Do you collect over $100K per year from Anthem BC/BS?

Do you collect more than $100K per year from Anthem BC/BS? If you answered yes, please read the article below. (This is Part 1 of a 2 Part Series.)

Anthem states that the services you provide must improve or restore functions which have been impaired. Benefits end when treatment is no longer medically necessary and the patient stops progressing. In order to get paid and keep your money, do the following:

  1. Your services must be aimed at improving, adapting or restoring functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality.
  2. Your services are for conditions that require the unique knowledge, skills, and judgment.
  3. There is an expectation that your care will result in a practical improvement in the level of functioning within a reasonable and predictable period of time. The documentation objectively verifies progressive functional improvement over specific time frames.

Treatment that does not generally require the skills of a qualified provider are considered not medically necessary. Examples include palliative massages, whirlpools, hot or cold packs, maintenance therapy, or other activities that an individual can self-practice independently or with a caregiver.

A comprehensive evaluation is essential to determine if services are medically necessary. Gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usually completed in a single session. An evaluation is needed before implementing any treatment. Evaluation begins with the administration of appropriate and relevant assessments using standardized assessments and tools.

The evaluation must include:

  • Prior functional level
  • Specific standardized and non-standardized tests, assessments, and tools
  • Objective, measurable, and functional descriptions of an individual’s deficits
  • Plan of care with specific treatment techniques or activities to be used in treatment sessions that should be updated as the individual’s condition changes
  • Frequency and duration of treatment plan
  • Functional, measurable, and time-framed long-term and short-term goals based on appropriate and relevant evaluation data

Treatment Sessions

A session can vary from fifteen minutes to four hours per day; however, treatment sessions lasting more than one hour per day are rare in outpatient settings. Treatment sessions for more than one hour per day may be medically appropriate for inpatient acute settings, day treatment programs, and select outpatient situations, but must be supported in the treatment plan and based on an individual’s condition. A session may include:

  • An evaluation
  • Therapeutic exercise, including neuromuscular reeducation, coordination, and balance
  • Functional training in self-care and home management
  • Functional training in and modification of environments (home, work, school, or community)
  • Manual therapy techniques, including soft tissue mobilization, joint mobilization, and manual lymphatic drainage
  • Reevaluations, if there is a significant change in the individual’s condition.

Over the last six months, we have seen a dramatic increase in the amount of pre- and post-payment audits. A reliable source just told me that one insurance company just hired 19 additional investigators to conduct payment reviews.

Contact Dr. John Pecora Jpecoradc@wbcgp.com for more info on a free 15-minute consultation if you collect more than $100K from any BC/BS plan – that includes Anthem BC/BS, Empire BC/BS and Horizon BC/BS.

For more info check out http://www.targetcoding.com/seminars.php


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