In response to ACR members expressing frustration with denials from two payers, the ACR’s Insurance Subcommittee (ISC) took action, leading to system corrections that restored set reimbursements for common rheumatology practices, according to ISC Subcommittee Chair Chris Phillips, MD, and ACR Practice Advocacy Director Meredith Strozier.
In one correction, the ISC reached out to Aetna after members reported denials for corticosteroid injections for patients with osteoarthritis. Aetna fixed the system error causing these inappropriate denials, acknowledged the error, and sent an updated explanation of benefits and payments to impacted providers.
In a separate complaint, the ISC reached out to CGS, a Medicare contractor, after being made aware that CGS was not reimbursing for advanced-practice providers administering certain in-office treatments. CGS agreed that these services should be covered and made the necessary adjustments in their payment system.
“These two wins highlight the ability of the ISC to advocate on behalf of individual practices regarding payer issues, which might be very regional, might not be system-wide, but could negatively impact bottom lines of small practices if not remediated,” notes Dr. Phillips. “The ISC targets large, system-wide issues, but is equally equipped to assist with individual practice issues if it seems insurance carriers are misbehaving.”
Ongoing ISC Priorities
Based on input from members and early awareness through Ms. Strozier and the ACR’s practice advocacy team, the ISC is currently advocating on behalf of rheumatologists and their patients across several fronts.
UnitedHealthcare (UHC) consultation codes policy
UHC is discontinuing payments for consultation codes (CPT 99241–99255), with implementation to occur in two phases. As of June 1, 2019, UHC eliminated the consultation codes for practices whose contracted rates are based on a stated year 2010 or later Medicare fee schedule. On Oct. 1, 2019, UHC will eliminate consultation codes for all practices.
UHC proposed a similar policy in 2017 and 2018; however, in both cases, the policy was subsequently delayed after strong opposition from the ACR and other provider organizations.
After addressing the issue of practices with older fee schedules, UHC is now committed to moving forward and aligning their policy with Medicare. The ISC has continued to oppose elimination of these codes and advocate for appropriate recognition and compensation of rheumatologists’ expertise and training.
“UHC is moving forward with these changes, in spite of vocal opposition by the ACR and others,” Dr. Phillips says. “We will monitor for and advocate against similar changes by other carriers, and work with the American Medical Association [AMA] and its CPT/RUC committees to advocate to the CMS on behalf of adequate valuation for cognitive care provided by rheumatologists.”
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.”
Raise Your Concerns
Member input provides significant awareness to the ISC and the ACR when practices are experiencing challenges with payers. Dr. Phillips and Ms. Strozier encourage all members to share any payer challenges with the ISC.
Additional Resources
Learn more about the ISC and the Committee on Rheumatologic Care.
Read more about the ACR’s work in advocating for providers and patients regarding payer policies and find more on recent ISC wins on the payer front, and about ISC Chair Dr. Phillips.
Carina Stanton is a freelance science journalist based in Denver.
