Anthem BCBS Cuts. Grim for several states.

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Torsed

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From my watchdog group Vachette:

Vachette has come across an issue some states are facing with Anthem BCBS. At this time it will not affect you because it is not in your state but we wanted you to be aware just in case other Blue plans decide to do the same thing. For pathology groups listed in the below 13 states they are going to be seeing a major cut to the reimbursement rates and only be getting between 40-60% of Medicare. We are working with our groups who are going to be affected to fight this and will continue to monitor this situation. If we see other states are starting to implement this as well we will be on top of getting any additional information out.

We are writing to you with information regarding Anthem Blue Cross Blue Shield.

Back in January we were notified that Anthem had cut rates in Missouri, effective November 1, for the following products:
  • Blue Access
  • Blue Access Choice
  • Blue Preferred
  • Pathway
  • Pathway X
  • Anthem Alliance
Alarmingly, these new rates reflected a more than 70 percent reduction from previously negotiated rates for many groups, which is significantly below 2019 Medicare rates published in the Medicare Physician Fee Schedule and Clinical Laboratory Fee Schedule.

When we inquired with Anthem representatives about this drastic policy shift, we received the following response:
“Anthem members should experience the same out of pocket costs regardless of site of service. Anthem updated their professional fee schedules to align compensation for lab rates in all settings. This change helps drive a consistent out-of-pocket cost experience based on services rendered.”

Needless to say, this change is unprecedented for laboratories and pathology groups.

However, 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. It appears they’ve now turned their attention to making similar changes for pathology services.

Our intention for this email is to raise awareness of this issue. We have been recently informed that letters are now going out to pathology groups in the following states:

OH
IN
KY
CA
CO
CT
GA
NH
ME
NV
NY
VA
WI

Attached is an example of a letter received for a group in Ohio.

Many pathology groups we’ve spoken with either were not aware of these cuts, or had not received letters to date. We’ve projected some groups we work with within the state could lose roughly 50 percent of their annual revenue from Anthem due to these reductions.

If you could please forward the letter if you receive, that would be appreciated. We are also including your biller who may receive the letter as well.

Our goal is to fight this and assist our clients in doing so. We have already been in contact with CAP and will continue to press for advocacy on this issue.

More to follow as we get additional information. Please let me know if you have any questions. Again, if you have received this letter, please notify us immediately. There is a time deadline for response.

The actual letter (Ohio version):

Anthem.00
-
April 10, 2019

Note: “Notice of Material Amendment/Change to Contract

Dear Participating Provider:

Anthem Blue Cross and Blue Shield (Anthem) would like to thank you for your continued participation in the Anthem Networks. We want to make you aware of upcoming changes to the Anthem Blue Cross and Blue Shield fee schedules for the Ohio Health Service Areas. The new fee schedules will apply to Covered Services rendered on, or after, July 10, 2019 for Blue Traditional, Blue Access, Blue Preferred, Blue Priority, OH Exchange PPO, OH Exchange HMO, OH Pathway Group HMO and Anthem Medicare Advantage members.

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 service 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.

A“material amendment” pursuant to Ohio Revised Code section 3963.01 is defined, in part, as an amendment to the Agreement that decreases a Provider's payment or compensation with certain listed exceptions. Given that this Amendment contains a change to the fee schedule that may decrease reimbursement depending on your medical practice's utilization of laboratory codes and/or behavioral health codes, Anthem is providing you with this ninety (90) day Notice of Material Amendment/Change to Contract.
Again, thank you for your cooperation. If you have any questions, contact your local Network Relations consultant or go to www.Avality.com after June 1, 2019 to check code allowances electronically.

Sincerely,

Community Insurance Company (d/b/a Anthem Blue Cross and Blue Shield)

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
 
We just heard of this from our billing company. At cuts of up to 50% of our Anthem revenue, this would be an existential threat to our practice.
How would you fight this? Go non-par?
 
Torsed said:
From my watchdog group Vachette:

Vachette has come across an issue some states are facing with Anthem BCBS. At this time it will not affect you because it is not in your state but we wanted you to be aware just in case other Blue plans decide to do the same thing. For pathology groups listed in the below 13 states they are going to be seeing a major cut to the reimbursement rates and only be getting between 40-60% of Medicare. We are working with our groups who are going to be affected to fight this and will continue to monitor this situation. If we see other states are starting to implement this as well we will be on top of getting any additional information out.

We are writing to you with information regarding Anthem Blue Cross Blue Shield.

Back in January we were notified that Anthem had cut rates in Missouri, effective November 1, for the following products:
  • Blue Access
  • Blue Access Choice
  • Blue Preferred
  • Pathway
  • Pathway X
  • Anthem Alliance
Alarmingly, these new rates reflected a more than 70 percent reduction from previously negotiated rates for many groups, which is significantly below 2019 Medicare rates published in the Medicare Physician Fee Schedule and Clinical Laboratory Fee Schedule.

When we inquired with Anthem representatives about this drastic policy shift, we received the following response:
“Anthem members should experience the same out of pocket costs regardless of site of service. Anthem updated their professional fee schedules to align compensation for lab rates in all settings. This change helps drive a consistent out-of-pocket cost experience based on services rendered.”

Needless to say, this change is unprecedented for laboratories and pathology groups.

However, 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. It appears they’ve now turned their attention to making similar changes for pathology services.

Our intention for this email is to raise awareness of this issue. We have been recently informed that letters are now going out to pathology groups in the following states:

OH
IN
KY
CA
CO
CT
GA
NH
ME
NV
NY
VA
WI

Attached is an example of a letter received for a group in Ohio.

Many pathology groups we’ve spoken with either were not aware of these cuts, or had not received letters to date. We’ve projected some groups we work with within the state could lose roughly 50 percent of their annual revenue from Anthem due to these reductions.

If you could please forward the letter if you receive, that would be appreciated. We are also including your biller who may receive the letter as well.

Our goal is to fight this and assist our clients in doing so. We have already been in contact with CAP and will continue to press for advocacy on this issue.

More to follow as we get additional information. Please let me know if you have any questions. Again, if you have received this letter, please notify us immediately. There is a time deadline for response.

The actual letter (Ohio version):

Anthem.00
-
April 10, 2019

Note: “Notice of Material Amendment/Change to Contract

Dear Participating Provider:

Anthem Blue Cross and Blue Shield (Anthem) would like to thank you for your continued participation in the Anthem Networks. We want to make you aware of upcoming changes to the Anthem Blue Cross and Blue Shield fee schedules for the Ohio Health Service Areas. The new fee schedules will apply to Covered Services rendered on, or after, July 10, 2019 for Blue Traditional, Blue Access, Blue Preferred, Blue Priority, OH Exchange PPO, OH Exchange HMO, OH Pathway Group HMO and Anthem Medicare Advantage members.

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 service 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.

A“material amendment” pursuant to Ohio Revised Code section 3963.01 is defined, in part, as an amendment to the Agreement that decreases a Provider's payment or compensation with certain listed exceptions. Given that this Amendment contains a change to the fee schedule that may decrease reimbursement depending on your medical practice's utilization of laboratory codes and/or behavioral health codes, Anthem is providing you with this ninety (90) day Notice of Material Amendment/Change to Contract.
Again, thank you for your cooperation. If you have any questions, contact your local Network Relations consultant or go to www.Avality.com after June 1, 2019 to check code allowances electronically.

Sincerely,

Community Insurance Company (d/b/a Anthem Blue Cross and Blue Shield)

Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Click to expand...
Our worst nightmare-the government as our best payor.Can't wait for the CAP to defend us.Bring on socialized medicine and at least i will be paid for self pay=no pay.
 
Well this ended up being much ado about nothing. The cuts aren't nearly this bad we found out. We are getting a small cut though.
 
That's great news. I hope it is true for everyone in the Anthem service area
( I was told by some of my contacts they were facing a cuts greater than 50%)
 
Small practice in Maine here. Our 88305-26 will be cut to $24, much less than what Medicare pays. If it goes through July 1 like the letter we received says, we expect a 30-40% drop in revenue, a killer for a small practice like ours. CAP’s economic affairs committee said there is very little they can do with private payers. Calling Anthem was a dead end. Hospital is no help so far. We have no state society here. Is there any requirements in the ACA we can hold them to, to at least pay Medicare rates? If we accept that small of reimbursement from them, wouldn’t it be Medicare fraud to charge Medicare more? Can we sue Anthem? How soon before other payers follow suit?
 
Dr. And Mom said:
Small practice in Maine here. Our 88305-26 will be cut to $24, much less than what Medicare pays. If it goes through July 1 like the letter we received says, we expect a 30-40% drop in revenue, a killer for a small practice like ours. CAP’s economic affairs committee said there is very little they can do with private payers. Calling Anthem was a dead end. Hospital is no help so far. We have no state society here. Is there any requirements in the ACA we can hold them to, to at least pay Medicare rates? If we accept that small of reimbursement from them, wouldn’t it be Medicare fraud to charge Medicare more? Can we sue Anthem? How soon before other payers follow suit?
Click to expand...
I’d be eternally grateful to you if you fought this battle in court for us. I’m still in training but would be in your debt if you worked with an attorney to fight these corrupt insurance companies.
 
-No. They can pay far below medicare rates if you except it.

- "wouldn’t it be Medicare fraud to charge Medicare more"

20 years ago a few physicians told me this too. I have never seen a statute that implies this.
I am fairly certain this is not the case. The big box lab have been receiving less than medicare for at least 30 years

-Legal battles are for those with deep pockets even if you have a good case.

-You have only a few choices.

Take what they offer and suffer loss.
Go out of network and collect as best you can (tricky business but can be done in well in some situations)
Quit and find another job. This might mean becoming a hospital employee too.
Have your practice join another one with a stronger market position.

Maine is pretty small state.
You should start communicating with as many other private groups as can.
Putting as many pathologists under one banner might save jobs not just salaries.

Stuff like this is a death blow to most of us in small practices.

Pathology business is not much fun these days Dr And Mom.

Most of us are in the same boat and it is starting to sink ....

You might be able to bail water by taking the hit for awhile.
Eventually, most of us will try one of the other options.
Revenue drops like this force change and conflict
 
AZpath said:
-No. They can pay far below medicare rates if you except it.

- "wouldn’t it be Medicare fraud to charge Medicare more"

20 years ago a few physicians told me this too. I have never seen a statute that implies this.
I am fairly certain this is not the case. The big box lab have been receiving less than medicare for at least 30 years

-Legal battles are for those with deep pockets even if you have a good case.

-You have only a few choices.

Take what they offer and suffer loss.
Go out of network and collect as best you can (tricky business but can be done in well in some situations)
Quit and find another job. This might mean becoming a hospital employee too.
Have your practice join another one with a stronger market position.

Maine is pretty small state.
You should start communicating with as many other private groups as can.
Putting as many pathologists under one banner might save jobs not just salaries.

Stuff like this is a death blow to most of us in small practices.

Pathology business is not much fun these days Dr And Mom.

Most of us are in the same boat and it is starting to sink ....

You might be able to bail water by taking the hit for awhile.
Eventually, most of us will try one of the other options.
Revenue drops like this force change and conflict
Click to expand...
Thank you, great info. Last question, is Vashette worth the money or are those negotiations beyond their capabilities?
 
I work with Vachette currently and endorse them.
That does not mean Anthem will suddenly cave if you hire them.
Certainly, it is worth exploring.

They can also advise you on the viability of an out of network strategy.
Billing advice is their core product.
The have always charged us a flat fee per month with 90 day notice in their contract.
If this how you contract with them, then the downside is limited is to three months.

When I started my lab BCBS of Arizona wanted to pay 50-60% of MC too.
I remained out of network for nearly a year.
BCBS of AZ would send a check direct to the patient for our services.
The did not even send us an EOB.
That made billing very hard.
Neverthelesss, we still collected more than the in network amount.
BCBS eventually gave us a fairly good contract.
I am mostly hospital based. My hospital was very understanding.
We did not lose clients.

We are all facing more and more challenges these days.
Jobs are on the line with cut like these.
Hiring new folks is out of the question for states with Anthem.
Makes the job market it tougher for new the fellows coming out.
 
AZpath said:
-No. They can pay far below medicare rates if you except it.

- "wouldn’t it be Medicare fraud to charge Medicare more"

20 years ago a few physicians told me this too. I have never seen a statute that implies this.
I am fairly certain this is not the case. The big box lab have been receiving less than medicare for at least 30 years

-Legal battles are for those with deep pockets even if you have a good case.

-You have only a few choices.

Take what they offer and suffer loss.
Go out of network and collect as best you can (tricky business but can be done in well in some situations)
Quit and find another job. This might mean becoming a hospital employee too.
Have your practice join another one with a stronger market position.

Maine is pretty small state.
You should start communicating with as many other private groups as can.
Putting as many pathologists under one banner might save jobs not just salaries.

Stuff like this is a death blow to most of us in small practices.

Pathology business is not much fun these days Dr And Mom.

Most of us are in the same boat and it is starting to sink ....

You might be able to bail water by taking the hit for awhile.
Eventually, most of us will try one of the other options.
Revenue drops like this force change and conflict
Click to expand...
Ask DR. REMICK for his sage advice
 
AZpath said:
I work with Vachette currently and endorse them.
That does not mean Anthem will suddenly cave if you hire them.
Certainly, it is worth exploring.

They can also advise you on the viability of an out of network strategy.
Billing advice is their core product.
The have always charged us a flat fee per month with 90 day notice in their contract.
If this how you contract with them, then the downside is limited is to three months.

When I started my lab BCBS of Arizona wanted to pay 50-60% of MC too.
I remained out of network for nearly a year.
BCBS of AZ would send a check direct to the patient for our services.
The did not even send us an EOB.
That made billing very hard.
Neverthelesss, we still collected more than the in network amount.
BCBS eventually gave us a fairly good contract.
I am mostly hospital based. My hospital was very understanding.
We did not lose clients.

We are all facing more and more challenges these days.
Jobs are on the line with cut like these.
Hiring new folks is out of the question for states with Anthem.
Makes the job market it tougher for new the fellows coming out.
Click to expand...

You have to communicate with the patient ASAP or they will spend that check. We used to send a letter. It is more work but you can collect much more than the in network amount. Going out of network can be done. We did it with these people for a long time.

Seems like Maine would be an easy place to use your small ranks to band together and fight this. How many groups does Maine even have? Three or Four?
 
WEBB PINKERTON said:
You have to communicate with the patient ASAP or they will spend that check. We used to send a letter. It is more work but you can collect much more than the in network amount. Going out of network can be done. We did it with these people for a long time.

Seems like Maine would be an easy place to use your small ranks to band together and fight this. How many groups does Maine even have? Three or Four?
Click to expand...
2 large groups, for whom these changes are not affecting, to my knowledge (more negotiating power, I guess). Maybe 15 other pathologists in the rest of the state in smaller groups like ours or solo practice, likely also getting picked off.
 
The main ones they pass over are low ball players like Lab Corp and Quest
They are lucky if they are not get hit.
 
Update on my situation; our PPO we joined several years ago negotiates rates separately so the “state wide” rate cut doesn’t apply (somehow, our billing company didn’t know this). Big relief for us, not so much for smaller providers and practices. Missed this bullet but their chambers are by no means emptied.
 
Lucky break. My industry contacts tell me if you negotiated a rate your ok.
If you joined their network and accepted their network fee schedule then you are getting killed.

By the way, how does a PPO negotiate rates ?
 
AZpath said:
Lucky break. My industry contacts tell me if you negotiated a rate your ok.
If you joined their network and accepted their network fee schedule then you are getting killed.

By the way, how does a PPO negotiate rates ?
Click to expand...
I think it is bundled with all the rates contracted for in our organization, including hospital and gen lab fees, radiology, etc but I’m not completely sure.
 
I use Vachette too. Many conference calls about reviewing the blueprints for the titanic. My biller is not as motivated as Vachette.

My biller is APS who is overall B+. I don't know which biller everyone else uses.
 
Torsed said:
I use Vachette too. Many conference calls about reviewing the blueprints for the titanic. My biller is not as motivated as Vachette.

My biller is APS who is overall B+. I don't know which biller everyone else uses.
Click to expand...

Just started with APS. Left Change/McKesson. Hope B+ is still an improvement.
 
We use Change/McKesson and I am unhappy they sat on that letter from Anthem for 2 months before bringing it to our attention (small practice without a practice manager).
 
Dr. And Mom said:
Update on my situation; our PPO we joined several years ago negotiates rates separately so the “state wide” rate cut doesn’t apply (somehow, our billing company didn’t know this). Big relief for us, not so much for smaller providers and practices. Missed this bullet but their chambers are by no means emptied.
Click to expand...
Well according to APS the up to 50 % medicare rates roll backs are continuing in next 2-6 weeks with ANTHEM BC-BS not showing proposed payments save through AVILITY GATEWAY-My main billing contact ask me what the CAP is doing to help us inducing a rant from me.Apparently the ACADEMY of OPHTHALMOLOGY fought a similar cut and won this year.
 
Last edited:
This was a fairly humorous event for me. See in California our fine Democratic supermajority often does things without the full realization of the impact of their half-baked SJW ideas.

Sometimes its a disaster for us, like AB2325 Ken Maddy's Law (although this ended up being totally revised to a trivial nature for CA pathologists) but sometimes, just sometimes there is a way of looking at it and employing their laws as "steel pikes" dismounting armored big insurance horsemen.

California has AB 72 which prevents patients from have to accept any of the risk if they go to a hospital where their insurance is accepted but the providers are not enrolled. Ostensibly, this was to prevent abuse by mainly Orthopods who would take patients to OP surgery centers, do surgery out of network and get 20K for like 2 hours of work. Not bad. The law is interesting in that if you are out of network, you get an auto 125% medicare on the entire fee schedule.

Yah 125% aint much, but it aint nothing. BUT you get that 125% even on codes that exist that Medicare doesnt pay because they are bundled in part A payments...

And these 125% are automatic, insurance companies cant argue and not pay them unless the underlying charge is fraudulent.

So I told the head of Anthem they should expect to pay me an extra 25-30K a month on the pro fees for lab tests as well as the normal 125% contract rate and they got back to me in 24hrs with a personal letter saying my practice was exempt from any changes related to this policy shift...hahahahaahaha

268460
 
LADoc00 said:
This was a fairly humorous event for me. See in California our fine Democratic supermajority often does things without the full realization of the impact of their half-baked SJW ideas.

Sometimes its a disaster for us, like AB2325 Ken Maddy's Law (although this ended up being totally revised to a trivial nature for CA pathologists) but sometimes, just sometimes there is a way of looking at it and employing their laws as "steel pikes" dismounting armored big insurance horsemen.

California has AB 72 which prevents patients from have to accept any of the risk if they go to a hospital where their insurance is accepted but the providers are not enrolled. Ostensibly, this was to prevent abuse by mainly Orthopods who would take patients to OP surgery centers, do surgery out of network and get 20K for like 2 hours of work. Not bad. The law is interesting in that if you are out of network, you get an auto 125% medicare on the entire fee schedule.

Yah 125% aint much, but it aint nothing. BUT you get that 125% even on codes that exist that Medicare doesnt pay because they are bundled in part A payments...

And these 125% are automatic, insurance companies cant argue and not pay them unless the underlying charge is fraudulent.

So I told the head of Anthem they should expect to pay me an extra 25-30K a month on the pro fees for lab tests as well as the normal 125% contract rate and they got back to me in 24hrs with a personal letter saying my practice was exempt from any changes related to this policy shift...hahahahaahaha

View attachment 268460
Click to expand...
Well most of us ain't in CALIFORNIA-by the way,A BIG WELCOME BACK-YOU'VE BEEN MISSED.ADDENDUM-Talked with a pathologist in DR. GODBEY group SEPA(SOUTHEASTERN PATHOLOGY ASSOCIATES)-told me he has recently discussed this with SIR GODBEY and the latter is checking into whether the CAP can do something-don't shoot the messenger
 
Last edited:
I am amazed at the lack of general alarm to this really draconian act to the business of pathology.I have been surprised by the general lack of knowledge about this in many close by pathology groups i have called.Other insurers will follow suit even in non ANTHEM states. Medicare will follow suit.Eventually ACADEMIA may be affected and the CAP may get involved right before single payer or nationalized medicine rolls in.WHERE IS THE CAP OR ACADEMIA.Going NON PAR may be my only choice but it is fraught with many difficulties and perils.Patients always blame us,never the providers.
 
Last edited:
LADoc00 said:
This was a fairly humorous event for me. See in California our fine Democratic supermajority often does things without the full realization of the impact of their half-baked SJW ideas.

Sometimes its a disaster for us, like AB2325 Ken Maddy's Law (although this ended up being totally revised to a trivial nature for CA pathologists) but sometimes, just sometimes there is a way of looking at it and employing their laws as "steel pikes" dismounting armored big insurance horsemen.

California has AB 72 which prevents patients from have to accept any of the risk if they go to a hospital where their insurance is accepted but the providers are not enrolled. Ostensibly, this was to prevent abuse by mainly Orthopods who would take patients to OP surgery centers, do surgery out of network and get 20K for like 2 hours of work. Not bad. The law is interesting in that if you are out of network, you get an auto 125% medicare on the entire fee schedule.

Yah 125% aint much, but it aint nothing. BUT you get that 125% even on codes that exist that Medicare doesnt pay because they are bundled in part A payments...

And these 125% are automatic, insurance companies cant argue and not pay them unless the underlying charge is fraudulent.

So I told the head of Anthem they should expect to pay me an extra 25-30K a month on the pro fees for lab tests as well as the normal 125% contract rate and they got back to me in 24hrs with a personal letter saying my practice was exempt from any changes related to this policy shift...hahahahaahaha
Click to expand...
Congratulations. You, sir, are well connected. That is not what they told me :blackeye:
 
Whatever happened with this? Did Ohio, Maine, etc. ever get hit with the cuts July 1? Was it as bad as the Vachette letter said it would be?
 
You hear more in the next few months as these claims get paid
 
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