Practicing Medicine Business of Medicine Private Payer Advocacy

Private Payer Advocacy

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 151,000 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.

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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, or by calling (888) 62-MYAOA.

View issue summaries and advocacy timelines detailing AOA efforts to address prior authorization, modifier 25 and prepayment clinical validation policies.


Prior Authorization

On Aug. 1, 2019, AOA advocacy in five states resulted in the reversal of Aetna’s prior authorization requirement for OMT. AOA partnered with its affiliates in New Jersey, New York, Pennsylvania, West Virginia and Delaware to earn the change, which affected more than 23,000 DOs and their patients.


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

In a significant win for DOs and their patients, Aetna has agreed to disable automatic claims denials of E/M services billed on the same day as OMT and appended with modifier 25. The AOA worked closely with our physician liaison at Aetna to implement the change, which allows E/M services billed on the same day as OMT codes 98925-98929 to bypass claims edits that previously triggered the denials. The Maine Osteopathic Association (MOA) also provided important advocacy support.

The change could impact DOs practicing in all 50 states and Washington, DC. “We are thrilled to see Aetna eliminate the automatic denial process that caused significant administrative headaches to so many of our physicians who provide OMT to their patients,” said AOA President Ronald Burns, DO, FACOFP. “This change will allow DOs to spend more time on patient care and less time on paperwork.”

The change is effective for services rendered on or after Jan. 1, 2020. For denials prior to this date, the AOA urges members to exercise the right to appeal unfavorable payer decisions. If Aetna rejects a claim for E/M services billed on the same day as OMT and appended with modifier 25 for services provided on or after Jan. 1, please contact AOA Physician Services for assistance.

Please note that you must follow Aetna’s guidelines for submitting appeals for denied claims. Also, if your documentation does not support the significant, separately identifiable E/M service and medical necessity for services provided, your claim will likely be denied regardless of Aetna’s policy change.

Anthem

On Feb. 2, 2019, Anthem sent a communication to providers titled “Update Regarding Evaluation and Management with Modifier 25 Same Day as Procedure when a Prior E/M for the Same or Similar Service has Occurred.”


HCSC

Health Care Services Corporation (HCSC) implemented  software and system updates to enhance outpatient facility auditing in November 2017.   Clinical claims validations began to flag all claims submitted with modifiers 25 (significant, separately identifiable E/M service) or 59 (distinct procedural service).


Prepayment Clinical Validation

In a July 2019 communication to network physicians, Anthem announced it will update the audit process for claims with modifiers used to bypass claim edits by conducting reviews using a new prepayment clinical validation review process. This new process could affect more than 20,000 DOs practicing in 14 states.

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