MMA Challenges BCBS MN Policies that Reduce Payment for Same-Day Services

November 7, 2024

In a letter sent October 29, the MMA formally requested that Blue Cross Blue Shield of Minnesota (BCBS MN) reconsider three of its publicly posted reimbursement policies that reduce physician payment for same-day services. 

Specifically, BCBS MN reduces payment for evaluation and management (E/M) services by 20% to 50%, depending on product line (i.e., commercial, Medicaid, Medicare), when appended with modifier 25. The Common Procedural Terminology® (CPT®) coding guidelines require that providers append modifier 25 to an E/M service to “indicate that a patient’s condition required a significant, separately identifiable E/M service above and beyond that associated with another procedure or service by the same physician…on the same date.”  

The MMA’s request follows a lengthy dialogue between the MMA and BCBS MN on the policies. The two first met in November 2023 after several MMA members flagged the policies. At that meeting, the chief medical officer at BCBS MN shared his belief that other Minnesota health plans had similar policies, and thus BCBS MN was within community standards. The MMA tabled the conversation to corroborate BCBS MN’s claim. 

Since then, MMA staff have concluded that, based on publicly available information confirmed by other health plan representatives, BCBS MN is the only health plan with modifier 25 payment reduction policies that apply in all cases that a modifier 25 is used. Three health plans have no modifier 25 payment reduction policies whatsoever. Three other health plans have modifier 25 payment reduction policies that apply only when the E/M service is billed with a same-day preventive service (e.g., CPT codes 99381-99387, 99391- 99397). 

At a follow-up meeting on October 28, 2024, BCBS MN acknowledged the MMA’s findings, but argued that, since same-day services afford physicians overhead- and pre/post-op- synergies, the cost to provide care is less, and thus reimbursement should be less.  

The MMA agreed that there are synergies and overhead efficiencies generated when services are provided at the time of a patient visit. However, the MMA noted that the Relative Value Update Committee (RUC) regularly screens all CPT codes that are billed with E/M codes more than 50% of the time and then reduces the relative value units (RVUs) of those codes to prevent duplicate valuation of practice expenses and pre-/post-visit physician work (AMA, 2023, p. 35 of pdf). Therefore, the policies of BCBS MN to further, and arbitrarily, reduce payment for these services is inappropriately redundant.  

“The rationale provided by Blue Cross Blue Shield for their payment reduction policy does not hold up to scrutiny,” said MMA President Edwin Bogonko, MD, MBA.  “The policy is harmful to physicians and duplicates reductions that have already been accounted for by the RUC.” 

The MMA will update its members on the response from BCBS MN. Please contact Adrian Uphoff, health policy analyst, with questions.