September 12, 2019
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
Anthem Blue Cross recently issued a notice to physicians with an amendment to its Prudent Buyer Plan Participating Physician Agreement that automatically opts physicians into its Medicare Advantage network effective October 31, 2019. The amendment also makes changes to the reimbursement rate for the Anthem Medicare Advantage PPO plan.
The changes are reflected in updated Exhibits B and F.
- Exhibit B reflects a new Medicare Advantage PPO Fee Schedule. Effective October 31, reimbursement will be at the lesser of billed charges or a percentage of the CMS fee schedule by locality. Exhibit B also includes specific references to reimbursement rates for diagnostic imaging services and drugs, including injectables, immunizations and infused medications. According to the notice, provisions related to commercial PPO business contained in existing Exhibit B attachments will remain unchanged and in full effect.
- Exhibit F outlines updated terms specific to Anthem’s Medicare Advantage Participation product. While the notice states the changes apply to the Anthem Medicare Advantage PPO plan and “Medicare Advantage PPO” is referenced in both Exhibit B and Exhibit F, Section 5.8 of Exhibit F includes a reference to the plan’s HMO Medicare Advantage product. CMA asked Anthem for clarification on which Medicare Advantage products were included in the amendment, but Anthem declined to respond. Practices are encouraged to seek clarification from Anthem prior to the effective date to ensure they are clear on the terms and can comply.
Section 5.8 also requires physicians to advise Medicare Advantage patients if they are referring them out-of-network and ensure the patient understands they are responsible for the additional costs. However, it’s unclear whether Anthem requires an out-of-network referral form to be completed and signed by the patient.
Physicians who received the amendment have two options. Physicians who agree with the changes do not need to take any action. The changes will become effective on October 31, 2019. Physicians who do not agree with the proposed changes can opt out of the changes by sending written notification to Anthem at CAcontractSupport@anthem.com. Anthem has advised CMA that the decision to opt out of participation in the Medicare Advantage PPO product will not affect the practice’s underlying Anthem Blue Cross Prudent Buyer contract.
CMA has also learned that some providers received amendments with an incorrect timely filing limit for claims submission. The amendment indicated the timely filing limit is 365 days instead of the recently announced change to 90 days. Anthem is working to identify providers that received the incorrect amendment and will issue a new letter and corrected amendment delaying the effective date of the amendment.
As always, physicians are encouraged to carefully review all proposed amendments to payor contracts to fully understand how the changes will affect their practice.
Physicians who are unsure whether or not they are affected by this change, or those who have general questions about the amendment, can contact Anthem Blue Cross Contract Support at CAContractSupport@anthem.com.