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Limited Seating
2025 Washington Policy Mid-Year Update – MGMA Webinar
Where: POET Office
When: July 22, 2025, Tuesday
Time: 12 noon
Lunch will be served
Limited Seating Available
During this webinar, MGMA Government Affairs staff will provide an update on current and potential policy developments impacting medical group practices. The speaker will discuss the latest legislative and regulatory issues covering topics such as Medicare reimbursement, telehealth, quality reporting, and surprise medical billing.
This 60-minute webinar will provide you with the knowledge to:
Identify key regulatory developments
Discuss legislative issues impacting medical groups
Describe MGMA advocacy initiatives
Please call (936) 637-7638 or Email [email protected]
Cigna Comm. New Reimbursement Policy for E/M
Cigna Healthcare® will implement a new reimbursement policy, Evaluation and Management Coding Accuracy (R49), to review professional claims billed with Current Procedural Terminology (CPT®) evaluation and management (E/M) codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy in alignment with American Medical Association (AMA) E/M services guidelines.
Effective for dates of service on or after October 1, 2025, services may be adjusted by one level to reflect the appropriate reimbursement when the AMA guidelines are not met.
What this means to you
Cigna Healthcare will conduct periodic claim reviews to verify compliance. Based on that review, providers may be eligible to be removed from the program. Supporting documentation will be requested should we determine the established guidelines were not followed.
Reconsideration requests
Providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service should follow the reconsideration and appeals processes.
To request a reconsideration, please submit the customer’s full record of the encounter to the secure Cigna Healthcarefax number 833.392.2092. Should the original determination be overturned, claims will be adjusted, and an updated explanation of payment will be issued.
Administrative appeal rights are available if the original determination is upheld.
Cigna Comm. Removes 96 Codes from Prior Auth. List.
To help reduce the paperwork and time providers (and patients) spend seeking approvals for more routine services, Cigna Healthcare will remove 96 codes from the list of services that require prior authorization for dates of service on and after May 31, 2025. These codes include commonly requested cardiology, otolaryngology (ENT), and other routine services.
A Familiar Name Returns to Healthcare
In a landscape cluttered with brand mashups, logo overload, and forgettable names—WellThis, WellThat, PlusThis, PlusThat, and the never-ending bowl of Alphabet Soup—clarity is a breath of fresh air. Amidst the noise, we’re proud to reintroduce a name that brings familiarity, trust, and simplicity back into focus: HealthSpring
How to Search the BCBS Fee Schedule for Quarterly HCPCS (Updated)
Choose “Standards and Requirements”
Then “General Reimbursement Information”
Scroll to the Bottom and enter the password “Manual”, then click submit
Read the Policies Disclaimer or scroll to the bottom and click “Continue”
Then choose “Blue Choice PPO, Blue Essentials, Blue Premier, Blue Advantage HMO, MyBlue Health, Blue High Performance Network Schedules”
Directly under that, select “2024 Schedules effective 2/1/2024”
Scroll down to “CPT/HCPCS Drug Schedule” click
The schedule will open in a PDF. You may search by using “CTRL F”
HIPAA Compliance is Not A Choice
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The HHS Office for Civil Rights (OCR) just sent another clear message: HIPAA compliance isn’t optional no matter your practice size. The OCR has reached a resolution with Vision Upright MRI, a small California imaging provider, after a breach of unsecured protected health information (PHI) impacted 21,778 patients. The breach originated from an unsecured server that housed radiology images and lacked proper risk analysis, audit controls, and breach notification procedures. What happened:
As a result, the total settlement cost was a $5,000 fine plus 2 years of monitoring in addition to mandatory corrective actions including:
Why this matters to you:Whether you’re a solo provider or part of a large system, OCR expects every HIPAA-covered entity to:
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VA Seeking Refunds for Past CHAMPVA Claims
The U.S. Department of Veterans Affairs (VA) announced it aims to recover more than $41 million in “overpaid claims” paid to physicians and other health care professionals and entities through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) program.
Texas Medical Association staff caution that physicians receiving CHAMPVA refund requests should take several steps to satisfy the VA request without immediately losing payment for care already delivered:
- Confirm the legitimacy of the request letter. As refund letters typically come from third-party companies, a practice may call CHAMPVA and ask them if the third-party company is one they contracted with to collect the overpayment;
- Check the letter for details on how to appeal, including any payment or appeal deadlines; and
- Check the letter for information about which insurer VA says is responsible for payment.
From there, physicians can choose one of two actions. If it appears the alleged overpayment has been identified in error, start the appeal process to try to keep the CHAMPVA payment already received. If not pursuing an appeal – or if an appeal is ultimately denied – refund the overpayment to VA and seek payment from the insurer VA says is responsible for payment. For a physician seeking payment from that insurer, TMA recommends including, as part of that request, the initial CHAMPVA explanation of benefits and any information from VA indicating that the insurer is the proper payer, especially if the filing deadline has passed.
For assistance with CHAMPVA refund requests or other payment matters, contact TMA’s Physician Payment Resource Center.
More on HCSC Acquisition of Cigna MA
Can this get anymore confusing?
🏢 What is HCSC?
Health Care Service Corporation (HCSC) is:
The largest customer-owned (non-investor-owned) health insurer in the U.S.
A licensee of the Blue Cross and Blue Shield Association (BCBSA).
It operates five Blue Cross Blue Shield health plans:
Blue Cross and Blue Shield of Illinois
Blue Cross and Blue Shield of Texas
Blue Cross and Blue Shield of New Mexico
Blue Cross and Blue Shield of Oklahoma
Blue Cross and Blue Shield of Montana
🔗 What is the Relationship Between HCSC and BCBS?
BCBS is a national brand and association, not a single company. It licenses its brand to independent regional companies.
HCSC is one of those companies, and it owns and operates the BCBS plans in the five states listed above.
So, when someone has BCBS of Illinois, for example, their insurance is actually managed and provided by HCSC.
Acquisition Completed March 19, 2025.
It has been stated:
- Members will have the same plan, benefits, and network structure.
- No changes are expected for 2025.
- Members should not expect any changes in coverage of out-of-pocket cost.
- And the one thing we hope will change is, BCBS says we can still expect the same level of service.
Cigna Commercial REMOVING Multiple Services from Their Pre-Cert List.
Many services will no longer require prior authorization (i.e. Precertification) for Cigna Commercial, beginning May 31, 2025.
Please note, however, that removal from precertification is not a guarantee of payment. Codes may be subject to standard code editing, benefit plan exclusions, and post-service review for coverage.
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