An unrelenting, uncompromising Academy push succeeded Friday, preventing a 12-state reimbursement cut for office visits bundled with same-day treatment that was slated to start March 1.
Anthem, Inc., sent a letter to the American Medical Association stating that it will immediately halt a planned 25 percent reduction to E/M services appended with modifier -25. To prevent this cut, we waged a months-long educational campaign, culminating with urgent talks with Anthem to explain how the policy would delay care on which patients rely.
Anthem BlueCross BlueShield alerted the Academy and the American Medical Association that it will immediately halt a planned 25 percent reduction to E/M services appended with modifier -25. The cut, which Anthem had already scaled back from 50 percent due to Academy objections, was set to take hold next week in the following 12 states:
- California;
- Colorado;
- Connecticut;
- Indiana;
- Kentucky;
- Maine;
- Missouri;
- Nevada;
- New Hampshire;
- New York;
- Ohio; and
- Wisconsin.
In its letter, Anthem said that it will formally notify its contracted providers of this decision in the coming days.
Note: This is unrelated to the Academy’s fight to prevent Anthem’s non-coverage of monitored anesthesia during cataract surgery. The Academy continues to fight that decision, bolstered by recent media reports that were highly critical of Anthem’s decision. Visit AAO.org for the latest on that issue.
Anthem’s announcement comes just days after a meeting with Academy leadership in which we told the carrier that we would not accept any compromise that affected physicians’ payments.
State ophthalmology societies were heavily engaged with us on this issue, along with their state medical society counterparts. The AMA and other affected specialty societies also supported this fight.
Background
Since last year, we’ve fought this planned cut, which would’ve reduced reimbursements for intravitreal injections. Anthem delayed its implementation in January, but remained insistent on a payment cut.
Why we fought
We believe the policy change could compel physicians to bring patients back to the office for an additional visit to ensure adequate reimbursements. We’re partnering with the affected ophthalmic state societies to halt this cut.
How we made this win a reality
As soon as the Academy learned of this issue, we began a fullcourt press to remedy the situation. We immediately contacted the carrier to address what at the time was a three-state issue. As it grew, we engaged state societies and kept the pressure on. Our physician leaders worked with staff and were in direct contact with Anthem throughout this process.
Stay compliant
This victory holds only if ophthalmologists continue to responsibly use modifier -25 for patient care. The Academy has specific guidance on its use. While medically necessary, if you perform the established patient exam solely to confirm the need for the minor surgical procedure, you cannot separately bill the exam.
Medicare Part B does not require you to append new patient exams with modifier -25 when you perform a minor surgical procedure the same day.