January 18, 2018

Advocates Tell Anthem to Rescind Imaging Policies

Eleven national medical specialty societies and patient advocacy groups joined a Jan. 16 letter, led by the American College of Radiology (ACR), asking Anthem Blue Cross Blue Shield to eliminate its new outpatient imaging policies.

As reported by Politico*, a national political and public policy news outlet, this diverse group of stakeholders urged Anthem to rescind a site-of-service denial policy that, with limited exceptions, prohibits beneficiaries from receiving advanced imaging services in hospital outpatient departments.

The advanced imaging policy is in effect in nine states, and Anthem plans to implement similar site-of-service prohibitions in as many as thirteen states as early as March 2018.

In a reference to the policy, Politico reports, “Last year, the country’s largest Blue Cross Blue Shield plan began cutting off payments for many patients who get MRI or CT scans at hospital-owned outpatient facilities.”

In addition, the letter highlights opposition to Anthem’s coverage denials for services administered in emergency departments that the insurer retroactively determines to be for “non-emergent” clinical conditions.

It also expresses concerns about automatic reimbursement reductions triggered by physician billing for Evaluation and Management (E/M) services using the “Modifier 25.” Typically, use of the Modifier 25 on a claim signifies that a single physician performed two discrete services during a single encounter, on the same day and, therefore, must receive full reimbursement for both activities. Anthem will now ignore this routine billing practice and, rather than providing full payment for both services, will reduce reimbursement for the E/M procedure by 25 percent beginning on March 1, 2018.

The emergency department policy is in effect in six states, and payment reductions associated with Modifier 25 will ultimately be operational in eight states later this year.

Referring to the letter to Anthem Executive Vice President and Chief Clinical Officer Craig Samitt, MD, Politico noted, “Failure to rescind these policies could jeopardize patient care and, furthermore, these new policies could serve to undermine a relationship between Anthem and a broad array of the physicians who treat your beneficiaries.”

Other medical groups, including the American Medical Association, have already urged Anthem to drop its controversial imaging policies.

The ACR, along with this group of medical specialty and patient advocacy organizations, will continue to educate Anthem about the numerous harmful consequences associated with payment policies for hospital outpatient services.

Radiologists should consult Advocacy in Action eNews and the ACR’s Anthem Outpatient Imaging Policy Resources page for more information on how you can help counter these arbitrary and unwise policies.

*Scroll halfway down page to article titled "Anthem's payment changes spark blowback."