In this article, Frier Levitt partner Guillermo Beades examines Horizon Blue Cross Blue Shield of New Jersey’s expanded Outlier Program for high-level E/M coding and its impact on New Jersey pediatric practices. As Horizon increasingly relies on automated claim-editing logic, practices may see E/M services downcoded and reimbursements reduced, often without advance notice or a request for medical records.
Published in the New Jersey Chapter, American Academy of Pediatrics (NJAAP)’s Winter 2025 issue of New Jersey Pediatrics, the article outlines the financial and administrative risks associated with automated audits, explains why pediatric practices are particularly vulnerable, and provides practical guidance on identifying claim adjustments, strengthening documentation, and pushing back against improper downcoding.
The full article appears on page 30 of the newsletter and can be accessed here:
