Higher coding spurs plan to "blend" pay rates

As electronic medical records systems improve physicians' ability to code, Ohio's WellPoint responds by paying CPT levels three and four at the same rate.

By Bob Cook, AMNews staff. Dec. 26, 2005.

On the one hand, WellPoint Inc.'s Anthem Blue Cross Blue Shield of Ohio division says it's encouraging physicians to adopt electronic medical records by paying doctors a bonus for using EMRs in the plan's pay-for-performance program.

On the other hand, Anthem is cutting reimbursement to some physicians who apparently were too good at using the systems to assist them in coding and billing.

The reimbursement cut comes through the use of something called "blended rates." Starting Nov. 1, Anthem Blue Cross Blue Shield of Ohio began paying CPT level-three and level-four codes for Cincinnati-area doctors at the same rate, rather than having separate reimbursement for each level. The rates for level-three codes were increased, and the rates for level-four codes were dropped.

Anthem instituted the blended rates because it found a 25% jump this year in the number of level-four coding submissions, said Barry C. Malinowski, MD, Anthem's Southern Ohio medical director.

He said the company found no evidence of fraudulent coding. Instead, Anthem's analysis of the increase found "a majority of physicians that were using the higher levels were using EMR." Extra documentation required to use a higher code, such as family history, medical history and social history, is "just a little easier" with an EMR, Dr. Malinowski said.

Under blended rates, Anthem says 75% of physicians should see no change, or a small increase, in reimbursement. But 25% will see less. Dr. Malinowski said, however, that practices might be able to make up any decrease through Anthem's newly expanded pay-for-performance plan, which rewards physicians for EMR usage.