From the
PRESIDENT
Robert A. Zaring, MD, MMM
GLMS President | [email protected]
GET EDUCATED on Modifier 25
Note: GLMS, on your behalf, has aggressively pushed back against Anthem’s changes to Modifier 25, changes which were going to significantly reduce physi-
cian payments and hurt patient outcomes. Responding when the news broke, GLMS hosted a meeting in December 2017 between Anthem representatives and
physicians at our headquarters, published an Op-Ed arguing against the changes in The Courier-Journal, and maintained our dialogue through an aggressive
social med ia campaign which included the release of an informative and passionate DocTalks video. We are proud to say that our efforts were successful.
Anthem has agreed to fully rescind their proposed cuts to Modifier 25. This could not have been done without the dedication of our physicians. Thank you all
for your advocacy.
I
n the Declaration of Independence, Thomas
Jefferson wrote, ”But when a long train of
abuses and usurpations, pursuing invariably
the same object, evinces a design to reduce
them under absolute despotism, it is their
Right, it is their Duty, to throw off such govern-
ment, and to provide new guards for their future
security.” No, I am not suggesting a revolution
against our government, but those words stick
in my mind when I consider some of the ploys
insurance companies have used to decrease reim-
bursements, deny claims or hinder patient treat-
ment. The latest of these schemes is Anthem’s
decrease in payment when using Modifier 25.
For those unfamiliar with this change, I offer
a brief history. Anthem decided in October of
2017 to make effective in January 2018 a reduc-
tion of 50 percent for Evaluation and Manage-
ment (E/M) services billed with a Current Pro-
cedural Terminology. To better understand this,
it is important to take a close look at Modifier
25. Modifier 25 is appended to an E/M service to
indicate that a significant and separately identifi-
able E/M service was provided on the same day
as a minor surgical procedure. Anthem’s change
will reduce by 50 percent the E/M service. This
will significantly affect many providers such as
Dermatology but others as well. The reason Mod-
ifier 25 exists is so that when physicians identify
other problems, they can take care of them at the
same visit. Two examples the Kentucky Medical
Association (KMA) have given on the use of
Modifier 25 will better elucidate the issue. They
include the following:
1. “A patient has a nosebleed. The physician
performs packing of the nose in the office, which
stops the bleeding. At the same visit, the phy-
sician then evaluates the patient for moderate
hypertension that was not well controlled and
adjusts the antihypertensive medications.”
2. “A patient presents to the physician with
symptoms of urinary retention. The physician
performs a thorough E/M service and decides to
perform a cystourethroscopy. Cystourethroscopy
is performed the same day as the E/M code.”
Anthem was contacted by numerous orga-
nizations including the KMA and GLMS about
this change. The result was that Anthem reduced
the decrease from 50 percent to 25 percent. I find
this wholly unacceptable, and simply the latest
in a long train of abuses and usurpations perpe-
trated on providers and patients. My grievances
with this action are manifold. To begin, Anthem
released the information regarding the decrease
in a newsletter update and not in the orange en-
velope as required by law for significant changes
to a provider contract. Anthem’s argument was
that a 50 percent decrease in reimbursement
for this code was not a significant change. This
is not a legitimate response. If a patient were to
pay 50 percent of Anthem’s monthly premium,
I can guarantee Anthem would consider that
significant. To make matters worse in regarding
this dramatic change, Anthem placed the infor-
mation deep within the newsletter.
In this action, Anthem not only disregarded
the law, but they showed no concern for their
customers or their covered patients. Modifier
25 is used so clinicians can do more work in
one visit. This helps patients limit travel time
and lost work, thus creating a fitter patient and
workforce. With the decrease in reimbursement,
physicians will likely opt for a return visit by the
patient instead of interrupting clinic workflows
as they might have tried to do before. All of
this benefits no one except the deep pockets of
Anthem. They will see a handsome 25 percent
increase on the E/M code. But they could also
potentially benefit when a patient can simply
not return for a visit due to time constraints and
Anthem saves by not having the patient get the
care they need.
Anthem now states the new decrease to Mod-
ifier 25 is due to duplications in components
of RVUs making up the E/M codes. But, when
looking at the history, it is clear the change is
really due to lazy auditing. Furthermore, in 2012
Anthem decided this was not a good idea. I won-
der if this change of heart is due to their growing
monopolistic share of the market in areas such
as Kentucky, or is it related to losing money on
their blocked merger with Cigna?
Regardless of why the Anthem leadership
has changed its strategy, the excuses and tactics
used are preposterous and should be summarily
rejected. We as physicians need to protect our
patients and throw off the despotism of these
actions because it is our right and duty. We must
voice our displeasure with Anthem’s decision to
Anthem, organized medicine and legal bodies,
then explain the issue to patients so they may
do the same.
Dr. Zaring is an anatomic and clinical pathologist
with Louisville Pathology Associates and practices
at Jewish Hospital.
MARCH 2018
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