Payor Issues

Today’s physicians must navigate the complex and ever-changing health care environment while balancing the needs of their patients against the requirements of the marketplace. In recent years, physicians have reportedly found it more difficult to understand, adapt and address the multitude of changes and requirements being placed upon them.

The California Medical Association (CMA) is proud to advocate on issues that directly affect physician practices, including reimbursement, regulatory burdens, payor practices and other key issues. Explore the below resources and latest news, organized by payor.


Anthem Blue Cross

Modifier 25 Payment Policy: This past fall 2017, 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. UPDATE: Due to the overwhelming opposition from organized medicine, Anthem announced it would not proceed with its Modifier 25 policy.

Anthem Blue Cross Prudent Buyer Contract: Anthem Blue Cross recently announced changes to its Prudent Buyer Participating Physician Agreement and fee schedule effective July 1, 2019.

Blue Shield

Health Net

Medicare/Medi-Cal Payment Policy Implementation: Health Net has announced modifier 25 and emergency services payment policies for its Medicare and Medi-Cal lines of business will go into effect on July 1, 2018 - a delay from their original date to allow time for review of provider concerns and continue discussions with CMA and other stakeholders.


Medicare Beneficiary Identification: The Centers for Medicare and Medicaid Services (CMS) will remove social security numbers from all Medicare cards by April 2019 and replace them with a new Medicare Beneficiary Identification (MBI) number for all Medicare transactions, as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MARCA). 


Medi-Cal Reimbursement, ACA Primary Rate Increase and the California Health Care, Research and Prevention tobacco Tax Act of 2016 (Proposition 56): Currently, over 14.3 million (on in three) Californians are covered by Medi-Cal, including over 50 percent of the state's children. CMA's ongoing advocacy with the Department of Health Care Services (DHCS) will continue to ensure increased funding for all Medi-Cal providers.


UnitedHealthcare payment of consultation services: UnitedHealthcare (UHC) has announced that it will no longer reimburse consultation services for commercial product lines.


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