Rules and regulations

Anthem proceeds with Modifier 25 audits, prepayment clinical validation policy

More than 20,000 DOs could see increased denials and delays for claims.

Officials from Anthem told AOA leadership that the insurer plans to continue its audits of claims billed with modifier 25, despite finding no widespread misuse of common modifiers.

In a recent call with the insurer, Anthem executives also said they have no plans to exclude physicians who have repeatedly shown their coding is accurate from future audits, according to AOA CEO Kevin Klauer, DO, EJD.

“AOA challenged Anthem to justify continuing this practice. We see that physicians who code and document correctly are continuing to be penalized by unjustified claims denials or delays in payment for appropriately billed services,” Dr. Klauer added.

“We will continue advocating with Anthem on behalf of our members and hope they will come back to the table and lift this burden from those who have proven they are billing appropriately.”

At the same time, Anthem is proceeding with its new prepayment clinical validation process, which affects claims submitted with modifiers 25 (significant, separately identifiable E/M service), 59 (distinct procedural service) and 57 (decision for surgery). Anatomical modifiers, including left side (LT) and right side (RT), are also subject to review.

Claims billed with these modifiers will trigger a prepayment clinical validation review process within the automated claims software to evaluate their proper use, according to the insurer.

AOA President Ron Burns, DO, has requested clarification of the policy from Anthem.

“We are extremely concerned about the effects this policy will have on our physicians, many of whom are running small and solo practices that cannot absorb the additional administrative burden this automatic review creates,” Dr. Burns said.

Approximately 20,000 DOs practicing in 14 states could see the ramifications of the new policy this month.

DOs experiencing payment issues due to the Anthem policies are asked to submit two to three EOBs and any supporting documents–with all protected health information redacted–to the AOA Physician Services Team at

Learn more about AOA’s advocacy efforts with private payers here.

Related reading:

Anthem’s new clinical review process may disrupt payment

Prior authorization requirement for OMT ends for Aetna patients in five states


  1. Blaine Price, DO

    We are getting requests from Anthem to send records every time we see their patients. We are going to keep a copy of the patients full medical record to fax each time. Maybe if everyone did this and Anthem started to burn through a bunch of paper and toner, they’d change their stupid policy.

  2. Gregory Funk, DO

    We need to say NO!!
    This is why doctors are burnt out. More work less pay. I have dropped all insurance and Medicare. No more EMR, I was on my 4th EMR, spent at least $200-300,000 on EMR, that money could be in my pocket. Expenses exceed income = burn out. Will work for money, just like the guy on the side of the road.
    If more of us leave the system the powers that be can regulate themselves and put a target on there own backs

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