OSMA Facilitates Discussions with Anthem

Update on Proposed Reimbursement Policy Changes

At the end of the year, the OSMA brought together specialty societies and Anthem to discuss three of its proposed reimbursement policy changes.
For the past several months, the OSMA, AMA and other statewide medical associations have voiced opposition to several new Anthem policies slated to go into effect in 2018. One of the most concerning was payment reductions for evaluation and management (E&M) codes appropriately reported with a Current Procedural Terminology (CPT) modifier 25. Considerable concerns regarding this issue have been raised by many state medical associations and national medical specialty societies, most recently regarding Anthem’s new policy to reduce payments by 50% for E&M services billed with CPT modifier 25 when reported with a minor surgical procedure code or a preventive/wellness exam. Anthem had announced that it would be implementing this policy in many states, including Ohio, in January 2018.
Through organized efforts of the AMA and the OSMA, Anthem responded to these concerns. On December 22, Anthem informed the AMA that it still plans to reduce payments for E&M services billed with CPT modifier 25, but that payments will be reduced by 25% instead of 50%, as originally planned. Additionally, the policy will be effective March 1, 2018, in all states where physicians have been notified of the policy change (California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin), which represents an implementation delay for some states. Anthem will be issuing formal guidance to network physicians communicating these changes within the coming weeks.
While this adjustment is an improvement on Anthem’s original planned policy, the OSMA still strongly opposes this unjustified reduction of physician payment and further analysis will continue. There are several other policies that are of concern to patient care, including those related to hospital outpatient imaging and retrospective review of payment for emergency services. The session in late December was the first step in working through alternatives to the original policies. The OSMA will continue to work with the appropriate specialty societies to ensure that we advocate directly with Anthem and regulators on behalf of the impacted physicians and patients.
Questions about these proposed changes and our efforts can be directed to info@osma.org.