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Anthem rescinds evaluation and management reimbursement policy to cut payments

The company had planned to reduce by 25 percent payments for evaluation and management services reported with modifier.

Susan Morse, Senior Editor

Anthem has dropped its plan to reduce by 25 percent payments for certain evaluation and management codes.

The policy was to have gone into effect on March 1 across the company's commercial health insurance businesses.

The insurer made the policy change in response to strong opposition from the American Medical Association and other physician groups, the AMA said on Friday, the same day it heard from Anthem.

Anthem Executive Vice President and Chief Clinical Officer Craig Samitt told AMA Board Chair Jack Resneck, Jr., MD, that Anthem is rescinding plans to implement the policy to reduce payments by 25 percent for evaluation and management codes reported with a current procedural terminology modifier 25. 

Anthem had made the move to avoid duplicate payment for fixed or indirect practice expenses when physicians bill an evaluation and management service appended with modifier 25 along with a minor surgical procedure performed on the same day.

However, Anthem said it believed that making a meaningful impact on rising healthcare costs required a different dialogue and engagement between payers and providers. 

Anthem plans to formally notify its contracted providers within the next few days of its decision. 

"Anthem's decision to drop its planned modifier 25 policy is a positive step forward, demonstrating again that when doctors and health plans work together, the best outcome for patients can be achieved," Resneck said. "This policy is one of a number of issues that the physician community has been working on with Anthem, and the AMA looks forward to continuing these efforts to find ways to collaborate on strategies to deliver affordable, high-quality, patient-centered care."

The other issues include Anthem's policies on the retrospective denial of payment for emergency room visits, restrictions on advanced imaging in hospital outpatient facilities, and the denial of payment for monitored anesthesia care or general anesthesia for cataract surgery.

"Anthem remains committed to continuing to work with the AMA, state medical associations and national medical specialty societies to address physician concerns with the company's policies and guidelines," Samitt said, adding he looked forward to together tackling rising healthcare costs in a meaningful way.

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