ACR Insurance Subcommittee Tackles Known Issues

The Insurance Subcommittee (ISC) of the ACR’s Committee on Rheumatologic Care has had a busy start to 2023, advocating to payers on behalf of our colleagues and the College. I’d like to share an update on some of the work this group has been doing to help address concerns about administrative burden, while ensuring continued access to critical therapies for our patients with rheumatic diseases.

Cigna Modifier 25

Dr. Shepherd

As of May 25, Cigna will require providers to submit chart notes with all modifier 25 claims. The payer will deny evaluation and management (E/M) claims that do not include documentation to show that a significant and separately identifiable service was performed. Cigna proposed a similar policy last summer, then rescinded it after it was met with significant pushback from the AMA, ACR and other medical societies. The ISC has sent a letter to Cigna once again urging the payer to rescind the policy, which will likely result in inappropriate denials or delayed payments for legitimate E/M services and increase the already high level of administrative burden on rheumatology practices. The ACR has also been working with the AMA and will sign on to its multispecialty letter.

Access to Hydroxychloroquine

The ISC has seen a recent increase in complaints about prior authorization requests and denials for hydroxychloroquine for rheumatology patients. We saw this problem briefly at the start of the COVID-19 pandemic; however, the issue hadn’t reemerged until earlier this year. The ISC has reached out to five payers and pharmacy benefit managers, including BlueCross BlueShield, Express Scripts and OptumRx, to address the inappropriate requirements and denials and to ensure continued access for patients with rheumatic diseases.

Coverage for Apremilast Combination Therapy

The ISC has been approached by numerous ACR members who are struggling with policy restrictions or denials for apremilast (Otezla) when prescribed in combination with a biologic drug. The ISC has reached out to payers directly to discuss this issue and has also created a template letter for ACR members who are seeking coverage for individual patients.

Prior Authorizations

Advocating for a more streamlined and appropriate prior authorization process continues to be a top priority for the ISC. We have engaged with several payers and pharmacy benefit managers over the past year, including Aetna, CVS Caremark and Express Scripts. We will be speaking with CVS Caremark leaders again later this month as part of an ongoing dialogue to address the length and content of their forms—specifically, criteria around the evaluation of treatment efficacy for continuation of therapy requests.

The mission of the ISC is to help members with issues related to insurance policies and payers. If you would like the ACR’s help regarding payer issues specific to your own practice or if there is a payer policy you think we should be aware of, reach out to [email protected].

Rebecca Shepherd, MD, MBA, FACR, FACP, is the chair of the Insurance Subcommittee of the ACR’s Committee on Rheumatologic Care. She is Chief of Rheumatology and Director of Osteoporosis Care at Lancaster General Health, Pa.