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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 186,000+ 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.

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.

April 2023 Reimbursement policy update: Documentation and Reporting Guidelines for E&M Services-Professional

February 2023 Documentation and Reporting Guidelines for Evaluation and Management Services – Professional policy C-09007

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

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The Blue Plans

Florida Blue

January 2022 Evaluation and Management for Office or Other Outpatient Services

September 2021 Submitting Claims with Multiple Diagnosis

HCSC

(Includes Blue Cross Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas)

January 2022 BCBSIL Commercial Claims Editing Coming April 2022

BCBSTX General Reimbursement Information

June 2018 BCBSTX Modifier 25 and 59 FAQs

April 2018 BCBSTX Claim Filing Tips

Oct 2017 BCBSTX Blue Review code-auditing software implementation

Horizon Blue

May 2022 Claim Reimbursement Update: E&M with Modifier 25

November 2021 Horizon E/M with OMT

April 2022 Revised Claim Editing Rules

August 2022 Reimbursement Update: E/M -25

Regence

AOA Physician Services sent numerous letters, including certified letters, emails and calls to multiple Regence and Cambia (Regence parent company) leadership and staff regarding customer service issues and various reimbursement policies, especially related to denials for E&M with OMT services. Regence’s lack of customer service and failure to communicate with the AOA is a very concerning issue. The AOA will continue to aggressively pursue Regence action. It may be helpful if you are having issues with Regence to no avail, to reach out to your state legislators for assistance in seeking Regence response.

November 2022 Chiropractic & Osteopathic Treatments Policy 138

September 2022 Bundling Edits Policy 105

July 2022 Modifier 25; Significant, Separately Identifiable Service

Register for Provider News- The Bulletin & The Connection

Reimbursement Policy Feedback Form

Regence medical policy comments from physicians and other health care professionals

Premera

May 2023 manipulation services: In the osteopathic manipulative treatment section, added that an assessment is considered part of the manipulation procedure code. Also added reference to the CMS National Physician Fee Schedule stating that the OMT codes are classified as minor procedures.

Osteopathic Manipulations:

  • We limit osteopathic manipulative therapy to one manipulation code, per provider, per patient, per day.
  • A new patient Evaluation and Management (E&M) code will be reimbursed consistent with the new/established patient guidelines.  All E&M services billed on the same day as an osteopathic manipulation will be reimbursed when billed consistent with Modifier 25 payment policy if the E&M service represents a service above and beyond the usual preservice/post service work associated with the osteopathic service. Documentation must support the use of Modifier 25.

January 2023 E&M Visit: Added third paragraph to indicate that the appending of Modifier 25 is not a guarantee of payment. Added the last paragraph in the policy to indicate appending Modifier 25 to the E&M must be documented in the notes as a separate and distinct E&M service.

March 2022 Modifier 25 Policy Updates: Added clarification on the correct use of Modifier 25 on evaluation and management (E&M) services indicating that appending Modifier 25 does not result in automatic reimbursement unless supported by the documentation in the member’s medical record as a separately identifiable service.

Register for Premera Newsletter


Cigna

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 99212-99215 and Modifier 25 when a minor procedure is billed. The policy was scheduled to take effect on Aug. 13, 2022, and again on May 25, 2023. 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.

Official Cigna Notification Banner: Cigna will delay the implementation to require the submission of documentation to support the use of Modifier 25 when billed with E/M CPT® codes 99212 – 99215 and a minor procedure. Cigna will continue to review for future implementation.

Modifier 25 Reimbursement Policy: Modifier 25 – Significant, Separately Identifiable 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.

The AOA has joined the multi-organizational sign-on letter (172 national and state medical specialty societies, patient organizations, foundations, physician groups, hospitals and industry) to UHC asking them not to implement the United Healthcare’s (UHC) gastrointestinal (GI) endoscopy prior authorization program.

June 2023 Prior authorization for gastroenterology endoscopy services

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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