push back against blanket downcoding. Allowing even a small % of physicians to take the hit could lead to downcoding expansion.

Why not auto-reduce the top 20% of physician billers? Why not the top 49%, in theory? That’s why I don’t like policies that auto-targeting outliers. We’re not all average.

There’s also no small degree of hypocrisy afoot. MA plans have no problem reporting every HCC possible to Medicare to boost their per member per month reimbursement, then turn around and raise premiums and cut member benefits.

As is happening right now.

It leaves me feeling, as I often do when I think of the insurer-provider reimbursement tug-of-war, bone-weary and drowning in cynicism. Silver lining: At least the coding and billing world isn’t boring?

In the end every insurer is trying to improve its bottom line. Which puts coders and their work on the front lines at a premium. As well as good denials specialists and legal representation.

References

• Becker’s, BCBS Massachusetts expanding claims reviews to target provider ‘overcoding’: https://www.beckerspayer.com/policy-updates/bcbs-massachusetts-expanding-claims-reviews-to-target-provider-overcoding/
• American Osteopathic Association letter to BCBS Massachusetts: https://osteopathic.org/index.php?aam-media=/wp-content/uploads/AOA-Letter-to-BCBSMA.pdf
• Norwood, Cigna auto-downgrade of high E/M levels a troubling start to new fiscal year: https://www.norwood.com/cigna-auto-downgrade-of-high-e-m-levels-a-troubling-start-to-new-fiscal-year/