Insurers will fight against unscheduled procedures of patients

Increasingly, health insurance companies require additional information from physicians when they perform unscheduled minor procedures on patients on the same day as visits for other reasons, such as blood draws, skin biopsies, or electrocardiograms.

Insurers focus on provider evaluation and management statements that include a modifier of 25. Providers use evaluation and management codes in statements to evaluate or monitor patients’ health, such as when they visit an office or perform surgical procedures. They add a modifier of 25 when they provide significant and separately identifiable services during the same visits to a patient, such as removing a mole.

Insurers have previously paid out huge sums because they denied modifier 25 payouts, and their new policy has resulted in new lawsuits, said Ed Gaines, vice president of regulation and industry relations at Zotec Partners, a revenue cycle management company.

“This is history repeating itself,” said Gaines, who sits on the American College of Emergency Physicians’ reimbursement committee and has been involved in litigation over the practice in the past.

New Jersey-based Horizon Blue Cross Blue Shield is considering a plan to halve payments on all claims that include modifier 25 starting November 1, according to a notice sent to service providers. Initially, the non-profit insurance company was supposed to introduce the policy in early August. According to the notice, the company attributed the reduction in reimbursement to changes Change Healthcare made to its ClaimsXten claims editing software.

Change Healthcare and Horizon, New Jersey’s largest carrier with over 3.8 million members, did not respond to interview requests.

“These modifiers just take into account real life,” said Larry Downes, CEO and general counsel for the Medical Society of New Jersey. “That’s what’s happening. Patients come and they need additional services.”

Last month, a group of doctors sent a letter to Horizon asking the insurance company to revise the policy. According to Downes, the standard coding methods work according to the “multi-procedure logic” theory, which lowers fees for additional care provided during a patient appointment to avoid double charges for services such as anesthesia and service fees. According to this theory, the requirements of modifier 25 are no longer taken into account, he said. Reducing the payment of these modifiers will increase healthcare costs as patients will have to schedule individual visits and delay needed care, he said.

“We refrain from reducing these services because they are already discounted and take into account that the patient is already on site. You already have a patient,” Downes said. “Policy changes like this are just trying to get more money off the table and pay doctors less for the services they provide to patients.”

Cigna has also shelved but will eventually move ahead with a plan to require health care providers to provide patient medical records every time modifier 25 appears on claims. Initially, the insurer planned to deny payment to all providers who failed to fax them supporting medical documentation. starting August 13th.

“We have delayed the implementation of this policy to ensure that the application process is as seamless as possible for suppliers and are committed to moving forward to ensure that suppliers who apply with these modifiers are properly paid in full,” the spokesperson wrote. Cigna in an email. Cigna clarified that the proposed policy will not apply to new patients.

The health insurer did not state in its letters to providers why it is strengthening its modifier 25 claims review. Cigna employees regularly review their coverage policies and take into account evidence-based medicine, professional community guidelines, Medicare and Medicaid Services Center guidelines, industry standards, and other existing policies when developing guidelines. , according to a notice the insurer sent to providers in May.

According to the California Medical Association, if Cigna’s policy is passed, there will be a $3.30 fee added for each claim provider filed with modifier 25. he is supposed to do and what he is entitled to,” said Dr. Ted Meiser, a San Diego otolaryngologist and former president of the California Physicians Organization.

The American Medical Association has committed to actively advocate for health care providers to receive full payment for claims, including those with modifier 25, the spokesperson wrote in an email.

However, health insurance companies may face a real problem. In 2002, 35% of Medicare claims containing modifier 25 either misused it or were missing supporting documentation, according to a 2005 report by the Office of the Inspector General of the Department of Health and Human Services. OIG also found that 62% of private insurers reviews of physician use of Modifier 25 over the past four years, and that 41% found high rates of misuse.

And CMS warned just last year that the 25 modifier could be a means to increase requirements coding to maximize Medicare payouts. “Upcoding occurs when a provider uses a modifier of 25 to require payment for medically unnecessary [evaluation and management] service, an E/M service not explicitly separated from the procedure, or another service provided, or an E/M service that does not go beyond the care normally associated with the procedure,” the agency wrote in a statement. notification to providers. Massachusetts Eye and Ear in Boston settled the lawsuit claiming to have coded modifier 25 last year and agreed to pay the federal government $2.6 million.

On the other hand, ISPs have successfully challenged insurance companies that allegedly denied claims with Modifer 25.

In 2007, 24 Blue Cross and Blue Shield member companies, including Horizon, agreed to pay $130 million to settle charges against 700,000 service providers that they wrongfully withhold, reduce or withhold payment for medically necessary services, including by systematically reducing payments for modifiers. 25.

The lawsuit alleged that insurers programmed their McKesson ClaimCheck editing software to automatically reject claims with a modifier of 25. Change Healthcare merged with McKesson’s information technology division in 2017 and adopted the ClaimsXten name for its claims editing software.

“Their software allows them to target modifier 25 claims and allows them to completely inappropriately request medical records or decode a service for no reason,” Gaines said.

As part of the settlement, each Blues plan agreed to publicly disclose how its modifier 25 billing practices differ from its standard procedures. Blues plans also agreed not to require providers to regularly provide medical information to justify billing for certain requirements, to establish physician advisory committees to discuss provider issues, and to establish external billing dispute resolution processes.

CVS Health Aetna, Cigna, Humana, and Elevance Health agreed to split physician billing in 2006 and agreed to release information on their websites if their modifier 25 billing differs from standard practice.

Most insurance companies audit vendors based on how often they bill modifier 25, said John Gwin, CEO of Auctus Group, a revenue cycle management company. If a supplier bills with a modifier of 25 above the industry average, insurers will ask for medical documentation to substantiate claims, he said.

“There is a strong argument that modifier 25 could be misused or attached to every assessment and management statement, and misbilled,” Gwin said. “I’m sure it’s happening. But to say “I will require medical records every time this modifier is used for every provider across the country” is a pretty harsh reaction to this accusation.”

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