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Anthem Blue Cross announced that effective March 1, 2020 they will reduce reimbursement rates (in some cases up to 35%) for applied behavior analysis services. The insurer has said this is non-negotiable and gives the following statement as to the reason why:
“Our goal is to help ensure access to high quality, affordable healthcare. One of the ways to help achieve that goal is to routinely analyze and rebalance professional fee schedules for medical services. This evaluation includes competitive benchmarking, analysis of government reimbursement, consideration in changes of delivery models and the impact that any rate changes may have on consumers we serve.
We have adjusted our fee schedule for applied behavior analysis in order to mitigate the effects of revision to the industry standard code reporting guidelines for this type of service, because those revisions could have the effect of increasing the cost of care.
We value the relationship we have with care providers we have in our network and understand their concern about these changes. As the cost of health care continues to rise at an unsustainable pace, we have the responsibility as a health care leader to help address the challenge of affordability facing Anthem consumers.”
To that I offer this response to Anthem
Beth Andersen
President, CA Commercial Business Division
Anthem Blue Cross
1 Well Point Way
Thousand Oaks, CA 91362
Dear Ms. Andersen,
On behalf of thousands of individuals, families and service providers who have in the past or currently do benefit from applied behavior analysis (ABA) services we whole-heartedly disagree with Anthem’s decision to reduce rates for these critical services. The reasoning provided in Anthem’s statement above is, quite simply, offensive for several reasons. First, it states the goal is to ensure high-quality and affordable access to health care when in reality reducing reimbursement rates will effectively reduce our access to ABA services. Second, in achieving this goal Anthem “routinely” analyzes and rebalances professional fee schedules for medical services, in part, by evaluating the impact any rate changes will have on the consumers you serve. Clearly, this has not been a factor in the decision as there has been a massive outcry from the community related to the impact and effect this would have on individuals and their families. In addition, Anthem states that they use competitive benchmarking and analysis of government reimbursements; however, it is clear to anyone who lives, works or provides services in California that Medi-Cal rates are all but unsustainable and have been for years. It is well known that as a result of the inadequate reimbursement rates associated with Medi-Cal, California faces widespread health profession shortages – again this will effectively reduce our access to services.
The specific reason given for the fee schedule “adjustment” – REDUCTION – to ABA codes is to “mitigate the effects of revision to the industry standard code reporting guidelines for this type of service, because those revisions could have the effect of increasing the cost of care.” We must ask…What does this even mean? For example, CPT Code 97153 is for adaptive behavior treatment by protocol, administered by a technician under the direction of a qualified healthcare practitioner, face-to-face with one patient (15-minute increments). So, based on the stated reasoning Anthem wants to reduce the payment for hands-on care? The rationale is puzzling, and one could argue that simply put this is “industry speak” for limiting utilization – again effectively limiting access to care.
Finally, Anthem states that they value their relationship with care providers in their network and understand their concerns. Perhaps that is true but WHAT ABOUT THE THOUSANDS OF INDIVIDUALS THAT RECEIVE ABA SERVICES – DO YOU VALUE YOUR RELATIONSHIP WITH THEM? As a company that is enjoying dramatic gains – with membership growing by 1.1 million (total 41.0 million enrollees), operating revenue of $27.1 billion in the last quarter of 2019 (an increase of $3.8 billion from the prior year quarter), cash dividend distribution of $204 million in the last quarter, and 3rd quarter (2019) profits came in around $1.3 billion – why restrict access to such a vital service for children and adults with disabilities and their families?
ABA is a covered service for a reason so much so that in California it is even an insurance mandate. This reduction disproportionately impacts people with disabilities, and we believe it is nothing short of discriminatory. In light of the fact that these reductions clearly restrict access to care we respectfully ask that Anthem withdraw the proposed reductions.
Sincerely,
Teresa Anderson
Public Policy Director
The Arc/UCP CA Collaboration
If you experience challenges getting ABA services covered please call the Department of Managed Health Care and ask for assistance. Information and assistance are available at www.HealthHelp.ca.gov or by calling 1-888-466-2219. If you are an Anthem beneficiary please send a letter (or feel free to use this one) to let them know about your concerns.