CMA urges Health Net to rescind recently announced payment policies

CAL/AAEM News Service at
Thu Jun 14 10:10:03 PDT 2018


June 14, 2018

CMA urges Health Net to rescind recently announced payment policies:
Modifier 25 reimbursement cut and Non-Emergent Emergency Room policy




Since Health Net first notified physicians in March of planned changes to
its modifier 25 and emergency services payment policies for Medicare and
Medi-Cal lines of business, the California Medical Association (CMA) has
been working to educate the payor about physician concerns with the new

Last month, at CMA's urging, Health Net agreed to delay implementation of
the new policies until July 1, 2018, to allow time to review provider
concerns with the new policies and to continue discussions with CMA and
other stakeholders.

CMA recently wrote to Health Net reiterating concerns raised during previous
meetings and again urged the payor to rescind the payment policies. CMA
expressed a willingness to work collaboratively with Health Net to identify
alternative strategies to address proper coding and cost concerns that will
not negatively impact patient care and practice viability.

"We believe a more collaborative approach to identify alternative
methodologies for cost containment, including provider education on proper
coding practices that do not bluntly penalize all physicians, will be more
effective and less costly long term," said Jodi Black, vice president of
CMA's Center for Economic Services in a letter to Health Net. "With the
shift to value-based care, this is a time where plans and physicians should
be identifying ways to work together."

With the July 1 effective date quickly approaching, Health Net has not yet
provided a final outcome on the policy and has said that it is still
internally reviewing the issue. CMA is closely following this issue and will
provide an update when available.

The policies at issue apply to Health Net's Medicare and Medi-Cal lines of
business and propose to cut reimbursement of an evaluation and management
service with modifier 25 by 50 percent when billed with a minor surgical
procedure or a preventive visit (CC.PP.052 and CC.PP.057). Additionally, CMA
is concerned with the planned implementation of the Non-Emergent Emergency
Room policy (CC.PP.053), which proposes to reduce reimbursement for Level 4
(99284) and Level 5 (99285) emergency services to a Level 3 (99283)
reimbursement rate if Health Net deems the diagnosis was non-emergent.

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 modifier 25 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.



Jeff Wells
Deputy Editor, CAL/AAEM News Service


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

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