Anthem Blue Cross announces plans to significantly cut reimbursement on E/M services with modifier 25

calaaem.news.service1 at gmail.com calaaem.news.service1 at gmail.com
Sun Nov 19 18:46:36 PST 2017


       

 

November 13, 2017

 

Anthem Blue Cross announces plans to significantly cut reimbursement on E/M
services with modifier 25

 

 

 <http://www.cmanet.org/cma-alert/archives/2017/november-13-2017/#3>
California Medical Association

 

 

Anthem Blue Cross recently notified physicians in several states of upcoming
changes to the payor’s reimbursement policies and claims editing software,
called ClaimsXten. As part of the policy changes, scheduled to become
effective on January 1, 2018, Anthem will begin reducing reimbursement of
evaluation and management (E/M) services billed with modifier 25 under the
following circumstances:

 

*	When a minor surgical procedure code (0 or 10-day global period) is
reported on the same day as an E/M code by the same physician, payment for
the E/M code will be reduced by 50 percent.

 

*	When a preventative/wellness exam and a problem-oriented E/M are
billed during the same encounter, payment for the problem-oriented E/M code
will be reduced by 50 percent.

 

The California Medical Association (CMA) is very concerned with the adverse
impacts of this new policy upon our physician members and is coordinating
with the American Medical Association and the American Association of
Dermatologists, along with many other state and specialty organizations, to
push back on the change.

 

These changes come in the wake of several controversial initiatives by
Anthem, including the termination of physicians for out-of-network
ambulatory surgical center referrals and its new outpatient advanced
radiologic imaging policy, delayed until at least December 1, 2017, which is
designed to restrict radiologic imaging procedures such as MRI, CT and PET
scan in the hospital outpatient department setting.

 

In August 2017, Anthem also announced it was exiting California’s health
benefit exchange, Covered California, except in three regions of Northern
California, thereby requiring over 150,000 enrollees to look for new
coverage.

 

Physicians are urged to thoroughly review and assess the impact any proposed
modifications to their contract would have on their individual practices. To
assist physicians in analyzing the change, CMA has developed a simple
worksheet that will help calculate the net financial impact to their
practice resulting from this change. The Modifier -25 financial impact
worksheet is available free to CMA members at www.cmanet.org/ces.

 

Physicians should be aware that California law requires health plans and
their contracting medical groups/IPAs to provide 45 business days’ advance
notice of a material change to a contract, manual, policy or procedure (28
C.C.R. §1300.71(m)). A change is considered “material” if “a reasonable
person would attach importance [to it] in determining the action to be taken
upon the provision.”

 

Physicians have the right to terminate the agreement prior to the
implementation of the change if the physician does not agree to the proposed
change (Health & Safety Code §1375.7; Insurance Code §10133.65). For more
information on physicians’ rights and options when a health plan makes a
material change to a contract, manual, policy or procedure, see CMA’s
resource titled, “Contract Amendments: An Action Guide for Physicians.”

 

 

 

Jeff Wells
Deputy Editor, CAL/AAEM News Service

 

Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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