Fee Schedules and Authorization Requirements for 2025
Several changes to healthcare provider fee schedules and authorization requirements are set to take effect in 2025:
Medicare Physician Fee Schedule:
- The 2025 Medicare conversion factor will be $32.35, a 2.83% decrease from $33.29 in 2024
- This reduction is due to budget neutrality requirements and expiration of temporary relief enacted by Congress
- Overall reimbursement for cardiovascular services is projected to remain flat compared to 2024
UnitedHealthcare Changes:
For Medicare Advantage plans, UnitedHealthcare is implementing new prior authorization requirements effective January 1, 2025
Delayed care and preventive services
Deductibles also influence how patients use healthcare services. Patients tend to delay or forgo care, including preventive services, when facing high deductibles. This can lead to more severe health issues down the road, potentially impacting a provider’s ability to deliver timely and effective care.
Financial risks for providers
As patients become responsible for larger portions of their healthcare costs, providers face increased financial risks. They may struggle to collect payments from patients who cannot afford their deductibles, affecting the providers’ revenue stream. Given the potential financial burden of high deductibles, providers may need to offer payment plans to help patients manage their healthcare costs and receive the care they need.
Shift in service utilization patterns
Demand for services tends to slacken across the board during the deductible phase, including both preventive care and expensive tests. This shift can impact providers’ workflow and resource allocation.
Authorization Requirements:
- Superior HealthPlan outlines specific documentation required for prior authorization requests, including member information, provider details, service codes, and clinical justification
- CMS established a nationwide prior authorization process for certain hospital outpatient department services
Other Notable Changes
- CMS will allow payment for code G2211 in some situations when modifier 25 is used with certain preventive services
- Six new optional Merit-based Incentive Payment System Value Pathways will be available for reporting in 2025
- For Medicare Shared Savings Program, CMS finalized policies to mitigate the impact of anomalous billing activity
- Safety planning interventions: HCPCS code G0560 for 20-minute increments of safety planning for patients in crisis
- Post-discharge follow-up: HCPCS code G0544 for monthly billing of post-discharge follow-up contacts with patients discharged from emergency departments after crisis encounters
- Advanced Primary Care Model (APCM) codes: New codes to recognize and reward primary care physicians providing comprehensive care, including behavioral health services
Increased focus on behavioral health integration:
- Enhanced reimbursement for behavioral health services, particularly those related to substance use disorders
- Emphasis on integrating behavioral health into primary care settings
- Telehealth expansion: CMS will preserve and expand the scope of and access to telehealth services for behavioral health
Specific fee examples (for licensed psychologists):
- Psychiatric Diagnostic Evaluation without Medical Services: $131.16
- Psychotherapy, 30 min: $61.63
- Psychotherapy, 45 min: $109.04
- Psychotherapy, 60 min: $131.16
Healthcare providers should review these changes carefully and prepare for potential impacts on reimbursement and administrative processes in the coming year.
