> Dear Dr. Strouse,
>
> You can certainly submit a request for an increase in the current fee schedule. Once received, it will be reviewed and presented to the Reimbursement Committee for consideration. To assist with the analysis of your request for a fee review, a proposal should include the following:
>
>
>
> 1) * Practice demographics (locations, number of practitioners and license held, years in practice, certifications/accreditations)
> 2) * Please provide names/locations of facilities supported.
> 3) * What percent of patient base is Anthem?
> 4) * What counties do you draw patients from?
> 5) * Since Anthem reimburses from a statewide fee schedule, please include justification as to why practice should be considered for an increase (i.e., what services provided by the practice are unique and not generally provided by other practices of the same type)."
> 6) * In-office labs are reimbursed according to Anthem's Reference Lab Fee Schedule and will not be considered for an increase.
> 7) * J-codes are reimbursed at ASP + 6% and will not be considered for an increase.
> 8) * E&M codes are not negotiable.
>
>
>
> Anthem will not accept proposals submitted as an across the board or as a percentage of Medicare. Please email the proposal, attaching an excel table with requested CPT codes, and proposed fees for consideration
And my reply:
Thank you for your reply but I have a number of questions before proceeding. How can Anthem discriminate and pay one provider one fee and another something else as I know very well you are doing. It is against the law for me to do that. How does whether or not I provide unique services matter? If I provide a service, it should be reimbursed at the same rate as others providing the same service which I know you are not doing. Otherwise, one might construe this as being collusion on Anthem's part as regards to knowing and discussing what other providers are charging and accepting. It is against the law for me to do that. I believe before I send you any additional information, I will consult an attorney on these issues. In the meantime, I will stop performing these services on Anthem patients and instead refer them to the more costly providers.
Insurance companies are exempt from anti-trust. One of the things health care reform talked about was repealing it, but that went silent real quickly.
In response, I would reference their letter.
Questions 1,2,4 they should know better than you. They know where your patients are from, they know your certifications. Again point this out to them.
State that Question 3 would be considered anti-trust on your part and should not be devulged. It should be made clear that your leaving the service area would have a detrimental impact to their ability to service their patients.
6,7,8 state J codes, E&M are off the table
# 5 Suggests that all providers in the state get the same money. Please ask to know the variance as it applies to your state. You should then get the maximum since you work in a Medically Underserved Service Area.
It is reasonable to pick the codes that you are most interested. Since the majority of codes fall in 6,7 and 8, this may be a small number.
It should be pointed out to them that since they are significantly below what others reimburse, you will exit their market and make it even more difficult for their patients to seek services in an underserved area.
