Anthem Continues Audits on NE Ohio Physicians

Close to 1,300 NE Ohio physicians have been subjected to a professional audit performed by Healthcare Comprehensive Solutions (HCS) on behalf of Anthem. If you are subjected to an audit you may expect the following to occur: After completion of the initial audit, the audit results are sent back to the physician outlining the results and providing information on the appeals process. The physician is then notified of his/her appeal rights and has 30 days to submit an appeal in writing along with supporting documentation to HCS. Upon receipt of an appeal, HCS is supposed to assign a different auditor to perform the appeal review and the results of this review are to be sent back to the physician. If the physician continues to dispute the audit findings, the AMC/NOMA strongly suggests that physicians request a peer-to-peer conference with the Medical Director of HCS. Currently, HCS is utilizing the CMS 1995/1997 E/M Guidelines for these types of discussions. Anthem has stated that these audits are based solely on correct coding and supporting documentation and in no way questions the level of care provided by the physician. Anthem has indicated that this is being done to ensure that the level of code billed is supported by appropriate documentation. However, there appears to be some question on the part of physicians undergoing these audits as to how Anthem reviews “risk.” Some physicians have expressed concern that if the reviewers for Anthem merely assess the risk under medical decision making based on the eventual established diagnosis, it may not reflect the overall medical decision making work done for each patient. The AMC/NOMA strongly suggests that if you are subjected to an Anthem audit that you copy the Medical Director for Anthem in the Northern Ohio region (Dr. Thomas Weisman) and request a peer-to-peer review of the claims by HCS. The AMC/NOMA would also be interested to learn from our members if you have experienced any problems/issues due to these audits by Anthem. Send your comments to ksnider@amcnoma.org