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 145,000 DOs and medical students, the AOA physician services team engages with health care payers when polices delay or deny patient care, create added administrative work or otherwise hinder efficient health care delivery.

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.

Issue details

In late 2018, Aetna implemented a prior authorization policy for “Physical Medicine Services” in Delaware, New Jersey, New York, Pennsylvania, and West Virginia. The policy applied to OMT codes 98925 – 98929 and applied to Aetna’s Fully Insured Commercial and Medicare plans.

Notably, Aetna has a separate medical policy recognizing that OMT is not a form of chiropractic care or other treatment because OMT is only performed by a physician with a full and unrestricted license for medicine and surgery.  Aetna contradicted its own policy by treating OMT in the same manner as chiropractic, physical therapy, and occupation therapy services for the purpose of prior authorization.

Read more in The DO: Prior authorization requirement for OMT ends for Aetna patients in five states

Advocacy timeline

May 2019: The AOA expressed its concerns in a letter to Aetna. Several affiliates impacted by the prior authorization policy also sent letters to the payer.

July 2019: AOA physician leadership and staff convened a discussion with Aetna leadership, during which Aetna agreed to remove the OMT codes from its prior authorization policy.

August 2019: Effective August 1, Aetna no longer requires prior authorization for codes 98925 – 98929. View the Aetna notification.


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.

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.”

Issue details

The update, which affected commercial business lines in several states, indicated that Anthem may deny claims for E/M services with Modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.

The policy ignores medical necessity for patients with conditions that worsen or don’t improve within two months of the initial visit.

Advocacy timeline

February 1, 2019: Anthem sent communication to network providers entitled “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” beginning with commercial claims processed on or after March 01, 2019.

March 21, 2019: Physician Services sends email notification of Anthem communication/update to affiliate executive directors in the 14 affected states  and requests relevant claims denials information be sent to physician services to demonstrate the impact of the update.

May 29, 2019: AOA sends letter to Anthem expressing concerns regarding modifier 25 update and requesting a meeting.

June 27, 2019: Osteopathic Physicians and Surgeons of California (OPSC) sends letter to Anthem expressing concerns regarding Anthem’s modifier 25 update, provides sample clinical scenarios illustrating how the update ignores medical necessity, and requests a meeting.

August 15, 2019: AOA receives letter from Anthem, states March 2019 modifier 25 update does not change Anthem’s reimbursement policy on appropriate use of modifier 25, extends offer for meeting to discuss issue.

August 15, 2019: OPSC receives letter from Anthem, states March 2019 modifier 25 update does not change Anthem’s reimbursement policy on appropriate use of modifier 25, extends offer to discuss clinical scenarios OPSC provided in letter.

September 13, 2019: AOA/OPSC leadership call with Anthem staff (see summary document).

September 30, 2019: Physician Services continues to collect EOBs, related documents for Anthem modifier 25-related claims denials.

State policies

View policies for each of the 14 impacted states:


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).

Issue details

This update extends beyond an edit of E/M claims appended with modifier 25 where the E/M visit occurred on the same day as OMT because it impacts multiple specialties.  The AOA learned of this update in January 2018 and immediately alerted the profession, reached out to its affiliates, and participated in an informal coalition to address the issue.

Due to the broad scope of HCSC’s claims systems updates and the implementation of the clinical validation edit in multiple states across several lines of business, identifying the root cause of issues facing contracted providers is ongoing, with the goal of identifying a workable solution.

Advocacy timeline

March 2018 – AOA sent a letter to HCSC’s Chief Clinical Officer, Opella Ernest, MD, voicing concerns and requesting an in-person meeting.

April – July 2018 – AOA alerted the profession to the issues described and reached out to affiliates – including AAO, ACOFP and the state associations for Illinois, Oklahoma, Texas, New Mexico and Montana – requesting assistance in compiling complaints.

July 2018 – Dr. Ernest met with AOA leadership to discuss the March 2018 letter and the concerns of more than 10,000 DOs affected by the policy.  AOA Past President Boyd Buser, DO, participated in the discussion as a respected professional in the coding and payment communities and OMM expert.

HCSC agreed to co-host a webinar for our affiliates and members in the impacted markets/states to explain software changes and edits. Broader engagement between the AOA and HCSC was also discussed, including increasing DO appointments to advisory panels, physician workgroups, and/or state-based clinical review boards.  Both parties agreed the meeting was a good start and the beginning of more consistent communications  to help bridge the divide between providers and payers.

October 2018 – The original date of the webinar was October 26, 2018, but was postponed because AOA did not receive the slide deck from the HCSC legal team for review until 2:17 PM on October 25th.  After reviewing the slides and discussing with Dr. Buser, AOA concluded HCSC’s interpretation of what constituted an E/M visit provided on the same day as an OMT visit being covered for payment was vastly different from AOA’s interpretation. AOA brought this discrepancy to HCSC’s attention.

October 26, 2018 – AOA sent HCSC the latest National Government Services Local Coverage Determination (NGS LCD), the AOA Guide to Coding and Documentation Osteopathic Manipulative Treatment, and the November 28, 2011, Federal Register/Vol. 76, No. 228, CMS, and requested HCSC consider adopting the NGS LCD for their guidelines when paying for OMT.  HCSC replied on November 28, 2018 that they would provide availability to discuss a possible resolution with AOA and reschedule the webinar for our members and the affiliates.

December 16, 2018 – AOA sent a request for assistance to all state and specialty societies impacted by this issue with the goal of identifying more occurrences of this problem to share with HCSC.  AOA also reached out to those physicians who have contacted us to obtain a claim that ultimately was paid and a claim that was denied after appeal to ensure HCSC is consistent with their reasoning and following the information they provided on December 21, 2018.

December 21, 2018 – AOA staff, Dr. Buser, and HCSC participated in another call to discuss potential collaboration and a solution to this issue. While HCSC did not appear willing to adopt NGS LCD guidelines, they did state that, “HCSC will review and reimburse an E&M performed on the same day as an OMT visit based on the definition of modifier -25 and the supporting provider documentation indicating a significant and separately identifiable E&M service.”  Both parties agreed to work on slides for a webinar to help explain the appropriate steps when submitting such claims. AOA requested HCSC include both an example of a claim they would pay and one that they would not pay so our physicians have a clear understanding of HCSC’s expectations when evaluating claims. Additionally, AOA requested HCSC implement a process that would not force our members to appeal every single claim.

January 15, 2019 – AOA received the draft slide deck from HCSC for review and comments.

January 22, 2019 – AOA responded to HCSC with concerns regarding the slide deck; HCSC’s interpretation of the NCCI manual appears very restrictive and incongruent with both public and private payer interpretations. CMS has valued the OMT codes with the recognition that an E/M is typically reported on the same date of service as OMT. AOA requested once again that HCSC consider adopting NGS guidelines when paying for OMT.

February 8, 2019 – HCSC responded and stated this issue was escalated within Cotiviti – a data and analytics company processing claims for HCSC – and is waiting for a response following their discussion.  HCSC hoped to provide more information in the near future.

March 8, 2019 – AOA Physician Services staff reached out via email to allopathic medical societies to ascertain the impact, if any, the HCSC denials have had on medical society members in HCSC states. No responses to date.

March 11, 2019 – Physician Services conducted a call with Dr. Buser and AOA’s public policy and legal teams. Call participants discussed potential strategies/next steps including potential grassroots activities, other payer OMT policies, and drafting a letter for affiliates in HCSC states to send to their respective BCBS plans.

March/April 2019 – Physician Services team compiled OMT payment policies from various payers across the country to share with HCSC for the purpose of demonstrating that HCSC is an outlier in the public and private insurance markets related to how they interpret the NCCI manual concerning the usage of OMT being billed with an E/M code on the same date of service. The search yielded several results consistent with NGS/LCD guidelines but not as many as initially anticipated because many commercial plans do not have a distinct policy on this issue.

March 26, 2019 – Physician Services staff held a call to discuss a letter for affiliates in HCSC states to send to their respective BCBS plans. Call participants included AOA leadership, Physician Services staff and affiliate executive directors. The draft letter was shared with all call participants and instructions were provided for sending the letter – which requests a meeting to discuss the issue with the BCBS identified contact.  Several executive directors on the call confirmed they would send to the letter to BCBS and subsequently provided copies of the final letter when sent to BCBS.

Letter sent to BCBS Illinois

May 3, 2019 – Physician Services received an email from its Illinois affiliate that BCBSIL is willing to meet with IOMS and AOA leadership on the issue. We are waiting for BCBSIL to schedule this meeting.

May – August 2019 – Physician Services staff reached out to HCSC contact via phone/email on multiple occasions, with no response.

July 24, 2019 – IOMS physician leadership, staff met with BCBS-IL to seek clarification on Cotiviti automated claims denials and convey concerns (see meeting summary).

September 2019 – Physician Services reached out to BCBS-IL regarding next steps, awaiting reply. Dr. Buser reviewed Cotiviti education materials provided by BCBS-IL staff, provided comments/concerns to be addressed in forthcoming letter.

Relevant policies & documents
  • Illinois
  • Texas This notification best explains the update. However, third party claims editing software appears to vary by plan.

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.

Issue details

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.

Claims appended with modifiers 25 (significant, separately identifiable E/M service), 59 (distinct procedural service), and 57 (decision for surgery) are included in the new review process. Anatomical modifiers including left side (LT) and right side (RT) are also subject to review.

According to Anthem, “the clinical validation review process will evaluate the proper use of these modifiers in conjunction with the edits they are bypassing, such as the National Correct Coding Initiative (NCCI). Clinical analysts who are registered nurses and coders will review claims pended for validation, along with any related services, to determine whether it is appropriate for the modifier to bypass the edit.”

The AOA is seeking clarification on the pre-payment clinical validation policy.

Advocacy timeline

July 16, 2019: AOA Physician Services staff locates Anthem notifications to network physicians of new prepayment clinical validation policy during routine research on private payer policies.

 August 5, 2019: AOA sends letter to Anthem seeking clarification, waiting for response (9/30/19).

August 9, 2019: AOA alerts affiliates to new process, publishes article in Affiliate Friday Folder.

August 21, 2019: AOA Physician Services staff alerts AMA, other stakeholders to new Anthem policy during monthly AMA stakeholder call.

September 10, 2019: AOA publishes article in the DO to alert members of the new clinical validation process.

Relevant policies & documents

View policies for each of the 14 impacted states:

September 1, 2019

September 5, 2019

October 1, 2019

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