• Private Payer Issues

    The AAFP advocates to the five largest health plans for family physicians. The AAFP private payer advocacy agenda includes but is not limited to:

    • Holding private payers accountable for a commitment to increase investment in primary care.
    • The need for payers to support practices in value-based contracts.
    • Advocating for reduced or eliminated prior authorizations.
    • The need for administrative simplification by advocating for the adoption of the Core Quality Measures Collaborative’s core measure sets.

    Payer Acceptance of Supplemental Data

    It is the policy of the AAFP that health plans should provide a mechanism for physicians in value-based contracts to submit supplemental data for all lines of business. The Academy tracks what payers accept supplemental data for the top five payers with whom the AAFP has relationships.

    The AAFP developed model guidance which states, “In addition to receiving HEDIS data via claims and encounters, [payer] should also accept submission of supplemental data to satisfy HEDIS measures and close gaps in care in value-based contracts.” The consequences of a health plan’s inability to accept and record data may result in physicians not receiving payment otherwise earned under a value-based contract.

    Having a Problem with a Payer?

    Follow these steps:

    1. Contact the payer directly.
    2. Reach out to your local chapter for help.
    3. If the problem persists, contact the AAFP at (800) 274-2237.

    Payers That Accept Supplemental Data

    United Healthcare
    Yes Yes  
    Humana Yes Yes  
    No No Cigna Collaborative partners can use the iCollaborative software to manually attest to gap closure, thus improving their quality scores and gap closure rates.
    Aetna No Yes Aetna is considering accepting supplemental data for their commercial business as their systems evolve.
    Anthem No Yes Anthem is working to have a process in place to accept supplemental data for commercial business in 2019.

    Letter to Blue Cross Blue Shield Rhode Island (BCBSRI) Opposing Their Modifier 25 Policy

    In response to BCBSRI’s modifier 25 policy, the AAFP sent a letter asking them to re-evaluate their modifier 25 reporting and payment policy.

    The letter voices concern that BCBSRI’s modifier 25 policy significantly hampers family physician’s ability to financially operate a medical practice and transition to value-based care. It also is detrimental to patient access to care.

    Letter to BCBSRI