Modifier -25: This is used to report an E/M service on a day when another service was provided to the patient by the same physician. Anthem rescinded a proposed policy to reduce E/M reimbursements by 50% when billed under modifier -25.
“There are still issues around this, however,” Dr. Phillips said.
Anthem Blue Cross recently imposed a policy to deny payment for E/M billed with modifier -25 if the same or similar ICD-10 code was billed in recent months. The timeframe was left poorly defined, and the payer described the similarity of coding as in the “same family tree,” Dr. Phillips said. “I personally don’t know exactly what that means.”
Copay accumulator programs: Traditionally, copays for biologics that were covered by pharmaceutical companies counted toward a patient’s out-of-pocket maximum, but some payers are no longer applying these copays toward that max. When these copay assistance funds are not applied to the deductible, the fixed annual maximum copay assistance may be exhausted before the patient has met their deductible, potentially forcing patients to switch treatments.
This practice is “not prevalent yet,” but could become a bigger problem soon, Dr. Phillips said.
“We would welcome and invite changes in the biologic marketplace—the economic marketplace—to make the system more sustainable,” he said. “But we’re in the system we’re in right now, and we must advocate for patients’ affordable access to treatment they need.”
Thomas R. Collins is a freelance writer living in South Florida.
