Score one for doctors as Anthem rescinds policy to reduce payment for same-day services

Doctor putting money in pocket
Doctors won a battle with Anthem over a policy that would have had a negative impact on their reimbursement for services. (Getty/Niyazz)

In a victory for doctors, Anthem has decided to rescind a controversial policy that would reduce payment for certain same-day services.

Physicians were successful in their efforts to push back against the health insurer’s plan that would have reduced payment for evaluation and management (E/M) services when provided on the same day a provider performs a procedure or conducts a wellness exam.

In a Feb. 23 letter (PDF), Anthem said it decided against implementing the payment modifier 25 policy that was set to take effect on March 1 and was expected to have a significant impact on physician practices across the country. The policy would have reduced payments for E/M codes reported with a CPT modifier 25.


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“Anthem’s decision to drop its planned modifier 25 policy is a positive step forward, demonstrating again that when doctors and health plans work together, the best outcome for patients can be achieved,” said Jack Resneck, Jr., M.D., the chair-elect of the American Medical Association’s board of trustees, which had fought the policy change. Resneck said the advocacy efforts of many state medical associations and national medical specialty societies contributed to Anthem’s decision to reverse the policy.

Anthem earlier adjusted its reimbursement policy relating to physician use of payment modifier 25 to cut pay by 25% instead of its original 50% cut, before saying it would not proceed with the policy.

“While Anthem is confident that duplication of payment for fixed/indirect practice expenses exists when physicians bill an E/M service appended with modifier 25 along with a minor surgical procedure (0 or 10 day global) performed on the same day, the company believes making a meaningful impact on rising healthcare costs requires a different dialogue and engagement between payers and providers,” Anthem’s Executive Vice President and Chief Clinical Officer Craig E. Samitt, M.D., said in the letter. Samitt said the insurer will officially notify contracted providers of the decision.

The modifier 25 policy is just one of the recent policy changes by Anthem that has drawn fire from physician groups, and it’s not the first time the health insurer has had to modify those policies. Seeking to address mounting concerns from providers and other stakeholders, Anthem earlier this month made changes to policies it previously rolled out that restrict coverage for emergency room visits.

Anthem’s program was meant to deter members from using the emergency room for illnesses or injuries that aren’t life-threatening, but in response to critics it implemented a series of “always pay” exceptions for certain circumstances, such as when the ER visit was associated with an outpatient or inpatient admission, or when the patient received any kind of surgery or an MRI or CT scan.

Also controversial is a policy that categorizes monitored anesthesia care as “not medically necessary” during routine cataract surgery and a policy aimed at steering patients toward freestanding imaging centers—rather than hospitals—for services like CT scans or MRIs.

Resneck said the fight over those policies is not over. “This [modifier 25] policy is one of a number of issues that the physician community has been working on with Anthem, and the AMA looks forward to continuing these efforts to find ways to collaborate on strategies to deliver affordable, high-quality, patient-centered care,” he said.

In its letter, Anthem said it was committed to continuing to work with physician groups to address their concerns with policies and guidelines. In an email to Fierce Healthcare, Anthem said it is committed to providing access to high quality care while focusing efforts on making that care affordable. 

"Anthem believes that making a meaningful impact on rising healthcare costs requires collaboration between healthcare providers and health plans. We have been and will continue to have a dialog with our providers and medical societies to discuss any of our programs," the company said.

(Editor's note: Additional comments from Anthem were added to the original article.)