Sharing Insights on Medical Claims Accuracy

BCBST Staff |

The Tennessee employers and families who count on us for health coverage are facing an affordability crisis, and we’re working hard to deliver fair, practical solutions. One key effort is making sure that payments for high-complexity claims are accurate based on the documentation submitted. And we’ve been sharing information on this work since last Spring. Most recently, we discussed claims accuracy in a guest column for the Tennessean.

One of our clinical leaders, Dr. J.B. Sobel spoke to the House Insurance Committee at the Tennessee General Assembly on Tuesday, Feb. 3, about these efforts. Dr. Sobel presented and answered questions about:

  • How providers are using AI-enabled software tools for claims submissions
  • How we are evaluating high-complexity evaluation and management (E&M) claims
  • Real-world examples where the data shows billing for diagnoses without supporting treatments

In his remarks, Dr. Sobel made it clear we don’t consider these discrepancies to be fraudulent and that we don’t believe providers are intentionally miscoding claims. He recognized the values of these software tools for improving efficiency but shared how they may be inaccurately raising the complexity level of some claims.

From April 15 – Dec. 31, 2025:

  • We adjusted only 1% of total BlueCross claims
  • We identified 14% of providers with outlier patterns for E&M claims
  • We adjusted 7% of E&M claims

It’s important to note that any adjustments are made following review by a clinician. We do not use AI to deny or adjust claims.

Why claims accuracy matters to Tennesseans

Dr. Sobel also shared that many of our employer group customers are “self-funded,” meaning they pay for the claims directly while hiring us to manage their plan. That’s important because it means the dollars we save through claims audits go directly back to these employers, or to members who are paying for services on a high-deductible plan.

We saw claims costs rise 25% over a five-year period, so every dollar we can save for our members counts.

As a taxpaying, not-for-profit health plan, we’re here to offer affordable access to quality care for the people we serve. We also believe it’s our responsibility to communicate openly about our work, including how we use the premium dollars we collect. 

In 2024, 90 cents from every premium dollar went to pay for our members’ care. Less than 1 cent went to our reserves, which are there to protect the stability Tennesseans count on. 

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