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.

Sept. 2023 | Liberalized COVID-19 telemedicine services no longer effective Dec. 1, 2023

March 2022 | E/M Levels 4 or 5 Coding Edits

Sept. 2020 | New York New Claim Edits Billing with Modifier -25

Sept. 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

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

March 2020 Modifier use reminders – Reimbursement Policies updates

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

Feb. 2019 Update regarding E/M with Modifier 25

Register for Provider News


The Blue Plans

Blue Shield of California

June 2024 | Following advocacy efforts by the AOA/AOIA Physician Services Team, the AOA has been informed by Blue Shield of California (BSC) that they have rescinded the recently announced update to their Global Surgical Period Payment Policy. The policy would have reduced their reimbursement by 50% for evaluation and management (E&M) services appended with modifier 25 and billed along with minor procedure codes that have a global period of 0-10 days, like osteopathic manipulative treatment (OMT). This advocacy win is due to joint efforts in the form of a letter sent by the AOA, AOA Physician Services and the Osteopathic Physicians & Surgeons of California (OPSC) on behalf of its physician and student members

May 2024 | Global Surgical Period Policy effective date of service on or after July 14, 2024, when certain office or other outpatient visit E/M procedures (CPT codes: 92002, 92004, 92012, 92014 and 99201-99215) appended with Modifier 25 are billed appropriately during the minor (0- or 10-day) by the  same specialty physician and/or other health care professional performing the 0/10 day global procedure, Blue Shield of California will reimburse the E/M services at 50% of the Blue Shield Provider Allowance.

Register for Provider News

Florida Blue

Jan. 2022 | Evaluation and Management for Office or Other Outpatient Services

Sept. 2021 | Submitting Claims with Multiple Diagnosis

Blue Cross Complete of Michigan

Dec. 2023 | Update on Chiropractic and Osteopathic Manipulation benefits

Register for Provider News

BlueCross BlueShield of North Carolina

June 2024 | Effective June 27, 2024, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has made the decision to rescind the reimbursement policy for evaluation and management (E&M) services with a fifty percent (50%) reduction when performed by the same provider/group practice on the same day as a minor procedure. This decision to rescind is applicable to all lines of business, including Commercial, Host, State Health Plan (SHP), Federal Employee Program (FEP) and Medicare Advantage. The above update is in reference to this previously posted Provider News.

May 2024 | Effective Sept. 1, 2024, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will begin reimbursing evaluation and management services at fifty percent (50%) when performed by the same provider/group practice on the same day as a minor procedure. This policy update applies to Commercial, Host, State Health Plan (SHP), Federal Employee Program (FEP) and Medicare Advantage.

Register for Provider News

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

Jan. 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

Dec. 2022 | E&M Codes Appended with Modifier 25

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

Nov. 2021 | Horizon E/M with OMT

April 2022 | Revised Claim Editing Rules

Aug. 2022 | Reimbursement Update: E/M -25

Regence

June 2024 | Effective Sept. 1, 2024. When Modifier 25 is appropriately appended to an evaluation & management (E&M) service and is submitted on the same date of service as a minor procedure, by the same physician or other qualified health care provider, the E&M service will be reimbursed at 50% of the allowed amount. Regence announced change to their Global Days #101 and Modifier 25 #103 reimbursement policies but has not been updated as of yet.

AOA Physician Services communicated with Regence and Cambia (Regence parent company) leadership regarding customer service issues and various reimbursement policies, especially related to denials for E&M with OMT services. Regence responded that appealed claims have a 3.4% overturn rate and that they have adjusted their claim editing process, beginning in 2022, which demonstrates less overall impact to providers. Regence confirmed that changes were made in their customer service department that hopefully result in better provider experience. The AOA will continue to aggressively pursue Regence action. If you are still having customer service issues with Regence, please let Physician Services know. Studies show that 65% of denied claims annually do not get appealed. We strongly encourage physicians to appeal against all claims.

Nov. 2023 Chiropractic and Osteopathic Treatments Policy No. 138 | Effective March 1, 2024

Nov. 2022 Chiropractic & Osteopathic Treatments Policy 138

Sept. 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.

Jan. 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

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

Oct. 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

Aug. 2021 | UHC MA Osteopathic Manipulations Policy Guidelines

July 2021 | UHC Commercial Manipulative Therapy Medical Policy

Registration UHC Email Briefs

Back To Top