The Honorable George Jepsen

November 27, 2017

The Honorable George Jepsen

Attorney General

55 Elm Street

Hartford, CT 06106

Dear Attorney General Jepsen,

On behalf of the physicians of the Connecticut State Medical Society (CSMS), we are writing to you today to express significant concern with Anthem’s new policy to drastically reduce payment to physicians and other clinicians who use the Current Procedural Terminology (CPT) Modifier 25 with an Evaluation and Management code when reporting, documenting and billing for the services provided to Anthem patients. This policy will have a significant negative impact on the quality of care provided to Connecticut patients and a negative financial impact as well.

By way of background, the CPTindicates that Modifier 25 is used when reporting/billing to indicate that a physician or other clinician performed an unrelated evaluation and management (E/M) that is “a significant, separately identifiable service performed on the same day as another procedure or service.” As you know, this situation arises daily in a physician practice: a patient goes to his/her doctor for a service or a procedure and says “while I am here, can you look at this other issue I am having.” For example, a patient has a scheduled pain injection with his orthopedist for a shoulder injury. After the patient receives the injection, the patient indicates to the doctor that he rolled his ankle yesterday and it was swollen and sore. The physician undertakes a separate evaluation and management of the ankle injury. The physician should appropriately use the Modifier 25 to identify the services provided to the patient that were unrelated to the shoulder injection.

Looking at Anthem’s new policy in the context of the fact scenario described above as well as other similar scenarios that happen daily in a physician’s office, the physician would receive very little additional payment for the time the physician took to do a separate evaluation and management of the patient’s ankle and some additional history and, of course, the associated medical decision-making that goes into the evaluation and treatment regimen for the ankle. The reality is that many physicians are struggling in this State to remain in an independent practice setting and to continue to care for their patients who are insured by Anthem. Insurer policies, such as the one involving Modifier 25 by Anthem, will force physicians to change their practices from a scheduling, care delivery, access, and billing perspective to the detriment of patient access to care. Physicians will have to tell patients, such as the one in the scenario above, that they will have to make a separate appointment for the ankle evaluation on a different date. This will not only reduce the quality of care provided to the patient, but force the patient to pay additional co-pays, deductibles, etc., for the out-of-pocket costs that will be incurred in a separate visit. The level of compliance will also suffer as the patient may not come back for that second visit on another day.

CSMS can unequivocally state that this is not how physicians want to practice medicine. Physicians want to be able to help their patients in a timely and efficient manner. Insurance companies, such as Anthem, are counting on physicians to provide the care regardless of payment. Unfortunately, as physicians struggle to

remain independent, they will not be able to provide what essentially amounts to uncompensated care, and patients will suffer through policies designed only to delay, reduce, or completely eliminate medical care at the time it is needed and most readily available.

In addition to the patient suffering, employers and the State of Connecticut who pay for the cost of their employees’ care will also suffer. Patients will incur numerous co-payments for additional medical visits and will require additional time away from work to attend these visits. Patients are also likely to incur longer wait times to see physicians, and additional office visits will need to be scheduled. The quality of patient care will suffer, and the negative economic impact to patients and employers alike will be significant.

The American Medical Association (AMA) has recognized the importance of preserving the Modifier 25 and, at the most recent InterimMeeting of its House of Delegates, held in November of 2017, the AMA House of Delegates passed new policy relative to Modifier 25 which states that the AMA “aggressively and immediately advocate through any legal means possible, including direct payer negotiations, regulations, legislation, or litigation, to ensure when an evaluation and management (E&M) code is appropriately reported with a modifier 25, that both the procedure and E&M codes are paid at the non-reduced, allowable payment rate.” The CSMS strongly supported and advocated for this policy.

Providing medically necessary, distinct services on the same date allows physicians to provide effective and efficient high quality care, in many cases saving patients a return visit. If Anthem is permitted to enact this policy, it is only a matter of time before the other insurers follow suit. This will inevitably lead to increases in healthcare costs for patients, employers, and the State of Connecticut, along with the further demise of the independent physician practice.

We must collectively work to stop Anthem and other insurers from dictating how medicine is to be practiced in the State of Connecticut.

Sincerely,

Matthew C. Katz

Executive Vice President/CEO