Members play a key role in helping the ACR learn about insurance challenges or harmful policies that hurt patients—often, the ACR first hears about such problems from members. To help out, the College has a dedicated team of insurance advocacy experts who communicate directly with payers when they learn that a practice is having difficulty with a third-party payer.
Take the College’s recent success with shifting the tide on underwater biosimilars. Members like Donald Thomas, MD, FACP, FACR, RhMSUS, CCD, a rheumatologist with Arthritis and Pain Associates of PG County in Greenbelt, Md., sought advice from the ACR earlier this year after insurance companies started requiring certain biosimilar intravenous biologics that they were reimbursing at rates below the drug purchase price.
The ACR took action. “After investigating, we quickly learned that pricing strategies aimed at getting biosimilars a favorable formulary placement had the unfortunate side effect of lowering these drugs’ average sales price below acquisition cost,” says ACR Practice Advocacy Director Meredith Strozier.
She collaborated with Rebecca Shepherd, MD, MBA, FACP, FACR, chair of the ACR Committee for Rheumatologic Care (CORC)’s Insurance Subcommittee (ISC). The ISC moved swiftly to educate commercial payers on this problem and how it was “leaving practices unable to provide these critical therapies to patients,” notes Dr. Shepherd.
Since then, Aetna, UnitedHealthcare, Cigna, Blue Cross NC and CareFirst have made temporary changes to their fee schedules to help ensure practices are reimbursed enough to continue providing these drugs.
“After I informed Meredith’s team, the insurance companies responded by appropriately reimbursing the medications so that our patients can continue to receive treatment,” Dr. Thomas notes.
This favorable shift in reimbursement for biosimilars is a perfect example of how members sharing their insurance questions or problems with the ACR can help us understand where to direct our efforts with payers, Dr. Shepherd stresses. And this advocacy work is ongoing, she says. “A large push by the ACR is underway for broad talks regarding a global fix for underwater biosimilars with many stakeholders as well as discussions with individual health insurers.”
Getting to Know Your ACR Insurance Advocacy Experts
Ms. Strozier is part of ACR’s practice team, a group of ACR staff with expertise on a range of rheumatology practice issues, spanning individual members’ specific coding or insurance concerns to broader policy issues impacting many rheumatologists and patients across the country. “Most often,” she notes, “if one practice has a new challenge pop up with a payer, other practices are likely facing it, too.”
She also coordinates with volunteer members serving on the CORC and ISC, who apply their knowledge and experience as practicing rheumatologists to inform outreach with payers and strategic alliances with other physician groups.
Current ISC Chair Dr. Shepherd works closely with Ms. Strozier and ACR insurance advocacy staff experts. Together, these advocates target specific coverage and reimbursement issues to help address concerns about the impact of payer policies on the practice of rheumatology at the local, regional and national levels.
“Essentially, we are a collective voice for our members,” Dr. Shepherd says. “We are ready and able to help provide support to practices and providers as they undertake the difficult work of caring for patients while navigating third-party payer issues.”
Celebrating Recent ACR Insurance Advocacy Wins
In addition to the continuing work to secure adequate reimbursement for biosimilars, the ACR has been working on appropriate reimbursement for the complex care rheumatologists provide. The ACR also advocates against excessive step therapy requirements and other utilization management concerns, such as lengthy prior authorization processes, unwarranted denials and lack of peer-to-peer review in appeals.
“Our shared goal is to reduce administrative burden on practices,” Ms. Strozier notes. She highlighted several updates on these fronts.
Improved recognition and reimbursement for code G2211 from commercial payers. This year, the Centers for Medicare & Medicaid Services (CMS) introduced the G2211 code for outpatient office visits to recognize the specialty training and work that goes into managing complex and chronic rheumatic diseases. The ACR continues to advocate for reimbursement of the G2211 code in the setting of the Modifier 25 code for outpatient office visits. The College has initiated conversations to encourage private payers to follow suit and has successfully worked with Medicare Advantage plans to appropriately reimburse G2211.
Dr. Shepherd, Ms. Strozier and their team recently led a multispecialty sign-on letter to UnitedHealthcare urging the payer to reconsider its decision to discontinue reimbursement for G2211 for commercial plans as of Sept. 1.
Target payer policy/utilization management concerns. The ISC routinely contacts commercial payers regarding policies and formulary requirements that create significant, unpaid administrative work for practices and result in reduced access to treatment for patients.
For example, the ISC reached out to payers regarding excessive step therapy requirements. In one recent case, a payer required a patient to fail to respond to three tumor necrosis factor (TNF) inhibitors before approving a drug from another class. In other cases, the ACR team has advocated against payers requiring patients to fail to respond to a non-FDA-approved therapy before approving coverage for FDA-approved treatment.
Connecting with Your Practice Advocacy Team
“ACR members are our best source of information about the insurance-related challenges facing rheumatology practices,” Ms. Strozier reiterates.
Specifically, ACR practice staff and members of the ISC want to hear from practices about their experiences with such payer issues as denials, coverage changes, step therapy requirements, prior authorizations, programs limiting use copay assistance funds and more. Report an issue by completing ACR’s online health plan complaint form or emailing [email protected].
“If you have difficulty with a patient not being able to get medically necessary therapy and for any reason are unable to get it due to illogical insurance practices, or if reimbursements are not being given for services in a reasonable manner, do not hesitate to contact the ACR’s insurance advocacy team,” Dr. Thomas says.
Carina Stanton is a freelance science journalist based in Denver.
