Anthem Abandons Reduction for ‘Modifier 25’ Codes; Opens Door to New Dialogue With Physicians

Anthem notified organized medicine on Feb. 23 that, after several meetings and discussions with state medical societies like the North Carolina Medical Society (NCMS), specialty societies and the AMA, it would not proceed with its reduction in payments for evaluation and management (E&M) codes. The new policy was slated to take effect March 1, but instead Anthem is notifying its contracted practices that the change will not be implemented.

Significantly, the Executive Vice President and Chief Clinical Officer at Anthem, Craig E. Samitt, MD, MBA, acknowledged in his letter to the AMA that “the company believes making a meaningful impact on rising health care costs requires a different dialogue and engagement between payers and providers. As such, Anthem looks forward to pursuing an effective collaboration with the AMA to truly transform health care in our country to make it simpler, higher‐quality, affordable and accessible.” Read the letter.

The NCMS along with other state and specialty societies and the AMA had strenuously voiced objections to this policy, which originally would have reduced payments for E&M codes by 50 percent. While this is a promising shift, organized medicine at both the state and national levels continues to advocate on behalf of our members on other Anthem policies such as 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.

The AMA and Anthem also jointly released a statement saying they will pursue opportunities for collaboration in the following areas:

  • Enhance consumer and patient health care literacy;
  • Develop/enhance and implement value-based payment models for primary and specialty care physicians;
  • Improve access to timely, actionable data to enhance patient care;
  • Streamline and/or eliminate low-value prior authorization requirements.

Watch your NCMS Bulletin for updates on these discussions and other issues affecting your practice.


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