In response to persistent efforts by the American College of Radiology (ACR), UnitedHealthcare (UHc) will announce plans in its November Network Bulletin to reduce its multiple procedure payment reduction (MPPR) rate for the professional component (PC) of advanced imaging services from the current 25 percent to five percent on Jan. 1, 2017.
The ACR has engaged in the discussions with UHc about its MPPR policy for more than two years. In the spring of 2014, UHc initially announced expansion of its MPPR policy to the PC of imaging to align with a controversial decision by the Centers for Medicare & Medicaid to set a 25 percent MPPR discount for the PC of high-tech imaging services covered by Medicare and performed by the same physician in the same session and same day. UHc delayed implementing the policy after a conference call where leaders of the ACR economics team informed them about a provision of the Protecting Access to Medicare Act of 2014 that required CMS to produce data used to justify its 25 percent MPPR discount.
Despite ongoing communications with the ACR, UHc announced plans in August 2015 to adopt the Medicare MPPR for the PC of advanced imaging services covered by its commercial health insurance plans. The reimbursement rate for interpretation of high-tech imaging services performed by the same physician in the same session was adjusted to 100 percent for the first service and 75 percent for the second and subsequent services. The policy was enacted on Nov. 1, 2015.
The ACR held another conference call with UHc executives between its August announcement and November implementation. UHc again stressed it was making the change to align with Medicare’s policy. The ACR educated UHc about a provision within the proposed 21st Century Cures Act (H.R. 6) that would repeal Medicare PC MPPR policy.
UHc executives indicated they would move forward with their planned implementation in November but expressed an interest in receiving updates on Congressional and Centers for Medicare & Medicaid Services (CMS) actions and said they would consider modifying the policy for their plans if Medicare’s MPPR policy itself was modified by CMS or Congress. They also indicated that practices could use the -59 modifier to indicate separate sessions as appropriate.
After the conference call, the ACR coordinated a sign-on letter for radiologists and referring physicians to express opposition to this policy and to request UHc not move forward with implementation. Over 1,800 physicians were represented in the sign-on letter.
In December, the ACR again urged UHc to change its policy after Congress passed the Consolidated Appropriations Act of 2016. It included a provision requiring Medicare to reduce its PC MPPR rate from 25 percent to five percent. UHc executives responded that they would wait for specific instructions from CMS before revising their policy. In August, CMS released the instructions to their contractors to implement the policy change as mandated on Jan. 1, 2017. UHc informed the ACR in early September that they would follow suit with Medicare.
The ACR continues to work with its Managed Care Network to ensure that private payers who have implemented the PC MPPR policy align with the Congressionally mandated Medicare policy change.
If you are aware of private payers who continue to apply a 25 percent MPPR, please contact Katie Keysor at email@example.com.