Facing Provider Resistance Anthem Softens Modifier 25 Policy Facing Provider Resistance Anthem Softens Modifier 25 Policy

Facing provider resistance, Anthem softens modifier 25 policy

By Grant Huang
Director of Content at DoctorsManagement

At least one Blue Cross Blue Shield (BCBS) payer has responded to provider pushback against the modifier 25 payment reduction policy by weakening it. Anthem BCBS has announced that it will change the payment reduction from 50% to 25% for all codes with modifier 25 appended. Anthem will also delay the implementation date of this policy from Jan. 1 to March 1, 2018 in 12 affected states. The change to a 25% reduction affects all Anthem states.

Remember: The modifier 25 policy was first adopted by Independence BCBS in Pennsylvania. It is a payment rule that affects all E/M codes with modifier 25 appended, reducing their reimbursement by 50%. Independence and other BCBS payers had defended the policy by saying it was necessary to rein in overutilization of modifier 25, citing internal data that showed their utilization was higher than national average.

The 12 states benefitting from the implementation delay are California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin. The move by Anthem comes after payer officials met with local medical societies from the affected states. National provider stakeholder groups such as the American Medical Association (AMA) and Medical Group Management Association (MGMA) also came out strongly against the modifier 25 payment reduction policy.

Anthem to allow splitting E/M and procedure

Shortly after Independence BCBS implemented the modifier 25 policy, it released an online FAQ stating that providers are not allowed to circumvent the new rule by performing the E/M on one day and the minor procedure associated with the E/M on another day.

“We do not expect that you will modify your approach to delivering services in a way that will impact patient care or satisfaction,” Independence states in its FAQ. “We will review and audit providers who ask patients to return for second visits.”

Anthem has decided to not to follow Independence on this point, says Danielle Fife, CEO at Advanced ENT and Allergy, a 14-physician practice in Louisville, KY. Fife, who attended a meeting between Anthem officials and provider groups. At that meeting, a top Anthem official stated that the payer will allow practices to bill for an E/M visit and then bill for a related procedure on a separate day.

So far, Anthem is the only BCBS payer that has reversed course, at least partially, on the modifier 25 rule. As this issue of The Business of Medicine goes to press, multiple other payers have implemented the 50% cut to modifier 25 services, including AmeriHealth New Jersey, Regence Blue Shield Idaho, and Tufts Health Plan of Massachusetts.

Author: Grant Huang (ghuang@drsmgmt.com)