Advocacy win: Anthem rescinds Modifier 25 policy

April 2018 – Vol. 37, No. 3

In the fall of 2017, Anthem announced its plan to reimburse Evaluation and Management (E/M) services at a 50 percent rate when a significant, separately identifiable E/M service (appended with the 25 modifier) and surgery/diagnostic procedural service were performed on the same day. This policy originally was scheduled to be implemented by Anthem in 14 states as early as January 2018. However, in December 2017, Anthem postponed its implementation date until March 1, 2018, and reduced the 50 percent cut to 25 percent. While an improvement, the underlying policy remained unacceptable, and the AAO-HNS committed to work to eliminate the reduction completely.

On February 23, 2018, thanks to coordinated, sustained efforts by the AAO-HNS, our members, and others in the house of medicine, Anthem rescinded its policy across its entire network relating to the Modifier 25 reduction. Our collective efforts paid off. This advocacy win will help members save thousands of dollars each year in revenue, and the two-pronged approach used to “communicate” to Anthem—at the national and state levels—is a great example of how multiple stakeholders using complementary approaches can effect change.

The AAO-HNS has since sent a letter to Anthem expressing appreciation for its willingness to change this misguided policy and for listening to concerns raised by our leadership, individual physicians, the house of medicine, and other organizations. In response, Anthem confirmed that the relationships developed with multiple individuals and groups over the past several months were key to their willingness to look at other opportunities to work collaboratively to improve the healthcare delivery system.

The AAO-HNS is hopeful that Anthem’s decision will be taken into account by others in the insurance industry as they consider this issue. The Academy will continue to advocate in those states affected by similar flawed policies.

To read more on the Modifier 25 advocacy efforts, visit: