Wiki modifier 25 reduction

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kcowan

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Has any had there office visit reduced by 50% because the use of modifier 25? i had a claim processed by medishare where we did the 69210 and 99214-25, the ov was reduced from 80 allowable to $40 because of hte use of modifier 25 reduced at 50%. i can't find any new rules except a article from 2018 where cms proposed the reduction, but i can't find where it was put in to action?page 26 25 modifier
 
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I'm not familiar with Medishare, but google tells me they are not an insurance company, but rather a healthshare. They don't need to follow any fee schedule, and all insurance regulations would not apply to them.
In our practice, any patient with a healthshare is treated as self pay (as it is NOT insurance) and given a receipt for them to submit on their own.
 
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I agree with what Christine said. I'd also add that from the website it looks like Medi-Share uses PHCS as a PPO network.

Does your office have a contractual agreement with PHCS? If so, the claim should have been paid according to your PHCS contractual rates, and you may want to look into whether you are contractually obligated to honor that discount. A PHCS contract could be where the OV reduction is coming from, and that may be something you want to double check before billing the patient for the difference. (Typically, the patient would have needed to present the Medi-Share card showing the PHCS network prior to services being rendered. If that didn't happen, you may not be obligated to honor a PHCS discount.)

If your office is not contracted with PHCS, the member is responsible for anything in excess of what Medi-Share paid.

Info above comes from the Medi-Share Program Guidelines, Section V: Preferred Provider Organization (PPO) https://www.medishare.com/medi-share-guidelines
 
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Looks like you received info above that applies. However I'd also like to point out that there are a number of payers that have reductions for modifier 25 usage according to their payer policy. Payers do not have to follow CMS guidelines.
 
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sls314 said:
I agree with what Christine said. I'd also add that from the website it looks like Medi-Share uses PHCS as a PPO network.

Does your office have a contractual agreement with PHCS? If so, the claim should have been paid according to your PHCS contractual rates, and you may want to look into whether you are contractually obligated to honor that discount. A PHCS contract could be where the OV reduction is coming from, and that may be something you want to double check before billing the patient for the difference. (Typically, the patient would have needed to present the Medi-Share card showing the PHCS network prior to services being rendered. If that didn't happen, you may not be obligated to honor a PHCS discount.)

If your office is not contracted with PHCS, the member is responsible for anything in excess of what Medi-Share paid.

Info above comes from the Medi-Share Program Guidelines, Section V: Preferred Provider Organization (PPO) https://www.medishare.com/medi-share-guidelines
Click to expand...
WE ARE CONTRACTED WITH PHCS AND MULTIPLAN?
 
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csperoni said:
I'm not familiar with Medishare, but google tells me they are not an insurance company, but rather a healthshare. They don't need to follow any fee schedule, and all insurance regulations would not apply to them.
In our practice, any patient with a healthshare is treated as self pay (as it is NOT insurance) and given a receipt for them to submit on their own.
Click to expand...
YES IT IS A DISCOUNT PROGRAM THEY UTILIZE PHCS AND MULTIPLAN WE ARE CONTRACTED WITH BOTH
 
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kcowan said:
WE ARE CONTRACTED WITH PHCS AND MULTIPLAN?
Click to expand...

Does your contract with PHCS say anything about a discount being applied to office visits? I'd look at the language in the contract.

If your PHCS contract and rate exhibit don't provide for a discount on an office visit and Medishare is supposed to be reimbursing according to your PHCS contracted rates, I would follow up with Medishare to advise that you weren't reimbursed according to your PHCS rates. They should be able to tell if that's the pricing returned by PHCS or if Medishare applied an additional discount.

You may be contractually obligated to honor any discounts that are spelled out in your PHCS contract. However, if Medishare is applying additional discounts beyond what your PHCS contract states, that's something that ultimately the patient may be responsible for.

 
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