Anthem halts controversial modifier 25 reimbursement policy — 4 insights

Written by Angie Stewart | March 02, 2018 | Print  |

Anthem Blue Cross Blue Shield won't proceed with a policy that would have slashed reimbursement rates for evaluation and management services billed with modifier 25 by 50 percent. Here are four insights.

1. The policy would have reduced payments for evaluation and management services provided the same day as a procedure or wellness exam from 50 percent to 25 percent. Anthem planned to implement the policy beginning March 1 to eliminate duplicate payments thought to be occurring.

2. Anthem's Executive Vice President and Chief Clinical Officer Craig Samitt, MD, announced the policy reversal Feb. 23 in a letter to the American Medical Association.

3. "While Anthem is confident that duplication of payment for fixed/indirect practice expenses exists when physicians bill an E/M service appended with modifier 25 along with a minor surgical procedure (0 or 10 day global) performed on the same day, the company believes making a meaningful impact on rising health care costs requires a different dialogue and engagement between payers and providers," Dr. Samitt stated in the letter.

4. Anthem's decision came after a coordinated effort by several organizations, including the California Medical Association, AMA and American Association of Dermatologists, to maintain the non-reduced rate.

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