Practice Management Alert

If your New Jersey practice participates with Horizon Blue Cross Blue Shield (BCBS), you'll have some difficult decisions to make if the policy change takes effect. Take a look at these options to see how your practice can overcome the impending modifier payment reductions.

There has been talk by some practitioners of dropping their participating status with Horizon because of this change. If you don't agree with Horizon's decision, you have 30 days from the date of the notice to terminate your physician agreement. This won't be an easy choice, however, says Brian Fornutaro, a billing professional with Medi-corp in Cranford, NJ. "There might be cases that the group just cannot drop out, and groups that need to be in for certain situations," he says.

BCBS's power in the market also makes this option unappealing, says Karla Westerfield, COPM, business manager at Southeast Wyoming Ear, Nose and Throat Clinic in Cheyenne. Experts believe the 30-day time frame is very short, especially considering some practices received the memo a full two weeks after other practices.

You might be forced to make patients schedule separate visits for each individual problem in order to get your full reimbursement.

Example: An ear, nose and throat (ENT) practice has a patient come in with chronic laryngitis (476.0) that requires a full work-up EM service (99213, Office or other outpatient visit for the evaluation and management of an established patient ...). The physician also looks down the patient's throat with a scope (31575: Laryngoscopy, flexible fiberoptic; diagnostic) since the mirror did not provide sufficient visualization. To avoid needing a modifier to get reimbursement for both services, you would need to have the patient make two separate appointments and pay the copay twice, says Janet Palazzo, CPC, of Regional Otolaryngology in Cherry Hill, NJ.

If patients voice their displeasure with having to come back multiple times, you should explain the changes and direct them to speak with their employer or other policy provider, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, coding and compliance supervisor with Proliance Orthopedics and Sports Medicine in Seattle, Wash.

Patients are not the only ones who should be making their opinions known, but you as well, Stumpf says. Even if you're not in New Jersey, you should beaware of the ramifications of Horizon's proposal. The policy change has many medical office professionals across the country taking notice. Many are ready to fight if the same ruling comes their way. "Practices should carefully read all correspondence that they receive," Palazzo says.

Stumpf suggests not only lobbying your payer if a similar ruling appears, but voicing your opinion elsewhere as well: writing to the appropriate medical associations, to your state legislature, to Congress, and specialty societies.