Silent PPOs • Appealing Palmetto Claims • Modifier 25

QUESTION: If a silent PPO is offering us a good rate, why would it be bad to contract with them?

ANSWER: Silent PPOs are rental networks and bring little value to physicians. The big issue with these entities is that they lease the physician’s discounts and names out to other payers. They don’t pay claims, as they are not insurance companies. CMA’s main concern with these entities is the lack of regulation. They are not licensed or regulated by anyone. For example, if you have a contract dispute or are having any problems getting paid, you can’t go to the Department of Insurance (DOI) or the Department of Managed Health Care (DMHC). Stopping these entities from practice is one of CMA’s big priorities. It’s impossible for physicians to get out of these contracts once they sign, and the discounts that are taken are large. Once you become contracted with them, it is difficult to extract yourself from that relationship.

QUESTION: I am trying to send Palmetto an appeal for one of my claims. What address do I need to send this to?

ANSWER: Palmetto GBA-J1 Mac, P.O. Box 1252, Augusta, GA 30903-1252

QUESTION: I thought if someone came in for a physical/well-woman exam you would bill a preventative medicine service code, and if there were additional medical problems that came up during the exam, a separate E&M code could be billed. I did this, and Blue Shield denied it.

ANSWER: Modifier “-25” needs to be used for the second/additional E&M codes. This alerts the payer that there were two separate and distinct services. The payment policy on the Blue Shield website states, “Preventive Care Visits: Blue Shield provides separate reimbursement for E&M services performed at the same time as a preventive care visit. To ensure payment, providers are reminded to append a modifier 25 to the E&M code. Blue Shield has consulted with members of the AMA CPT coding committee, and it is noted that the E&M code should only be added when significantly separately identifiable cognitive services are documented as having been performed.”

The physician may wish to re-bill using the appropriate modifier.