Private Payor Advocacy

Advocacy in action

AOA private payor advocacy: Supporting osteopathic physicians nationwide

The AOA works to reduce administrative burden and protect patient access to care. Representing more than 207,000 DOs and osteopathic medical students, the AOA Physician Services Team engages directly with healthcare payers to address policies that:

Delay or deny care
Create administrative barriers
Result in downcoding or inappropriate denials
Reduce or threaten fair reimbursement

This page provides up-to-date policy changes, AOA advocacy actions and resources to support members navigating the private payor landscape.

AOA members in need of assistance can contact our Physician Services Team by email or call (312) 202-8000. To access these and all member benefits, you may join or renew your AOA membership online.

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Administrative burden, Modifier 25 & downcoding

Insurers continue to implement automated edits, documentation requirements and review programs that increase administrative burden and threaten fair reimbursement.

Two of the most persistent issues affecting osteopathic physicians are Modifier 25-related denials and downcoding of Evaluation & Management (E/M) services.

These payor policies can result in delayed claims, reduced payments and unnecessary administrative workload that disrupts efficient patient care.

AOA advocacy

The AOA Physician Services Team actively works with members and payors to address these challenges by:

Challenging policies that trigger automatic audits, denials, or prepayment reviews, including modifier edits and automated downcoding
Providing direct support to members facing claim delays, denials or downcoded services
Engaging payer leadership to ensure that their review processes align with clinical practice standards and clean-claims laws
Offering tailored guidance to help physicians submit appeals, strengthen documentation and navigate payor requests
Monitoring and responding to emerging policy changes across insurers to protect fair and accurate reimbursement

The AOA encourages members who encounter Modifier 25 denials, E/M downcoding or other administrative barriers to reach out to the Physician Services Team so trends can be identified and addressed directly with payer leadership.

Payor advocacy letters

Anthem/Elevance Health

Blue Shield of California

June 2024

BlueCross BlueShield of Massachusetts

Sept. 2025

BlueCross BlueShield of North Carolina

July 2024

Christian Healthcare Ministries

Aug. 2024

Cigna

MVP Healthcare

NALC Health Benefit Plan

Feb. 2026

Regence BlueCross BlueShield

UnitedHealthcare

May 2023

Insurer policies that may impact DOs

Aetna

Sept. 2023 | Liberalized COVID-19 telemedicine services no longer effective Dec. 1, 2023
March 2022 | E/M Levels 4 or 5 Coding Edits

Aetna Provider Newsletter

Christian Healthcare Ministries

Aug. 2024 | Following advocacy efforts by the AOA/AOiA Physician Services Team, unfortunately CHM has remained steadfast on their guidelines, reconfirming that osteopathic manipulation will not be covered.

Cigna

July 2025 | Cigna Evaluation and Management Coding Accuracy Reimbursement Policy (R49): Effective Oct. 1, 2025, Cigna may adjust E/M CPT codes—specifically 99204-99205, 99214-99215 and 99244-99245—downward by one level if the submitted claim does not meet the criteria for the higher-level code. The AOA has sent a letter formally opposing this policy, urging Cigna to reconsider. As of November 2025, Cigna has only acknowledged receipt of our letter, and that the policy has been implemented.
April 2023 | 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.

Cigna Provider Newsletters

Humana

MVP Healthcare

July 2025 | Following advocacy efforts by the AOA/AOiA Physician Servies Team, MVP Healthcare has officially revised their Payment Policy, confirming that OMT will be covered for all DOs and MDs without any limitations, exclusions or prior authorization requirements. This advocacy win is due to joint efforts in the form of a letter sent by the AOA, AOA Physician Services, the American Academy of Osteopathy (AAO), the New York State Osteopathic Medical Society (NYSOMS) and the Vermont State Assn of Osteopathic Physicians and Surgeons (VSAOPS) on behalf of its physician and student members.

NALC Health Benefit Plan

Feb. 2026 | The AOA has submitted a formal advocacy letter to the NALC Health Benefit Plan (HBP) & Cigna Healthcare urging correction of how OMT is classified. OMT is a physician-performed medical service and should be adjudicated under Medical/Physician Services, not counted toward PT/OT/SLP therapy visit limits. Misclassification leads to improper denials and reduced patient access. Success with NALC would establish a strong precedent and support broader efforts to correct similar misclassification across other health plans.

UnitedHealthcare

June 2023 | Prior authorization for gastroenterology endoscopy services
May 2023 | 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 UnitedHealthcare’s (UHC) gastrointestinal (GI) endoscopy prior authorization program.

The Blue Plans

Anthem/Elevance Health

Nov. 2025 | Anthem’s Facility Administrative Policy: Use of a Nonparticipating Care Provider, scheduled to take effect Jan. 1, 2026, will penalize hospitals with a 10%
reimbursement reduction when out-of-network physicians provide care to Anthem members at in-network facilities and may result in termination from Anthem’s network for continued use of nonparticipating physicians. The AOA has sent a letter formally opposing this policy, urging Anthem to rescind.
March 2025 | Certain modifiers for outpatient claims will receive prepayment coding
review
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
Aug. 2019 | Anthem’s response to advocacy efforts made to Modifier 25 policy
May 2019 | Advocacy efforts by the AOA to reconsider Anthem’s recent payment policy modifications related to Evaluation and Management (E/M) services appended with Current Procedural Terminology (CPT) Modifier 25

Blue Cross Complete of Michigan

April 2025 | Use new telemedicine codes, starting July 1, 2025: If rendering a virtual E/M service that’s audio-only or audio-video, don’t submit claims for these services using E/M codes 99202-99205 or 99212-99215 with the telemedicine place of service codes or modifiers. The claims processing systems will be updated to deny these E/M codes when billed with any telemedicine place of service or modifiers as provider liable effective July 1, 2025.
Dec. 2023 | Update on Chiropractic and Osteopathic Manipulation benefits

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 healthcare 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.

BlueCross BlueShield of Massachusetts

Nov. 2025 | Following advocacy efforts by the AOA/AOiA Physician Services Team and the Massachusetts Osteopathic Society (MOS), BCBSMA replied that the program will target only providers with unusually high rates of high-level E/M coding (“outliers”), not the majority of network providers. Claims from these providers will be reviewed, and if overcoding is found, payments may be reduced. Providers can appeal decisions, and those no longer considered outliers will be removed from the program after periodic review.
Aug. 2025 | BCBSMA Evaluation and Management Overcoding Program: Effective Nov. 3, 2025, BCBSMA will expand their pre-payment claims editing to review professional services for evaluation and management (E/M) overcoding. They will assess Level 4 and 5 E/M codes to determine if the level of service billed is appropriate for the severity of the members’ condition as reported in the claim. If they identify overcoding, they may adjust reimbursement to a lower-level E/M. The AOA sent a letter formally opposing this program, urging BCBSMA to reconsider.

Provider News

BlueCross BlueShield of North Carolina

July 2024 | Advocacy efforts were sent to BCBSNC to express AOA concerns and
confirmation that the E/M Reimbursement Policy was rescinded.
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.

Florida Blue

Bluemail & Bulletins

HCSC (includes Blue Cross Blue Shield of Illinois [BCBSIL], Montana [BCBSMT], New Mexico [BCBSNM], Oklahoma [BCBSOK] and Texas [BCBSTX])

Highmark BlueCross BlueShield

Aug. 2025 | Following advocacy efforts by the AOA/AOiA Physician Services Team, effective Sept. 1, 2025, Highmark’s List of Procedures/DME Requiring Authorization, which had inclusion of OMT codes (98925-98929) prior (dated back to CY2024), have been updated to reflect no prior authorization is required for OMT codes across all regions (Pennsylvania, West Virginia, Delaware and New York). All OMT claims denied for prior authorization can be resubmitted for adjudication. If you continue to have denials, please contact AOA Physician Services immediately.

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

Horizon Blue Cross Blue Shield of New Jersey

Blue Review

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.
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.

Regence

March 2025 | Following advocacy efforts by the AOA/AOiA Physician Services Team, along with AAO, ACOFP, IOPA, OPSO, UOMA and WOMA, The Bulletin announced that Regence has decided not to implement changes to its Modifier 25; Significant, Separately Identifiable Service (Modifier #103) and Global Days (Administrative #101) reimbursement policies at this time.
Dec. 2024 | The Bulletin states for services delivered on or after March 1, 2025, when modifier 25 is appended to an E&M service (CPT 92002, 92004, 92012, 92014, 99202-99205, 99211-99215) delivered on the same date as a minor procedure (i.e., services with a global surgery indicator of 00 or 10) performed by the same provider, we will reduce E&M reimbursement by 50% to offset the redundant practice expenses.
Aug. 2024 | Following advocacy efforts by the AOA/AOiA Physician Services Team,
along with IOPA, OPSO, UOMA and WOMA, it was announced The Connection announced postponing updates to the Modifier 25; Significant, Separately Identifiable Service (Modifier #103) and Global Days (Administrative #101) reimbursement policies. They had previously announced in the June 2024 issues of The Bulletin and The Connection that they would update these policies effective Sept. 1, 2024. Look for more information in the Oct. 2024 issues of The Bulletin and newsletter.
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 healthcare 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.
May 2023 | Following advocacy efforts by the AOA Physician Services Team, we 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.
Aug. 2022 | An AOA advocacy letter was sent requesting clarification on Regence’s “enhanced claim editing” which has caused an increase in denials impacting members and their patients. These automatic denials of Evaluation and Management (E/M) services on the same day as osteopathic manipulative treatment (OMT) have threatened the ability of osteopathic physicians to provide accessible care to patients and obtain fair reimbursement for services provided.