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Health Net to delay modifier 25 and emergency services policy changes until July 1



May 04, 2018
Area(s) of Interest: Emergency Services Hospitals and Health Facilities Payor Issues and Reimbursement Practice Management 

Health Net has advised the California Medical Association (CMA) that it will delay implementation of its recently announced modifier 25 and emergency services payment policies for its Medicare and Medi-Cal lines of business until July 1, 2018, to allow time to review provider concerns over the new policies.  


Health Net first notified physicians in March of the new payment policies set to go into effect on May 16, 2018. CMA, along with several specialty societies, raised significant concerns with Health Net about the proposed changes and urged that the policies be rescinded. 


CMA, along with the California Podiatric Medical Association, met with Health Net representatives to request that the policies be rescinded. Following this discussion, Health Net verbally agreed to delay implementation so it can further review the policies and continue the dialogue with providers about their concerns. Health Net will be sending out an official notice to physicians about the implementation delay. 


The policies delayed until July 1 would: 



  • Reduce reimbursement of evaluation and management (E/M) services when billed with modifier 25 under the following circumstances:

    • When a minor surgical procedure code is reported on the same day as an E/M code by the same physician, payment for the E/M code will be reduced by 50 percent.

    • When a preventative/wellness exam and a problem-oriented E/M are billed during the same encounter, payment for the problem-oriented E/M code will be reduced by 50 percent.



  • Reduce reimbursement for level 4 (CPT 99284) and level 5 (CPT 99285) emergency room services that are billed with what Health Net deems a non-emergent diagnosis to a level 3 (CPT 99283) contracted rate. 


Health Net has advised that it will, however, proceed with the May 16 implementation of the policy to no longer recognize or reimburse for consultation codes (99241-99255). However, consultation codes billed will be crosswalked to the appropriate E/M level code for reimbursement. 


CMA appreciates Health Net’s willingness to delay the implementation to allow more time to review the policy changes and further dialogue with CMA and others. 


For more information about the proposed payment policies and CMA’s concerns, click here.

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