Experts Discuss Current Insurance Issues Challenging Rheumatology

Dr. Bryant

Prior authorizations: The ACR has worked to ease the burden of prior authorization policies, “which can delay or deny care,” Dr. Bryant said.

United has limited prior authorization requirements for certain procedures and radiologic treatments, but reserves the right to review after the fact, which “may be worse,” Dr. Bryant said. “If you provide the service and then they deny it on the back end, that’s going to take appeal time and that’s even more burden,” he said. “And so these are things you need to be aware of about what the prior authorization policies are.”

Biologic therapy: The U.S. Food & Drug Administration recently issued guidance on the interchangeability of biologics, and no biosimilars are currently considered interchangeable to the bio-originator product, Dr. Phillips said.

But several payers and even local hos­pitals have insisted on force switching patients who are stable on the bio-originator to biosimilars for infliximab, he said. One carrier is even requiring biosimilars for rituximab for all new medication starts, including rheumatic conditions, even though rituximab is only approved for oncologic conditions.

“Our position essentially is that unless these drugs are proven to be interchangeable, the decision to switch should belong to the patient and to the provider,” Dr. Phillips said.

Infusion sites: Anthem Blue Cross has shown data suggesting a 40% cost savings on infusions if they’re moved out of the hospital outpatient setting, so that is a big incentive to move patients to other infusion locations, Dr. Bryant said. And other payers have placed hospital outpatient infusions under close scrutiny.

“We’ve worked with, I believe, one payer this year who wanted to insist on home infusion of rituximab, which we thought was interesting,” he said, although that request was later dropped.

The ACR advocates for safe and timely access to the right treatment and urges the “recognition and mitigation of barriers related to travel for patients with arthritis and other rheumatic conditions.” The ACR also has not endorsed home infusions for complex biologics.

Modifier -25: This is used to report an E/M service on a day when another service was provided to the patient by the same physician. Anthem rescinded a proposed policy to reduce E/M reimbursements by 50% when billed under modifier -25.

“There are still issues around this, however,” Dr. Phillips said.

Anthem Blue Cross recently imposed a policy to deny payment for E/M billed with modifier -25 if the same or similar ICD-10 code was billed in recent months. The time frame was left poorly defined, and the payer described the similarity of coding as in the “same family tree,” Dr. Phillips said. “I personally don’t know exactly what that means.”

Copay accumulator programs: Traditionally, copays for biologics that were covered by pharmaceutical companies counted toward a patient’s out-of-pocket maximum, but some payers are no longer applying these copays toward that max. When these copay assistance funds are not applied to the deductible, the fixed annual maximum copay assistance may be exhausted before the patient has met their deductible, potentially forcing patients to switch treatments.

This practice is “not prevalent yet,” but could become a bigger problem soon, Dr. Phillips said.

“We would welcome and invite changes in the biologic marketplace—the economic marketplace—to make the system more sustainable,” he said. “But we’re in the system we’re in right now, and we must advocate for patients’ affordable access to treatment they need.”

Thomas R. Collins is a freelance writer living in South Florida.