Providers reimbursed a percentage of their billed charges for Medicare Advantage hospital emergency department evaluation and management services may see a significant impact on reimbursement
Effective August 1, 2025, Anthem will implement a new claims-editing process that adjusts payments for Medicare Advantage (MA) claims based on an undisclosed, customized chargemaster table. The announcement identifies claims for emergency room evaluation and management (ED E/M) services as subject to additional review and "ER leveling … for consistency with submitted claim elements." Anthem's announcement does not disclose the methodology it will use to determine whether billed charges align with "with submitted claim elements," but Anthem states that it "will use historical claim data to determine the appropriate billed charge amount."
Anthem's announcement leaves several critical questions unanswered regarding the scope and impact of these claim edits, including:
- Which providers will Anthem classify as "reimbursed on a percentage-of-charge basis"? Does this include providers whose reimbursement is based on Medicare Allowed amounts?
- What is "ER leveling" and what will Anthem use to assess whether billed charges for an ED E/M claim are consistent with submitted claim elements?
- What "historical claim data" will Anthem use to determine the "appropriate billed charge amount"?
Although Anthem does not address these key issues, hospitals reimbursed for MA ED E/M claims based on a percentage of their billed charges appear to be clear targets for this new process. MA ED E/M claims paid on Medicare Allowed amounts may also be affected, if they qualify for outlier reimbursement.
Providers may have grounds to challenge Anthem's August implementation of its new ED E/M claims editing process, as well as similar efforts by other health plans to reduce reimbursement to providers for ED E/M services.
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