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Through the use of advanced analytics and data mining, concerning trends have been identified over the past year related to testing and vaccinations for COVID-19 and telehealth visits.
Additionally, Blue Cross continues to receive many complaints from members regarding inappropriate billing and unnecessary care.
Blue Cross will audit these trends and complaints to ensure appropriate application of our member’s benefits for medically necessary services. Patient interviews may be conducted as well to verify services rendered.
Refunds will be requested for any inappropriately billed services.
All evaluation and management services must be medically necessary and include all elements documented in the medical record to support the code submitted for payment. Patient interviews may be conducted as well to verify services rendered.
Some of the inappropriate billing schemes identified include:
- Insisting a patient have an office visit when they only requested a COVID-19 test.
- Performing additional testing with every COVID-19 test, such as flu test, respiratory panels, and/or genetic tests with no clear medical necessity documented. Common cold symptoms are not an automatic indication for additional testing.
- Billing for an office visit when a patient had a vaccine in a drive-through setting.
- Billing for a telemedicine visit when calling the patient to give COVID-19 test results.
- Billing for an office visit when the patient was only seen to receive a COVID-19 vaccine.