Anthem modifier 25
In late 2017, Anthem introduced a policy that would have reduced reimbursement for E/M services when billed with modifier 25. After hearing strong opposition from the ACR and other stakeholders, Anthem ultimately rescinded the policy.
However, Anthem continues to believe that overuse/abuse is occurring, and they recently issued an update stating they will deny an E/M service billed with modifier 25 when the E/M service is also billed with the same or similar diagnosis within the previous two months.
The ACR is concerned this will lead to inappropriate denials and increased administrative burden, as practices will be forced to appeal. The ISC and several other provider organizations, including the AMA, have reached out to Anthem to express opposition.
Non-medical switching, specifically to biosimilars
Some health plans have begun implementing polices that force stable Remicade patients to switch to biosimilar Inflectra and/or Renflexis. In the last few months, the ISC has reached out to Priority Health in Michigan, BCN Michigan, and PacificSource in Oregon advocating for the plans to follow FDA guidance and not force switch patients between products that have not been ruled interchangeable. The ISC is also encouraging plans to add coverage for biosimilars while maintaining access to the originator product.
Dr. Phillips explains that the ACR recognizes the high cost of biologic drugs, supports cost effective treatments, and supports uptake of biosimilars as a means of cost savings. However, “until or unless such drugs are deemed interchangeable with originator biologics, we will advocate strongly for the role of the provider and patient, not the insurance carrier, in deciding which version of a drug the patient receives.”
He describes this as a very active issue and invites ACR members running into these issues to reach out to the ISC.
Co-pay accumulator programs
The ISC continues to monitor the health insurance landscape for impacts of co-pay accumulator programs. There have been limited reports on this issue recently; however, the ISC expects that issues could emerge once co-pay funds run out in the second half of the year.
“While the ACR recognizes concerns about how co-pay savings programs may allow for cost inflation of biologics, we also recognize the role these programs play in allowing patients access to these life-changing drugs, at least in the current healthcare environment,” Dr. Phillips acknowledges. “Until or unless a systemic change in the economic model occurs, we oppose these new programs that essentially exhaust the patient’s co-pay assistance without touching their deductible, thereby leaving them obliged to switch therapy mid-year.”
