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Anthem agrees to fully rescind modifier 25 policy



February 23, 2018
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement 

This past fall, Anthem Blue Cross notified physicians in several states that effective January 1, 2018, it would reduce reimbursement of evaluation and management (E&M) services billed with modifier 25 by 50 percent. The California Medical Association (CMA) quickly jumped into action and coordinated with the American Medical Association (AMA) and the American Association of Dermatologists (AAD), along with many other state and specialty organizations, to push back on the proposed change.


In response to the Anthem policy announcement, CMA successfully introduced a resolution to the AMA House of Delegates, asking AMA to “aggressively and immediately advocate through any legal means possible, including direct payer negotiations, regulations, legislation, or litigation, to ensure when an evaluation and management (E&M) code is appropriately reported with a modifier 25, that both the procedure and E&M codes are paid at the non-reduced, allowable payment rate.” The adopted policy paved the way for increased pressure on Anthem to halt implementation of its policy.


Due to the overwhelming opposition from organized medicine, Anthem recently announced it will not proceed with its policy to reduce payments for E&M services reported with modifier 25. Anthem plans to formally notify its contracted providers within the next few days of this decision.


Additionally, Anthem expressed a commitment to working with CMA, AMA and others in organized medicine to address physician concerns with other policies and guidelines. There have been a number of serious concerns raised recently regarding 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.


We are hopeful that Anthem’s decision reflects a growing recognition of the need for a different type of dialogue and engagement between health plans and the physician community to improve health care quality, access and affordability.

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