Health Net to rescind modifier 25 and emergency services payment policies

June 19, 2018
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

In March, Health Net notified physicians 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) was opposed to these policies and has been working in coordination with many national and state specialty organizations to push back on the proposed changes. 

Health Net has announced to CMA that it will not proceed with implementation of its modifier -25 and emergency services payment policies in California.  Health Net will be sending out an official notice to physicians about the change. Additionally, Health Net has expressed a commitment to work with CMA and others to implement an educational program focused on providing data and feedback to physicians, as well as information on proper coding practices for emergency department services. 

The policies at issue would have 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, Health Net planned to implement a Non-Emergent Emergency Room policy (CC.PP.053), which would have reduced reimbursement for Level 4 (99284) and Level 5 (99285) emergency services to a Level 3 (99283) reimbursement rate if Health Net deemed the diagnosis was non-emergent.

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 appreciates the collaborative dialogue with Health Net and its willingness to work with CMA and physicians to identify alternative strategies to address proper coding and cost concerns. We believe that Health Net’s decision reflects a growing recognition of the need for a different type of engagement between health plans and the physician community to improve health care quality, access and affordability. 


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