Anthem agrees to fully rescind modifier 25 cuts

Wednesday, February 28, 2018 10:40 AM

The Colorado Medical Society, American Medical Association, and other specialty and state medical societies successfully advocated against a plan by Anthem Blue Cross Blue Shield to reduce payment for significant, separately identifiable evaluation and management (E/M) services that are provided on the same day a procedure is performed or a wellness exam is conducted.

Craig E. Samitt, MD, MBA, executive vice president and chief clinical officer of Anthem, Inc., notified Jack Resneck Jr., MD, chair-elect of the AMA Board of Trustees, of the reversal in a Feb. 23 letter and said the company plans to formally notify its contracted providers "within the next few days."
 
Anthem originally announced in December that it would implement a pay cut of 50 percent for E/M services provided on the same day by the same provider, effective Jan. 1, 2018. Later in December, following pressure from organized medicine, the company announced that it would reduce the size of its planned pay cut from 50 percent to 25 percent and push back the implementation date to March 1, 2018.

On the state level, CMS President M. Robert Yakely, MD, and Elizabeth Kraft, MD, medical director of Anthem BCBS in Colorado, exchanged several letters about the issue while the AMA and other states waged similar campaigns. Our organizations continually expressed that the rationale for the pay cut cited by Anthem was incorrect and the reduction was inappropriate.

In the Feb. 23 letter, Samitt expressed Anthem's commitment to continuing to work with the AMA, state medical associations, and national medical specialty societies to address physician concerns with other policies and guidelines. The AMA has already raised concerns 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.

In a Feb. 23 email from Resneck to state society executives, he expressed the AMA's gratitude for the strong advocacy efforts carried out on the state level over the past few months. He said, "We believe that Anthem's decision reflects the 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."