Private Payer News Archive
Please select the links below for complete Private Payer articles and events of past years. View Current Private Payer News
10.22.08 AMA promoting Heal the Claims Process campaign
The American Medical Association (AMA) is introducing the Heal the Claims Process campaign (formerly called the “Cure for Claims” campaign), which is designed to reduce unnecessary administrative waste in the health care claims process.
The campaign’s objective is to reduce the amount that physicians spend to receive accurate payment for claims from as much as 14 percent of their total revenue to as little as one percent.
The campaign features two primary elements...
- The National Health Insurer Report Card
- Heal that Claim month in November, during which physicians will be able to review and reconcile their claims.
Click here for claims process resources
05.19.08 Video Educates Physicians About 'Cost of Care'
The Physicians Advocacy Institute (PAI), has produced a video called "Understanding Episodes of Care," which carries with it 3 CME credits. This video is intended to educate physicians about the intricacies of this latest methodology that rates physicians' "efficiency," most commonly known as "cost of care." It defines pertinent terminology and explains how the ETG methodology works. After completing this course, it is anticipated that physicians will be armed with the information they need to engage health plans in meaningful dialogue about the quality of care decisions and advocacy that physicians undertake on behalf of their patients.
Click Here for Video
05.01.08 AMA Announces Heal the Claims Process Month: Coming in November 2008
MAG invites its members to join the AMA Practice Management Center’s (PMC) effort to help physicians fight for accurate health care claims payments and reduce the administrative costs involved in submitting claims.
Heal that Claim Month is a campaign to heal the health care claims process and cut the national average of what physician practices spend on submitting claims from 10 to 18 percent to just 1 percent. The campaign urges physicians and their practices to – in November when many health insurers unfairly hold back claims payment – hold payers accountable by reviewing and auditing claims for accuracy.
Members can visit www.ama-assn.org/go/pmc to use the PMC’s online educational materials and tools. The PMC Web site offers a number of resources covering every aspect of managing a physician practice, ranging from contracting with insurers and setting a fee schedule to working through appeals and collections.
Visit the PMC's Web site to learn about the AMA's Heal that Claim month
03.04.08 MAG’s Third Party Payer Advocacy Has Saved Members $3.5 Million in 2008 By Convincing BCBSGA to Allow Modifier-25 with Code 69210
Effective May 1, 2008, Blue Cross Blue Shield of Georgia (BCBSGA) will begin allowing modifier-25 with procedure code 69210 (Removal impacted cerumen) in addition to the E&M visit. This change is a result of the involvement from MAG’s Department of Third Party Payer Advocacy on behalf of a member.
During 2008, this change will represent payments of an estimated $3,528,000 for the 147 MAG Members who are Otolaryngologists. Statewide, MAG’s Department of Third Party Payer projects that ENTs will receive more than $19 million for this procedure from BCBSGA in 2008 alone.
Please contact the Department at 678.303.9274 or tbaptiste@mag.org if you require third party payer assistance.
02.28.08 Aetna Announces Delay in Implementation of New Clinical Policy
Aetna today announced that it will delay the effective date of a new clinical policy addressing the medical necessity of an anesthesiologist’s services during routine upper and lower endoscopic procedures, such as a colonoscopy. MAG's Department of Third Party Payer Advocacy had been arguing against the new clinical policy. Aetna has always covered moderate sedation, which is delivered by the treating physician, and is the type of sedation used for the majority of colonoscopies across the country. In the new policy, which was announced in late December, Aetna continues to cover moderate sedation, but only covers monitored anesthesia care for high-risk patients. The policy was scheduled to be effective on April 1, 2008. Aetna will now delay implementation until patient-friendly alternatives – which will not require the added expense of an anesthesiologist – are approved by the Food and Drug Administration (FDA) and available in the marketplace.
Read Aetna's Press Release
Read Aetna's Letter to Providers
02.07.08 Update on Preventive Medicine Reimbursement Policy by UnitedHealthcare:
Claim adjustments to be retroactive to August 27, 2007
UnitedHealthcare is pleased to announce that revisions to its Preventive Medicine Reimbursement Policy are now in effect. As revised, the policy allows for separate reimbursement for preventive medicine services and acute care Evaluation and Management (E&M) services on the same date of service.
The claim system enhancement needed to implement the new policy occurred on December 8, 2007. The updated policy is available in the Reimbursement Policies section of Unitedhealthcareonline.com. Because of the unanticipated delays in the policy’s formal effective date, UnitedHealthcare will, as an accommodation to physicians, retroactively apply the new policy to claims with dates of service of August 27, 2007 or later.
UnitedHealthcare is currently identifying and adjusting claims that were processed prior to the new policy becoming effective that had service dates between August 27, 2007, and December 8, 2007. Therefore, physicians do not need to seek adjustments of these claims.
Link to UnitedHealthcare's Web site
02.01.08 Important Announcement On Continuation of Epocrates Agreement by UnitedHealthcare
UnitedHealthcare's senior leadership has decided to extend its agreement with Epocrates to host prescription drug lists on physicians' handheld devices. As previously communicated, the agreement was set to expire on February 1. UnitedHealthcare will work directly with Epocrates on behalf of all UnitedHealth Group companies to draft an enterprise agreement. Physicians and businesses should have no interruption in their PDL hosting service from Epocrates.
12.12.07 Tiered and Narrow Physician Networks: How to Challenge your Profile or Placement
MAG's offices of the General Counsel and Third Party Payer Advocacy have teamed up with the AMA to disseminate a flyer giving tips on ways to challenge and improve your profile or placement.
Download Tiered Network Flyer
11.07.07 MAG Requesting Physician Reports on Health Plan Tiering:
Aetna Aexcel Designation; United Health Premium and Cigna Care
During recent months, many physicians have received letters from Aetna and United Health Care informing them whether they passed certain quality of care and efficiency measures for special designation under new or revised "Tiering" programs. These reports are often placed on the health plans’ Web site for viewing by patients and, reportedly, for health plans to move patients to higher quality and more efficient physicians.
MAG has received several reports from physicians about inaccuracies in these reports, including the addition of hospital charges in the physician profile. MAG is concerned about the misrepresentation of physician’s profiles based on inaccurate data and would like to hear from you. If you have noticed improper or incorrect data included, please send MAG copies of your designation report and background data. The information can be e-mailed, faxed or sent to:
Donald Palmisano, General Counsel, dpalmisano@mag.org
Cam Grayson, Director, Third Party Payer Advocacy, cgrayson@mag.org
Medical Association of Georgia
1849 The Exchange
Suite 200
Atlanta, GA 30339
Fax: 678.303.3732
If you have any questions, please contact Donald or Cam at 1.800.282.0224 or 678.303.9290.
03.05.07 Georgia Uniform Healthcare Practitioner Credentialing Application Form
The newest version of the Allied Healthcare Practitioner recredentialing application has been posted.
View form
11.12.06 Aetna's Urinalysis Dipstick and Pulse Oximetry Coding Change
After reviewing our policy related to urinalysis dipstick and pulse oximetry, and consulting with a committee comprised of state medical society representatives and members of the Physicians Advisory Board, Aetna is implementing the following coding change.
Beginning with claims processed as of November 12, 2006, we will pay the following codes when billed with office-based evaluation and management codes (E&Ms) appended with Modifier 25:
- Urinalysis dipstick CPT codes: 81002 and 81003
- Pulse oximetry CPT codes: 94760, 94761, 94762
- The office-based E&M codes that apply are 99201-99205, 99211-99215, 99241-99245 and 99381-99397.
All other policies will still apply and may impact the ultimate payment of the codes.
11.06.06 Important Message Regarding Aetna’s Payment Policy for Modifier-57 for Evaluation and Management (E&M) Visits
Aetna has reached an agreement with state medical societies to pay resubmitted claims for E&M visits billed with a Modifier-57 (indicating that the decision for surgery was made during the visit), for dates of service from January 1, 2005 through February 11, 2006.
When May Claims be Resubmitted? The resubmission period will begin on January 1, 2007 and will extend through April 30, 2007. Please do not resubmit these claims prior to January 1, 2007. They will be rejected as duplicate claims.
Read more
05.26.06 Modifier–25 Dispute with Aetna Resolved
As part of MAG’s landmark settlement with Aetna in the MDL RICO litigation, Aetna was required to pay physicians for both a procedure code and an evaluation and management code, appended with a modifier–25 when billed together.
Read more
05.26.06 Final order in the compliance dispute
View PDF
05.26.06 Codes to be reprocessed when billed with an E&M code appended with a modifier-25
View PDF
05.06 HIPAA and AMA Health Plan Complaint Forms
Read more
04.06 Blue Cross Blue Shield of Georgia RICO Contract Addendum Received
View PDF
04.06 Aetna Agrees to E&M Payments with Modifiers
View PDF
04.06 What to Do When Submitting Your Aetna Claims
Submit impacted claims with a cover letter that includes a subject line that reads "Rework Request for E&M Codes" or call the Aetna Provider Service Center to verbally request rework of the impacted claims.