Several of the nation’s largest health insurers rolled out reimbursement policy changes Sept. 1, ranging from new lab testing coverage limits at UnitedHealthcare to a billing overhaul at Blue Cross Blue Shield of Michigan that has drawn pushback from providers.
Six payer reimbursement changes to know:
1. UnitedHealthcare
UnitedHealthcare is tightening reimbursement for lab tests across its commercial, Medicare Advantage, exchange and Medicaid plans. Most commercial, exchange and MA changes take effect Sept. 1, with Medicaid rollouts staggered by state from August through December.
Five new lab testing policies apply across plans:
- An allergen testing policy that caps specific IgE testing at 20 allergens per year for patients 20 and older, while excluding ALCAT, basophil activation and IgG/IgA/IgM/IgD allergy testing.
- A hepatic fibrosis testing policy that restricts multianalyte assays to once every six months for patients with hepatitis B, hepatitis C, MASLD or alcoholic hepatitis.
- A policy that will not reimburse in vitro chemotherapy sensitivity and resistance assays.
- A testosterone testing policy that covers serum total testosterone monitoring for defined clinical indications but excludes testing for asymptomatic individuals or those with nonspecific symptoms.
- A vitamin B12 testing policy that limits total B12 testing to once every three months.
The insurer is also updating its genetic testing for neurological disorders policy for individual exchange plans, with revised clinical evidence and applicable codes.
2. Aetna
Aetna is making two major reimbursement changes:
- The insurer is expanding its Claim and Code Review Program with new claim edits based on CMS, AMA CPT and evidence-based guidelines. The edits apply to commercial, Medicare and student members.
- Aetna will apply a 15% payment reduction to radiology services billed with modifier CT, which denotes equipment that does not meet NEMA XR 29-2013 “Smart Dose” standards. The reduction applies to the technical component and the TC portion of global billing for both Medicare Physician Fee Schedule and Outpatient Prospective Payment System services, aligning with CMS guidelines.
3. BCBS Michigan
BCBS Michigan is phasing out incident-to billing, a practice under which non-physician providers supervised by a physician were reimbursed at the physician’s higher rate.
Starting Sept. 1, enrollment-eligible clinicians still billing incident-to must add modifier SA to their claims. Those claims will remain payable at the submitting clinician’s rate but will become ineligible for the insurer’s Physician Group Incentive Program and other value-based reimbursement.
A second phase takes effect March 1, 2027, when clinicians with their own NPI must bill directly. Those continuing incident-to billing will see reimbursement reduced to 80% of the professional fee schedule. Training-level clinicians, including students, residents and limited-license social workers, will lose incident-to billing eligibility in office settings entirely.
4. BCBS Texas
BCBS Texas is updating 24 lab-related reimbursement policies effective Sept. 4, covering areas including flow cytometry, PSA testing, allergen testing, hepatitis testing, thyroid disease testing, cardiovascular risk assessment, micronutrient testing, drug testing and colorectal cancer screening.
5. BCBS North Carolina
BCBS North Carolina is changing its multiple and bilateral surgery reimbursement policy, effective Sept. 1. For outpatient facility claims, the insurer is adding a tiered reduction for multiple surgeries performed on the same day: the primary procedure will be reimbursed at 100% of the allowance, the second and third procedures at 50%, and the fourth and subsequent procedures will not be eligible for reimbursement. On the professional side, the reduction schedule is changing to 100% for the primary procedure, 50% for the second and 25% for the third and beyond. The policy applies to all commercial and ASO members.
6. Molina Healthcare
Molina Healthcare of Ohio is implementing several Medicaid policy changes effective Sept. 1, including a new specialty medication administration site-of-care policy, new clinical coverage criteria for the gene therapy Otarmeni and revised buy-and-bill pharmacy policies for drugs including Briumvi, Kisunla, Lemtrada, Leqvio, Tysabri and biosimilars, and Tzield. The insurer also revised its duplicate claims payment integrity policy.
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