Major physician and hospital advocacy groups say Anthem’s decision to repeal its planned “modifier 25” policy does not go far enough to address their concerns over recent changes in coverage policies.
The American Hospital Association joined the American College of Radiology and the American College of Emergency Physicians to urge the insurer to rescind a set of coverage policies regarding emergency care and outpatient imaging. FierceHealthcare received an emailed copy of the organizations' Feb. 27 letter to Craig Samitt, M.D., Anthem’s executive vice president and chief clinical officer.
Anthem announced last year new policies that aimed to deny coverage for ER visits that do not end up qualifying as emergencies and to steer patients toward freestanding imaging centers rather than hospitals for radiology service. Providers have strongly opposed the changes. In recent weeks, the insurer has altered its ER coverage policies and announced its plan to drop its policy that would have reduced payments for evaluation and management codes reported with CPT modifier 25.
In the joint letter, the hospital and physician advocacy groups said Anthem’s announced changes still fall short of the mark. “The changes to the policy announced by Anthem last week do not address the underlying problem of putting patients in the potentially dangerous position of having to decide whether their symptoms are a medical emergency before they seek emergency care, or risk paying the entire bill if it is not,” they wrote.
Similarly, with regard to outpatient imaging the groups “believe more should be done to mitigate risks to patients,” above and beyond changes Anthem has already made to the policy. The letter pressed for full rescission of the policies, and requests that Anthem work with the groups “to design programs and to educate patients about the appropriate use of healthcare services and improve the coordination of care among providers, while increasing transparency requirements surrounding patient out-of-pocket cost responsibility.”
In an email to FierceHealthcare, Anthem said it stands behind its policies and initiatives aimed at reducing overall medical cost and improving consumer health. “We have been and will continue to have a dialog with our providers and medical societies to discuss any of our programs,” the insurer said.