Anthem Blue Cross recently announced changes to its Prudent Buyer Participating Physician Agreement and fee schedule effective July 1, 2019.  According to a notice issued to approximately half of its PPO network, the plan will be increasing payment for the more commonly billed Evaluation and Management (E/M) services. But, some physicians have reported decreases in payment for other services.  

The new rates are available on the Availity website by selecting “Payer Spaces” then “Anthem Blue Cross” (select Education and Reference Center> Administrative Support> Prudent Buyer Fee Schedule update). 

The Anthem notice also includes changes to Section 4.18 of the contract affecting reimbursement rates for workers’ compensation services. Previously the contract language stated physicians would be paid the lesser of the California Division of Workers’ Compensation Official Medical Fee Schedule (OMFS) or the Prudent Byer fee schedule in Exhibit B.  The new language indicates Anthem will reimburse the lessor of 85 percent of the OMFS, the physicians billed charges or the Prudent Buyer fee schedule in Exhibit B.

Anthem has clarified that providers who have already opted out of the Anthem Workers’ Compensation product will remain opted out and no further action is required. Providers previously contracted for the Anthem Workers’ Compensation product as of the date of the notice, may opt out of the workers compensation product only without affecting the terms of their current Prudent Buyer PPO agreement by indicating their desire to opt out via email to Anthem Work Comp Contracting Services at WCContractingServices@anthemwc.com.

Physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. The California Medical Association (CMA) reminds physicians that they do not have to accept substandard contracts that are not beneficial to their practice.

To help physicians understand their rights when a health plan has sent notice of a material change to a contract, CMA has published "Contract Amendments: an Action Guide for Physicians.". The guide—available free to CMA members—includes a discussion of options available to physicians when presented with a material change to a contract. Additionally, CMA created a financial impact worksheet to help physicians calculate the net impact of the fee schedule changes on their practice and make informed decisions.  

Physicians with questions about the notice can contact Anthem Blue Cross Network Relations staff at CAcontractsupport@Anthem.com.

Contact: Reimbursement Helpline, (888) 401-5911 or economicservices@cmadocs.org.