Health Net to Delay Modifier -25 and Emergency Services Policies Until July 1
Health Net has advised the California Medical Association (CMA) that it will delay implementation of its recently announced modifier 25 and emergency services payment policies for its Medicare and Medi-Cal lines of business until July 1, 2018, to allow time to review provider concerns over the new policies.
Health Net first
physicians in March of the new payment policies set to go into effect on May 16, 2018. CMA, along with several specialty societies, raised significant concerns with Health Net about the proposed changes and urged that the policies be rescinded.
CMA, along with the California Podiatric Medical Association, met with Health Net representatives to request that the policies be rescinded. Following this discussion, Health Net verbally agreed to delay implementation so it can further review the policies and continue the dialogue with providers about their concerns. Health Net will be sending out an official notice to physicians about the implementation delay.
The policies delayed until July 1 would:
- Reduce reimbursement of evaluation and management (E/M) services when billed with modifier 25 under the following circumstances:
- When a minor surgical procedure code is reported on the same day as an E/M code by the same physician, payment for the E/M code will be reduced by 50 percent.
- When a preventative/wellness exam and a problem-oriented E/M are billed during the same encounter, payment for the problem-oriented E/M code will be reduced by 50 percent.
- Reduce reimbursement for level 4 (CPT 99284) and level 5 (CPT 99285) emergency room services that are billed with what Health Net deems a non-emergent diagnosis to a level 3 (CPT 99283) contracted rate.
Health Net has advised that it will, however, proceed with the May 16 implementation of the policy to no longer recognize or reimburse for consultation codes (99241-99255). However, consultation codes billed will be crosswalked to the appropriate E/M level code for reimbursement.
CMA appreciates Health Net’s willingness to delay the implementation to allow more time to review the policy changes and further dialogue with CMA and others.
For more information about the proposed payment policies and CMA’s concerns,
Thank You Physician Members - We Defeated AB 3087
Today, the California Medical Association (CMA) killed Assembly Bill 3087 (Kalra) – dangerous legislation that would have created a commission of unelected political appointees empowered to arbitrarily cap rates for all health care services in all clinics, hospitals and physician practices in California. Due in large part to staunch opposition led by CMA, the bill died in the Assembly Appropriations Committee.
Key to the bill’s demise was a groundswell of physician opposition. Through CMA’s Grassroots Action Center, thousands of physician members contacted their legislators because AB 3087 would have:
- Decimated California’s health care delivery system.
- Disrupted care and limited choice for millions of California patients.
- Caused 175,000 health care workers to lose their jobs.
- Forced hospitals to close and pushed health care providers into early retirement
- Caused a “brain drain” of talented medical students and residents fleeing California for more ideal working conditions.
"I want to thank each of you for your support and dedication to CMA,” said CMA President Theodore M. Mazer, M.D. “We could not have dealt this bill such a resounding defeat without the united voices of our physician members. Together, we stand stronger."
CMA applauds the Assembly for recognizing that this deeply flawed legislation would result in enormous costs to the state and restricted access to care for millions. CMA remains fully committed to working with stakeholders on a practical solution that addresses the affordability and accessibility of health care in California.
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