The ACR Insurance Subcommittee (ISC) of the Committee on Rheumatologic Care has been busy as usual, and I’d like to provide an update on some of our active issues. These include recent activities regarding specialty pharmacy drug acquisition, consultation codes, modifier -25 policies and UnitedHealthcare’s (UHC) policy to move in-office treatments to self-administration.
Specialty Drug Acquisition
In November 2019, Blue Cross of Tennessee announced a policy in which many of its self-insured plans would require patients receiving in-office treatments to receive their drugs through a specialty pharmacy rather than allowing providers to “buy and bill.” As you might imagine, this policy has generated extensive pushback from the ACR, the Tennessee Rheumatology Society (TRS) and many other specialists (including dermatologists, gastroenterologists, ophthalmologists and urologists) within the state. Due to the degree of pushback, the policy is currently on a six-month delay, during which time we are working closely with the TRS, specialty societies and other rheumatology groups, such as the Coalition of State Rheumatology Societies (CSRO).
Our current advocacy plan includes appeals directly to the payer in Tennessee and, in collaboration with CSRO, preparing a press release and informational handouts for patients and employers in Tennessee and elsewhere. These outreach materials explain why many providers cannot accept specialty pharmacy drugs for in-office administration. The reasons include logistical challenges related to drug tracking, just-in-time delivery and dose adjustments, as well as financial burdens related to higher administrative costs and loss of drug margin to pay such costs.
Coincident to this policy in Tennessee, we are seeing the same issue pop up with certain employer groups with other payers, such as UHC in the St. Louis, Mo., area. Broadly speaking, we are concerned we may see more and more such policies as payers or pharmacy benefit managers (PBMs) try to sell employers on plans they market as “cost saving” through this specialty pharmacy mandate. We see the payers stating “the employers are asking for this,” but we believe most employers purchasing such plans are unaware of how they may limit access to care and hurt their employees.
Recent data from Medicare suggest the buy-and-bill system provides more effective cost containment of specialty drugs, with a 21% vs 45% increase in drug prices in parts B and D, respectively, from 2012–16.1 We see a strong argument that pushing drugs through the PBM system creates upward price pressure because a higher list price translates to a higher rebate, which is often not passed on to the employer or patient. By contrast, buy and bill creates downward price pressure by allowing providers to acquire a drug at the lowest possible price, which becomes reflected in average sales price several quarters later.
By providing employers with these data and an assessment of the access issues their employees will see, we hope employers will choose to opt out of specialty pharmacy plans. We have seen several employers in Tennessee back out once they understood the implications for their employees’ access to care. Stay tuned for more details and let us know if you see carve-outs on buy-and-bill treatments. The ISC can advocate on your behalf and provide you with literature to share with your local employer groups.
Physician-Administered Drugs
Many of you may recall the policy UHC announced and quickly rescinded on Oct. 1, 2019, that would require patients to document failure of the self-administered version of certain treatments before in-office treatment would be covered. We have talked with UHC, and it plans to re-introduce this policy, with modifications, possibly on July 1.
We are working with UHC on revisions to this policy, and we are pushing it to grandfather in stable patients and to include a reasonable list of exclusions for patients who may be better served by in-office treatments due to weight, compliance, frail health or other reasons we have provided to them. We are hopeful UHC will integrate our feedback to make this policy more manageable.
Modifier -25 Policies
A modifier -25, as defined by the American Medical Association Current Procedural Terminology book, is used to report a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” It requires documentation that satisfies the relevant criteria by payers for billing an evaluation and management (E/M) service and a procedure, such as an injection or infusion, on the same day.
Although both Medicare and Anthem pulled back plans in 2017 to reduce E/M reimbursement by 50% when billed with a modifier -25, this policy keeps rearing its head. We are now seeing Anthem implement prepayment reviews of such claims, which we worry may be burdensome to practices, and stating it will deny the payment altogether if the “same or similar” ICD-10 code has been billed in the previous two months. Anthem has not provided clarity on what “similar” means and as yet has been not been open to reconsidering this policy.
Additionally, Cigna will implement a plan on March 16 requiring review of documentation for medical necessity on E/M claims billed with a joint injection or aspiration. At this point we are unsure if this will trigger a burdensome records request on all such claims or only some, nor do we know how much payment delay may result. If your practice experiences adverse results of such policies, reach out to us at [email protected] with specifics so we can provide these payers with objective data on the administrative hardships such policies create.
We continue, every few months, to see payers trying to require home infusions of treatments including infliximab and rituximab. Contact us if you encounter these policies, because we strongly believe such policies are not in our patients’ best interests.
Consultation Codes
Finally, a note about consultation codes and valuation of cognitive care in general. UHC and Cigna stopped paying consultation codes last fall, both generally invoking a desire to “follow Medicare’s lead.” At the same time, we are thankful to see Medicare beginning to recognize the undervaluing of cognitive care, as evidenced by the evaluation and management fee schedule update planned for Jan. 1, 2021, which is estimated to provide a 15% increase in rheumatologists’ Medicare reimbursement. We have and will continue to press commercial payers to adjust their fee schedules to follow Medicare’s lead on this issue, citing their expressed intent to do so on previous occasions. We encourage our members to evaluate their own commercial contracts closely in light of these changes by the CMS so you can have informed conversations with your payers if or when your contracts are due for renegotiation.
Remember, the ISC exists 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 you see payer policies you think we should be aware of, reach out to [email protected].
Chris Phillips, MD, is the chair of the ACR Insurance Subcommittee of the Committee on Rheumatologic Care. He is a rheumatologist in a private practice in Paducah, Ky.
Reference
- McCormick N, Wallace ZS, Sacks CA, et al. Decomposition analysis of spending and price trends for biologic antirheumatic drugs in Medicare and Medicaid. Arthritis Rheumatol. 2020 Feb;72(2):234-241.
