BCBS IL Audit Resulting in More Denials

Late last year, BCBS IL quietly released a notice that they planned on implementing a code-auditing “enhance- ment” relating to modifier use. The results of their change are beginning to show up via more denials on 2018 charges.

The audits are mainly targeting modifier 25 and 59, but we have noticed issues the XS and XU as well. As a result, BCBS is denying more visits when billed with minor procedures, as well as bundling some secondary procedures they previously paid without issue.

Our initial attempts at appealing these denials per historical and Medicare guidelines have been rejected. In speaking with BCBS representatives, we have been informed that they will only consider appeals on these items when submitted with supporting medical records.

As a result, you may notice more record requests on your missing information lists. For such requests, please for- ward the corresponding records as soon as possible to aid our appeals. As always, please make sure your records include a substantial description of every billed service, as well as the medical necessity for any DME, therapy,

tests, or procedures.