Medical societies demand Anthem end arbitrary denials

Physician groups have sent a letter to the insurer outlining their concerns with a pattern of rejected and downcoded claims.

By Julie A. Jacob, AMNews staff. Aug. 19, 2002.

Anthem Inc.'s downcoding and bundling of claims submitted with certain modifiers is rankling physicians and medical societies, which are pressing Anthem to stop downcoding and reducing payments on those claims.

The AMA and several state and specialty societies sent a letter to Anthem on July 11 outlining physician concerns about Anthem's handling of claims submitted with modifiers 25 and 59.

In the past year, the AMA Dept. of Private Sector Advocacy has had an increase in complaints from state and specialty societies about claims with those modifiers that Anthem has downcoded or bundled.

"Anthem's apparent arbitrary and unilateral [and potentially inconsistent] application of CPT codes, guidelines and conventions has created confusion and uncertainty and, based upon the complaints we have received, has led to misunderstandings by physicians and nonphysician health care professionals regarding Anthem's payment rates for certain services," said the letter, signed by the AMA and 19 state, county and specialty medical societies.

Anthem responded with a letter from the company's chief medical officer, Samuel R. Nussbaum, MD, which stated that Anthem had made changes to some of its reimbursement practices, and that "many of the issues of the type you have described ... are handled by Anthem's medical directors and other personnel at the local and regional level."

Modifiers 25 and 59 indicate that two procedures were performed, but Anthem has been denying claims with the modifiers, asking that they be resubmitted or reducing the E&M payment on claims submitted with a 25 modifier, said Edward Probst, MD, a dermatologist and president of the Indiana State Medical Assn. [...]