Grassi Healthcare | Alert: Anthem's New Prepay Review Policy
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Alert: Anthem's New Prepay Review Policy

August 28, 2019
Anthem's new prepay review policy gives practices time to get the house in order…
We have been seeing higher levels of scrutiny and health plan push back when it comes to certain modifiers. Why? Because they bypass edits and trigger payment. According to a new policy, released in July, modifiers 25, 57 and 59  may also  trigger a prepayment review by Anthem BlueCross BlueShield plans as early as Sept. 1st. According to a recent article by Decision Health, at least 14 Anthem plans have announced that they will initiate a prepayment clinical validation review process for claims with a number of modifiers, including 25 (Significant, separately identifiable E/M service), 59 (Distinct procedural service), 57 (Decision for surgery), LT (Left side) and RT (Right side) “and other anatomical modifiers,” states the notice published in the July edition of the Providers Newsletter for a variety of Anthem plans.

  According to the new policy, registered nurses and coders will review claims to “evaluate the proper use of these modifiers in conjunction with the edits they are bypassing," such as the National Correct Coding Initiative. Providers will be able to appeal denials when they disagree with the findings, the announcement states. The article goes on to say, while it is obvious that Anthem wants to crack down on misuse of modifiers that circumvent edits, the scope of the review remains murky. Will frequency of utilization of certain modifiers be enough to trigger prepayment review or will the payer consider additional factors? Reviews will begin for the following NYS Plans on the dates below. Click the link to see the policy.

September 1, 2019  
New York Medicaid

October. 1, 2019
New York Empire BlueCross BlueShield

We have seen the impact on practices dealing with prepayment reviews. The strain on resources is significant, and real, not to mention the potential cash flow and financial impacts. It is critical that practices take this warning seriously and  be proactive to assure that modifiers are being utilized  appropriately. We highly recommend that practices stay on top of appealing all denied claims under prepayment review. A few proactive approaches a practice can take to prepare for these audits include:
  • Identify your usage, and utilization of these modifiers
  • Validate that documentation is 100% compliant
  • Prepare internally to handle any appeals that are necessary to overturn denied claims
  • Educate staff and providers on the requirements when using modifiers
For more information or assistance managing prepayment reviews please contact:

Alicia Shickle-Cline, AHFI, CHC, CPCO, CPC, CPMA, CPPM, CRC
Senior Manager, Physician Practice Advisory
(212) 223-1764