Some Anthem-insured patients and their doctors faced serious issues during October and early November. Maybe your practice is among those that contacted the ISMA for assistance. When the phone calls began to mount and practice advisors learned some surgeries were cancelled because precertification could not be obtained from Anthem, the ISMA requested a meeting.
“With calendars and scheduling conflicts, it took a while to arrange a meeting with Anthem to discuss this and other issues,” said Sandra Miller, director of Practice Management. “It’s sad that patient care was compromised before things were resolved.” One ob/gyn practice advised the ISMA that seven or eight planned surgeries had to be cancelled because Anthem did not respond to requests for precertification.
Concerns were also growing around reductions in reimbursement for same-day evaluation and management (E/M) services for preventive care visits, as well as verification for patients with marketplace plans.
Miller along with ISMA staff members Michael Rinebold, director of Government Relations, and Michael Brady, legislative coordinator, finally sat down with Anthem officials on Nov. 11. Here are the issues discussed and the outcomes reported to date.
Issue: Electronic prior authorization (PA) delays
Anthem response: Anthem response: Anthem confirmed PA requests became backlogged, partly due to implementation of a new precertification system. In evaluating the problem, Anthem discovered many of the cases landed in an inaccessible area of their system. Physicians were asked to resend the paperwork because Anthem had no record of receipt.
Anthem hired more technicians to address the problem. Anthem officials assured the ISMA that the average phone answer time is back to normal, and PA processing has also returned to normal.
Issue: A 50 percent reduction in reimbursement for same-day, problem-oriented E/M service when performed with a preventive exam
Anthem response: According to Anthem, the reduction in E/M services reimbursement was made to eliminate a duplicate practice expense payment when that pay is already included in the Relative Value Unit (RVU) calculation for the preventive exam. As a reminder, the RVU calculation considers three components: work expense, malpractice expense and practice expense. The practice expense portion represents overhead costs, staffing costs, etc. associated with patient visits.
Anthem pays the malpractice expense and the work expense separately for CPT codes billed, but has discontinued paying the practice expense for each CPT code billed because those costs are not duplicated when services are performed on the same day. Anthem officials advised that their plans in other states previously adopted this policy; Indiana plans are among the last to adopt it, following notification last summer.
Issue: Communication regarding 90-day grace period verifications for marketplace plans
Anthem response: Most physician practices have a goal of verifying patients’ grace period status before they arrive for appointments. Anthem advised this task can be accomplished through normal channels, using Availity. Knowing if a patient’s premium has not been paid offers practice staff the opportunity to make payment arrangements with the patient during the visit.
Anthem advised that in addition to Availity, premium-payment status can be obtained by calling the customer service phone number on the back of member ID cards. Medical practices should ensure all staff are aware of these processes for verification.
Jocelyn M. Forehand, CMPE, CPC, CEO of Southside OBGYN, advised their staff does check Availity for eligibility of patients, but they also call often because Availity doesn’t specify if the surgeon benefit is the same as the facility benefit.
“It also doesn’t always specify on precert(ification),” she said. “I personally have not been precertifying through Availity after all the previous trouble.
This time of year, volume is up and we are precertifying at the last minute. So, uploading and entering through Availity is not a quick process, nor is it user friendly.”
However, Forehand noted that precertification recently has been more timely, and her staff is not being transferred to voicemail, as in recent months.
If your practice has continued to have problems with these issues, please call the ISMA and ask to speak with Miller or a practice advisor.