Anthem Fully Rescinds Modifier 25 Cuts

Physician practices and hospitals participating with Anthem Blue Cross Blue Shield (BCBS) will NO longer see any payment reduction on E/M services they bill with modifier 25 attached, a top Anthem official confirms in a letter to the AMA. The insurer had been set to implement a 25% payment reduction to all E/M services with modifier 25 beginning March 1, though that amount was already scaled back from the original 50% reduction when Anthem announced the policy.

Anthem is the latest BCBS payer to adopt the modifier 25 reduction, but based on numerous meetings with provider groups, it first agreed to change the reduction from 50% to 25% and delay the implementation date from Jan. 1 to March 1. This latest move is based on further discussions with stakeholders and the AMA appears to have had a major influence. "Following several meetings and discussions with you, the AMA and other medical and medical specialty societies in recent months regarding the modifier 25 policy, Anthem has decided to not proceed with the policy," writes Craig Sammit, MD, executive vice president and chief clinical officer at Anthem.

Dr. Sammit stressed that Anthem still sees modifier 25 use as a source of overpayments, but has decided to find a different way to mitigate the effects of rising costs. "While Anthem is confident that duplication of payment for fixed/indirect practice expenses exists when physicians bill an E/M service appended with modifier 25 along with a minor surgical procedure (0 or 10 day global) performed on the same day, the company believes making a meaningful impact on rising health care costs requires a different dialogue and engagement between payers and providers," he writes.

While the modifier 25 policy is now rescinded, formal notifications from Anthem to all of its contracted providers will be coming in the following days, Dr. Sammit writes. The policy would have affected providers in 12 Anthem states: California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin.

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