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Practicing Medicine Business of Medicine Private Payer Advocacy and News

Private Payer Advocacy and News

Advocacy in action

AOA works to reduce administrative burden and protect patient care

The AOA advocates with private payers to decrease administrative burden for physicians, streamline payment of claims and improve outcomes for patients. Working on behalf of the nation’s 168,701 DOs and medical students, the AOA physician services team engages with health care payers when policies delay or deny patient care, create added administrative work or otherwise hinder efficient health care delivery.

If you have questions or need assistance, please contact Physician Services or call (312) 202-8194.  If your AOA membership is not current and you wish to take advantage of this and all other AOA member benefits, you may join or renew your membership online.


Insurer Policies that may impact DOs

Insurers continue to target claims involving modifier 25 with policies that trigger automatic audits, some may be based on the diagnosis and time between claims, others are based strictly on the use of the modifier. Other denials may be for prepayment clinical validation for a range of modifiers. AOA works closely with members experiencing increased denials or payment delays.


Modifier 25

Insurers are targeting claims involving modifier 25 with policies that trigger automatic audits, based on the diagnosis and time between claims, as well as prepayment clinical validation for a range of modifiers.  AOA works closely with members experiencing increased denials or payment delays.

Aetna

The Physician Services Team meets with Aetna annually to learn about new policies, or as warranted to express concerns from members.

March 2022 E/M Levels 4 or 5 Coding Edits

September 2020  New York New Claim Edits Billing with Modifier -25

September 2020 New Jersey Re-activated Code Edits Modifier -25

Aetna Provider Newsletters

Anthem

The Physician Services Team meets with Anthem monthly to learn about new policies and to express concerns from members.

March 2020 Modifier use reminders – Reimbursement Policies updates

October 2019 The DO Anthem proceeds with Modifier 25 audits, prepayment clinical validation policy

February 2019 Update regarding E/M with modifier 25

Register for Provider News



Cigna

The Physician Services Team meets with Cigna annually to learn about new policies or sooner if warranted to express concerns from members.

Following advocacy efforts by the AOA/AOIA Physician Services Team, the AMA and impacted specialties, Cigna announced that it plans to delay the implementation of their reimbursement policy requiring the submission of office notes with claims submitted with E/M codes 99212, 99213, 99214, or 99215 and modifier 25 when a minor procedure is billed. The policy was scheduled to take effect on August 13. While Cigna remains committed to ensuring appropriate usage and reporting of modifier 25, they have acknowledged that the policy does not comply with clean claims laws in 24 states. Cigna has not provided a new potential implementation date for the policy.

If you received a notice regarding the above mentioned policy you should be receiving this letter explaining the delay.

Official Cigna Notification: The Modifier 25 reimbursement policy update for denial of evaluation and management service codes 99212 – 99215 when performed with a minor procedure without the submission of office notes has been delayed. The policy is under additional review and Cigna will provide follow-up communication and new implementation information when available.

Existing Modifier 25 Policy relating to Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.

Cigna Evaluation & Management Coding Program

Cigna Information to Establish Medical Necessity

Cigna Provider Newsletters

Humana

The Physician Services Team meets with Humana annually to learn about new policies or sooner if warranted to express concerns from members.

October 2019 Humana E/M billed with Modifier 25

Registration Humana Newsletter

UnitedHealthcare

The Physician Services Team meets with UHC monthly to learn about new policies and to express concerns from members.

March 2022 UHC Electronic Payment Requirements

2022 Smart Edits FAQ

2022 UnitedHealthcare Smart Edits

2022 UHC Significant, Separately Identifiable Evaluation and Management Service

August 2021 UHC MA Osteopathic Manipulations Policy Guidelines

July 2021 UHC Commercial Manipulative Therapy Medical Policy

Registration UHC Email Briefs

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