A change in your payer contract is usually hard to miss. A change in a payer’s reimbursement policy may be much easier to overlook — until claims start being denied or payments decrease.
That distinction is becoming increasingly important for physician practices.
A recent report highlighted by Becker’s Payer Issues found that payer policy changes not incorporated into contracts are the leading source of revenue leakage for healthcare clinicians. The report, from Trek Health in partnership with the Healthcare Financial Management Association, surveyed 161 leaders from hospitals, health systems and other qualified health care organizations.
For allergy practices, the problem is particularly relevant. Allergists frequently provide services that are subject to detailed and changing payer policies, including allergen immunotherapy, allergy testing, biologics, evaluation and management services and other physician-administered treatments. A payer can change how one of these services is reimbursed without renegotiating the underlying physician contract.
The rules can change while the contract stays the same
UnitedHealthcare provides a recent example. The insurer announced a new commercial allergen-testing reimbursement policy scheduled to take effect Sept. 1, 2026, in most states. Among other provisions, the policy limits reimbursement for specific in-vitro IgE testing in patients age 20 and older to 20 allergen-specific antibodies per year and establishes additional restrictions on when serum IgE testing will be reimbursed.
Whether a practice agrees with the clinical basis for such a policy is one issue. From a business standpoint, however, there is another: practices need to know the policy changed before they perform the service. Otherwise, the first indication may be a denial weeks later. Unfortunately, payers may not always publicize reimbursement policy changes, so they can come as an unwelcome surprise to allergy practices.
Payer payment changes often go unnoticed by medical practices because they are harder to detect; there is often no denial to flag an appeal. And practice workflows are typically focused on identifying denials, not reimbursement variances. Unless you make it a priority to review your claims regularly and compare actual payments to expected payments, you may not discover these changes until long after they occur.
The College’s Advocacy Council has repeatedly raised concerns about payer requirements affecting allergists, including documentation demands involving allergen immunotherapy and CPT codes 95165, 95115 and 95117. These experiences illustrate why payer policy surveillance and regular claims review are increasingly becoming part of practice revenue-cycle management.
It is not just allergy testing
Commercial insurers are also increasing scrutiny of evaluation and management services.
Becker’s has documented several recent examples. Blue Cross Blue Shield of Illinois implemented a process allowing E/M services to be downcoded when the insurer determines that documentation does not support the billed level. Other insurers, including BC/BS of North Carolina, have pursued similar policies. We provided some guidance.
Cigna’s automatic E/M downcoding policy generated enough concern that Maryland regulators ordered the insurer to stop applying it in that state and imposed an $80,000 fine.
Modifier 25 is another area receiving increasing payer attention. Blue Cross Blue Shield of Michigan announced a policy reducing reimbursement for certain E/M services billed with modifier 25 when another procedure is performed on the same day.
These policies can be particularly relevant to specialties such as allergy/immunology, where an office visit and a separately identifiable procedure may appropriately occur during the same encounter.
What allergy practices can do
Practices should consider treating payer policy and claims reimbursement monitoring with the same attention traditionally given to contract negotiations.
A few relatively simple steps may help:
- Assign someone in the practice to review major payer provider bulletins and reimbursement-policy updates regularly.
- Pay particular attention to policies involving allergen immunotherapy, allergy testing, biologics, E/M coding, modifier 25, prior authorization and site-of-care requirements.
- Regularly compare actual claims payments by payer and service to expected payments in order to identify downcoding and reduced payments for individual services.
- Compare unexplained increases in denials or payment reductions with recently published payer policy changes.
- Appeal inappropriate denials and retain examples of problematic payer practices.
- Report significant or recurring payer problems to the College’s Advocacy Council so that patterns affecting allergists nationally can be identified.
The last point is particularly important. A single denial may look like an isolated billing problem. Similar denials occurring in dozens of allergy practices may indicate a new payer policy requiring broader action.
Watch payer policies and your reimbursements — not just the contracts
The changing payer environment means practices can no longer assume that the reimbursement rules in place when a contract was signed will remain unchanged.
As the recent Becker’s report illustrates, the financial impact of a payer policy change may not become apparent until revenue has already been lost.
For allergists, the lesson is straightforward: watching payer policies and monitoring reimbursements has become just as important as watching payer contracts.
ACAAI’s Advocacy Council and House of Delegates will continue to monitor this issue and work with our state and national partners to address inappropriate algorithmic downcoding of physician services.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
