Anthem slashing lab reimbursements in several states (update)

June 12, 2019

After significantly slashing payment rates for lab services in Missouri late last year, it appears Anthem is now moving to institute similar cuts in a number of other states, including Ohio, California and Indiana, according to letters recently received by Vachette clients.

Many of these new rates reflect a roughly 70 percent drop from previously negotiated reimbursements for many groups and are a significant reduction from 2019 CMS rates published in the Physician Fee Schedule and Clinical Laboratory Fee Schedule.

New rates will go into effect in Ohio for covered services provided on or after July 10. Providers in KY, NY, CO, CT, GA, NH, ME, MO, NV, VA and WI are also expected to experience similar cuts in the near future.

According to the letter sent to Ohio providers:

“For Blue Traditional, Blue Access, Blue Preferred, Blue Priority, OH Exchange PPO, OH Exchange HMO, OH Pathway Group HMO and Anthem Medicare Advantage Covered Services, the fees for:

  • Rates for codes in the 80000-89999 series will be modified to reflect the rates currently in place for dedicated laboratory services providers. Certain in-office testing will be exempt from the changes.
  • Rates for 0362T and 0373T will be reduced to be consistent with the recent changes to the codes definitions reducing the time per unit from 30 minutes to 15 minutes.
  • Rate for 97153 will be reduced to reflect an update to the manner in which adaptive behavior services may be billed.”

However, it is important to note these changes are not uniform across states. For example, in Kentucky 88300-88309 will not be impacted, possibly as a concession to those who have already pushed back against these changes in other states.

Those who disagree with these changes must send a Notice of Objection within 10 days of receipt of the letter.

As we have recently experienced with Anthem’s policies on ER visits and MRIs, Anthem is making moves to drastically cut reimbursements to ancillary providers at a time when its overall membership continues to grow, including the addition of 1.2 million new members and a reported 9.2 percent revenue growth to $24.4 billion in Q1 of 2019. It appears they’ve now turned their attention to making similar changes for pathology services.

As we’ve done in Missouri, we will continue to leverage our resources to push back on these misguided rate cuts. Recently, we were informed Anthem was “reconsidering” the changes after receiving significant pushback from St. Louis-area labs.

Additionally, the Ohio Society of Pathologists Board of Governors sent an urgent email to members urging them to be on the lookout for these notices.

Some of the states we have worked with have sent letters, but the only area that has the pathology group listed is on the envelope. The actual letter itself does not have the group name listed.

Vachette will continue to keep up on these Anthem cuts and keep all of our clients informed of any new information we come across.

Here are the most recent changes announced for each effected state:

MO – new fee schedule implemented 11/1/2018

AK – new fee schedule implemented 1/1/19

WA – new fee schedule implemented 1/1/19

CA – new fee schedule set to roll out 7/1/2019 (Prudent Buyer Plan)

OH – new fee schedule set to roll out 7/1/2019

IN – new fee schedule set to roll out 7/1/2019

WI – new fee schedule set to roll out 8/1/2019

KY – new fee schedule set to roll out 9/1/2019 (note:  88300-88309 will not be impacted)

VA – new fee schedule set to roll out on 9/1/19

NH – verifying with biller the new fee schedule effective date

NY – new fee schedule effective 1/1/2020

Highmark WV – new fee schedule 9/1/2019

GA – cuts go into effect 7/1/19 – clients need to request their own fee schedule.

In the meantime, please reach out to us at 517-486-4262 to see the full list of codes affected by these cuts, or to discuss options if your group is notified of any similar reductions in the near future.

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