Recoupment Request for No Prior Authorization

The KAC is aware that providers have been receiving recoupment requests for lack of prior authorization. In late 2019/early 2020, the KAC was successful in stopping Anthem from requiring prior authorization for chiropractors through AIM in Kentucky. Providers should have received a letter from Anthem that stated prior authorization was postponed indefinitely for chiropractors.

If providers are currently receiving recoupment requests for lack of prior authorization, we encourage all providers to reach out directly to their provider rep. You can share the letter Anthem sent to providers regarding the postponement of prior authorization.

What is the KAC working on?

The KAC is currently meeting with Anthem on a regular basis on a few different issues. We are also working with our lobbying team to get a meeting with the “higher ups” in Anthem to bring awareness and work to a resolution on this issue.

On November 22, 2021, the KAC sent a survey out to all providers to see how they have been impacted. Did you take our survey? If not, click here to take the 3-question survey.

Resources

Download a copy of Anthem’s letter in February 2020 regarding the postponement of prior authorization indefinitely here.

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Anthem Update – Modifier Rules and Guidelines for “Always Therapy” Codes

Recently, Anthem announced they were changing their modifier rules for physical medicine and rehabilitation codes. This change took effect November 1, 2021. These codes and modifiers align with the codes the Centers for Medicare & Medicaid Services (CMS) has designated as “always therapy” services and require GN, GO or GP modifiers for physical therapy, occupational therapy, or speech-language pathology services when billed on a professional claim.

CMS has a spreadsheet available to indicate which codes require which modifiers. Chiropractors will generally use the GP modifier code to indicate the patient is under a plan of care that includes physical therapy. Resources are below for your reference.

Resources

To view Anthem’s notice , please click here

To view the CMS website that has an archive of “always therapy” list of codes click here

To download the 2021 list of “always therapy” codes, click here

To download the 2022 list of “always therapy” codes, click here

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How to read the spreadsheets:

The best way to read the spreadsheets is to first, download them. Find the desired code you are using. Look for what columns are checked. Scroll to the top of the spreadsheet and hover over the number listed. Each column has a note or instructions that is associated with each column. Read the note and apply as applicable to your billing practices.


Most common codes use

Below is a list of most common codes used, however the list is not all inclusive. Please download the spreadsheet to review and be sure you are using the proper modifier when billing. These codes, when billed, will need the proper modifier attached (GN, GO, or GP). GP is the most common code used by chiropractors when using these codes to indicate the patient is under a plan of care that includes physical therapy. The GP modifier also indicates the service was performed in an outpatient setting.

97001-97004, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032-97036, 97039, 97110 , 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97161-97168, 97504, 97520, 97530

Anthem 10-7

Anthem has been denying codes 98940/98941 as not covered by this provider type.  We have reached out to Anthem executives about this issue and sent several examples to them.  Anthem has informed us that they have identified the system issue that was causing these denials.  All impacted claims have been pulled for reprocessing.  Providers should see reimbursement for these services in the next 30-45 days.

Anthem has also been denying 97140 manual therapies. We have been discussing this issue with them and believed this issue was resolved.  However, providers have stated this may not be the case.  Be sure you are using modifier 59 and this is being done in an area separate than the adjustment.  Also, providers must point their diagnosis codes to the procedure being performed.  We will continue working on this issue. 

Some providers received letters stating they were at least 20% higher than the 2019 mean number of visits per patient for the Anthem Chiropractic network in Kentucky.  We are reaching out to Anthem executives for more information on this letter and to get more clarification as to how these numbers were derived.    

Various Issues

As I am sure you are aware by now, Anthem has removed the requirement for prior authorization for physical medicine services performed in a chiropractic office.  You can read their statement here. However, providers have had multiple other issues arise since the first of the year.  Two of the major complaints have been denials for E/M services and denials for manual therapy.  We have sent claim examples to them and are awaiting a response.  

AIM

As you are hopefully aware, Anthem is planning on starting a new pre-authorization process for all therapy services, 97xxx codes, on March 1st. This process will require you to register with AIM for pre-certification of these services.

The KAC has had the stance from the beginning of this process that Anthem has not notified providers properly of this change. According to KRS 304-17A-235 a material change to a contract is defined as any change that will create a significant increase in administrative cost. Applying this new pre-authorization process is a significant increase in the administrative burden on a provider and thus this material change should be distributed to all providers in an orange envelope as required in KRS 304-17A-235.

The KAC has had many conversations with Anthem through this process. Anthem was willing to listen to our concerns and was helpful in providing information on the upcoming change. Ultimately we could not come to an agreement that the orange envelope notification was required. This led the KAC to meet with the Department of Insurance (DOI) and ask for their opinion on this issue.

Today we have received word from DOI that they have informed Anthem that the previous notifications of the new AIM process are not sufficient to meet the criteria of KRS 304.17A-235. Anthem has been instructed to not implement the AIM precertification until proper notification has been sent.

At this point, we have not heard from Anthem on their plan going forward, but we should be receiving a notification that the March 1st implementation date of AIM for Doctors of Chiropractic should be delayed. Please keep your eyes open for more information as we receive it. We know this is a significant and alarming change. We are continuing to work with Anthem toensure that your voice is heard about the impact of this change on your practice.  

We would like to take a moment and thank you for your continued membership in the KAC. The KAC has a dream. A dream that all chiropractors are successful in helping their patients achieve health. Working together we have been able to take a step closer to this dream. Your membership allowed us to accomplish this delay and hopeful change in Anthem’s policy.  

AIM

Anthem Pre-Authorization Change (Update)

Here are the details:

  •          Anthem is implementing preauthorization for all 97XXX codes starting March 1st, 2020. This is a directive from Anthem corporate and they are implementing for all provider types.
  •          You may have received a postcard directing you to read the December provider update. We do not believe this is sufficient notification for providers and have told Anthem that we believe they are in violation of Kentucky law.  The KAC believes this type of change falls under Kentucky’s Orange Envelope Law and requires a 90-day notice before implementation can occur.
  •          We are working closely with Anthem to find a solution, as we believe this will negatively impact patient access and add administrative costs to our doctors.
  •          At this time, we are not asking for any doctor or patient involvement but keep your eyes open for communication from the KAC.

    If you have received rejections from Anthem for missing pre-authorization of a 97XXX code, please remove all patient information and email it to Dr. Nick Payne at drpayne@thekac.org

Anthem Announces AIM

Anthem has stated that all therapy codes will need prior authorization starting March 1, 2020, through AIM.  This notice was sent out in their Provider News on 12/1/2020.  At this time, no provider we have spoken with has received notice in accordance with the “Orange Envelope Law”.  The KAC continues to work with Anthem to find a solution to this new process.