TN Health Plans Rescind Modifier 25 Payment Policies

TMA Persuades Insurance Companies to Change Course, Reimburse at Full Fee Schedule

September 19, 2018

Amerigroup, one of three companies that contracts with TennCare as a Managed Care Organization, has rescinded a policy that would have paid physicians only 50% of fee schedule for sick patient services delivered same day as a wellness visit.

The health plan had announced earlier this summer that claims with a CPT modifier 25 would be subject to the reduction, effective Sept. 1. Amerigroup had already delayed previous plans to implement the policy in February.

The Tennessee Medical Association fielded numerous complaints from medical practices across the state and asked Amerigroup officials to rescind the policy altogether.

Amerigroup recently issued a “correction” to healthcare providers stating that it will continue to reimburse sick and wellness services at full contracted rates, provided the services are accurately coded and billed.

TMA said the change allows physicians to deliver comprehensive care to every patient in every setting and still get paid for their services.

“Physicians are often able to identify a patient’s acute healthcare needs as part of routine, preventive visits, but the additional examination, testing, and decision-making should not go uncompensated. It saves lives and saves money,” said Matthew L. Mancini, MD, a Knoxville surgeon and 2018-2019 TMA President.

Anthem, Inc., Amerigroup’s parent company, had attempted the same policy on a wider scale but reconsidered earlier this year after pushback from the American Medical Association and other physician advocacy groups. AMA and Anthem released a joint statement in March in which the health plan expressed commitment to working with the AMA, state medical associations and other organizations to address physicians’ concerns with payment policies and guidelines.

“We appreciate Amerigroup listening and being receptive of physicians’ concerns. Our members just want a level playing field but often have no leverage and nowhere to turn when there is a problem with a payer. This outcome is fair to all parties and underscores the value of TMA as a single, unified voice that gets results,” said Dr. Mancini.

UnitedHealthcare also backed off its plans to implement a similar modifier 25 payment policy on October 1 after TMA and other organizations actively objected to the proposed change.