Health insurers Anthem and Aetna began denying providers' claims that include consultation codes this year, joining the growing ranks of payers cutting reimbursement amid an industrywide coding change.
Consultations are a type of evaluation and management service provided at the request of another physician. For example, a primary care physician may refer a patient to a cardiologist. The specialist would then examine the patient, offer an opinion and send the individual back to the primary care provider for treatment. The cardiologist in this case would bill for the visit using a consultation code.
Medicare stopped paying claims that include consult codes in 2010. Instead, providers bill for inpatient or outpatient visits using codes that pay less.
Now, more insurers are following the Centers for Medicare and Medicaid Services' lead and requiring providers to use different codes to bill for consultations. The change will scale back provider payment and could reduce communication between primary care providers and specialists, said Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association.
"It's unfortunate that more and more plans now are not reimbursing consult codes," Gilberg said. "It has the potential to disadvantage certain specialties as well as interfere with communication and could create some ambiguity about the roles of the referring physician and the consulting physician."
The California Medical Association is concerned that changing reimbursement for these services will affect patient care, Dr. Robert Wailes, the organization's president, wrote in an email.
"As communities, patients and physicians continue to struggle with the pandemic, health plans should be putting patient care first," Wailes wrote. "They should not be eliminating payment for specialist consultations that provide patients a higher level of care as a way to save money."
A decade ago, CMS's reasoning was twofold, said Nancy Enos, co-owner of Enos Medical Coding. With the adoption of the electronic medical records, the administrative costs associated with sending reports back to referring physicians were eliminated, making higher reimbursement harder for physicians to justify, Enos said.
The codes were also often misused. In 2001, 75% of clinicians used the codes incorrectly, artificially inflating reimbursement by $1.1 billion, according to a report from the Health and Human Services Department's Office of Inspector General.
"Many times specialists were using their initial visits for consults, or a transfer of care, or even actually taking the patient under their care and assuming treatment responsibility for the patient," Enos said.
Since then, health plans have slowly been following CMS's lead.
UnitedHealthcare stopped recognizing these codes in 2019 in an effort to align with federal practices. The nation's largest insurer implemented the policy after facing pushback from groups such as the American College of Rheumatology, the American Academy of Neurology and the American Psychiatric Association, which complained the change undervalued their members' services.
When CMS eliminated consultation codes in 2010, the agency offset the payment reduction by increasing reimbursement for new and established patient visits. UnitedHealthcare spent two years updating its physician contracts so they included higher fees for patient appointments prior to rolling out the new rules, doctors said at the time.
In 2019, Cigna ended reimbursement using consultation codes for its commercial policyholders. Now, Anthem and Aetna have halted reimbursement for the codes, as well. Anthem and Aetna did not respond to interview requests.
Insurers' policy changes are likely coming now because CMS plans to change how consultations are reimbursed next year, Enos said. Under a new rule, payments will be based on the time clinicians spend with patients and on the medical decisions made during consultations. The rate will decline $14 for every inpatient visit and $7.50 for every outpatient consult service offered, she said.
Patients could benefit financially, Enos said. "If they have a copay or deductible that's based on a percentage of the allowed charge, then there will be slight reductions to the patient's out-of-pocket responsibility," she said.
The administrative cost associated with updating billing could spell the end of consult codes, particularly for independent providers with fewer resources, said Dr. Michael Stearns, specialized consulting director of medical informatics at the consulting company Wolters Kluwer. The new policies could reduce the number of providers willing to come in during off-hours to see patients, he said.
"Specialists were not happy about this when it first came out," Stearns said. "There is concern about some providers will stop doing these visits. It's hard to get up in the middle of the night, go to the hospital and see the patient. This was a way of reimbursing more doctors more for doing the consultation."