Concerns Over Anthem Blue Cross E/M Claim Policy Changes
The California Medical Association (CMA) is voicing significant concerns over Anthem Blue Cross's impending policy changes affecting evaluation and management (E/M) claims starting February 15, 2026. These changes introduce AI-driven prior authorization delays and could lead to claim downcoding or payment holdups, impacting compliance with regulatory standards.
Payer Scrutiny and Regulatory Compliance
In a recent letter to Anthem's Vice President of Healthcare Networks, CMA highlighted the potential lack of transparency and adherence to industry-standard coding guidelines. The association fears these changes may conflict with California's regulatory compliance requirements, specifically laws regarding prompt payment and disclosure.
Review Process and Ambiguity
According to Anthem's November 13 notification, physicians whose E/M coding levels exceed their peers, as determined by risk-adjusted data, will face additional scrutiny. This review process, based solely on claim data, offers no clear criteria for selecting claims or determining appropriate service levels. Such ambiguity can increase uncertainty for providers and billing teams, complicating both claims processing and reimbursement efforts.
Alignment with National Standards
The new policy may contradict guidelines from authoritative bodies such as the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS). Expanded in 2021, these guidelines recommend calculating E/M levels using time or medical decision-making, involving medical record consideration rather than dependent solely on claim-level data.
Impact on Timely Claims Processing
California law requires timely payment for complete claims with adequate information to establish payer liability. Anthem’s approach might provoke payment delays by demanding unnecessary additional medical records beyond the scope necessary for claim assessment, increasing the administrative workload.
Financial Implications and Provider Recommendations
The cost of appealing these claims is significant, with industry estimates ranging from $40–$75 for practices and $50–$150 for payers. This underscores the substantial underwriting burden placed on providers under this policy. CMA urges Anthem to innovate collaborative approaches such as targeted education or working directly with providers who deviate from the norm, rather than imposing broad penalties.
As the insurance industry faces challenges from physician burnout, staffing shortages, and rising operational costs, CMA advocates for clearer guidelines, alignment with national standards, and collaborative strategies that emphasize quality patient care and streamlined risk management processes.