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New Anthem Policies Onerous for Hospital Reimbursement
July 15, 2016

In June 2016, Anthem Blue Cross issued two new internal policies regarding hospital-owned clinics and ambulatory surgical procedures that could materially affect the amount of reimbursement hospitals will receive under their contracts with Anthem.  We have learned that many hospitals have not been informed of one or both of the changes outlined in these policies.  

The first change is to Anthem’s Facility Manual.  The new policy provides that “services rendered in an office, professional building, medical office building, clinic or space owned by a hospital or institutional provider … must be billed on a CMS-1500 form and are not reimbursable if they are billed on an UB-04 form.”  The new policy provides examples of revenue codes that should not be billed on a UB-04 and will not be reimbursed, such as laboratory, radiology, PT, OT, ST, and pharmacy charges.

The second change is to the Anthem Clinical UM Guidelines.  This new policy essentially provides that outpatient surgeries will only be considered medically necessary “if the individual’s medical status or the procedure requires enhanced monitoring beyond what would routinely be needed for rendering such services in a free-standing ambulatory procedural setting” and “the potential changes in the individual’s medical status could require immediate access to specific services of a medical center/hospital ...”  “All other uses of a hospital based facility for an outpatient procedure are considered not medically necessary.”

HLB has been in communication with the California Hospital Association regarding these issues. We recommend that you review your contracts with Anthem to determine what actions you may wish to take.

If you require assistance with this matter, or have any additional questions, please contact Daron Tooch at 310.551.8192.

For media assistance, please contact Maura Fisher at 202-580-7714.