The Insurance Subcommittee (ISC) of the ACR Committee on Rheumatologic Care advocates to payers on behalf of the ACR and its members, addressing the most pressing coverage and reimbursement challenges facing rheumatology practices. Following is an update on the ISC’s recent advocacy work to help address concerns about reimbursement and administrative burden while ensuring continued access to critical therapies for rheumatic disease patients.
Formulary Requirements for Underwater Biosimilars
The ISC has been engaging with commercial payers regarding formulary requirements that would leave practices under water when treating patients with biosimilars. Numerous payers require patients to use specific biosimilars despite reimbursement for these drugs falling below acquisition cost for many rheumatology practices. The ACR supports the use of biosimilars and their overall impact on reducing drug costs, but requiring practices to infuse any drug at a loss undermines financial solvency and is unacceptable.
Since late 2023, the ISC has been engaging with payers and advocating for fair and appropriate formulary access and reimbursement for biosimilar therapies. These efforts have resulted in coverage and/or reimbursement adjustments with numerous payers, including Aetna, Blue Cross NC, Health Care Services Corporation (HCSC) and UnitedHealthcare. Most recently, the ISC sent a letter to CareFirst Blue Cross Blue Shield urging changes to formulary requirements that give preference to underwater biosimilar drugs and also cautioning against non-medical switching requirements that would force a patient to switch therapies to a biosimilar version of a different drug.
Prior Authorization Requirements for Mandated Switches to a Biosimilar
The ISC has received many complaints about health plans requiring patients to switch from an originator to a biosimilar drug. In many cases, the payer requires a new prior authorization for the preferred drug. In addition, the switches have been excessive at times, requiring patients to switch drugs multiple times within a short time period. Because these changes impact many patients simultaneously, the added administrative burden for practices has been significant.
The ISC is advocating for a more streamlined process and limitations on the number and frequency of these drug switches to help alleviate the burden on practices and ensure timely and undisrupted access to treatment for rheumatology patients.
Aetna Claim & Code Review Program
The ISC continues to dialogue with Aetna leaders regarding their Claim and Code Review Program, which is active in 12 of the 39 states where the payer operates. The program reviews level 4 and 5 evaluation and management (E/M) visits for “correct coding” and performs prepayment edits as the payer deems appropriate. This results in certain claims being paid at a lower rate than originally billed. Practices identified for inclusion in the review program are given 90 days advance notice and their status is reviewed annually.
The ACR has serious concerns about the inappropriate reduction of payment for rheumatology services, as well as the burden on practices to review and appeal the downcoded claims. The ISC has engaged Aetna leaders to discuss these concerns as well as the general lack of transparency around the program’s criteria and operation.
The AMA has also created resources to assist practices in the fight against inappropriate downcoding. AMA guidance on payer evaluation and management (E/M) downcoding programs provides information and tools to help practices recognize and fight downcoding and receive appropriate payment for downcoded claims, even after the fact.
In addition to the issues outlined above, the ISC has been active on numerous other insurance concerns reported since the start of the year, including formulary adjustments, drug coverage issues and payer coding and reimbursement errors. All of these issues continue to disrupt patient care and increase the administrative burden practices face. The ISC is committed to supporting ACR members by advocating for timely and appropriate resolution.
For more information about the issues above or to request the ACR’s help on other payer issues impacting your practice, reach out to [email protected].
