PRACTICE PAGE: The ACR Takes on Insurance Companies

In response to the increasing demands of medical necessity and denials for approved drugs, the ACR is taking a large step towards protecting the rights of members when dealing with insurance companies.

In 2009, the ACR created the Insurance Subcommittee to improve the rheumatology practice environment as it is affected by health insurers, including issues such as patient access to high-quality care and treatment, reimbursement, regulation, and drug and treatment policies.

The Insurance Subcommittee continuously makes connections with medical directors and key decision makers at the major insurance companies in order to build a solid working relationship and to educate them on the growing changes in disease management for rheumatology patients. “[The Insurance Subcommittee] has reached out to various payors in order to work with them on updating their medical and drug policies,” states subcommittee chair Rudy Molina, MD.

Dr. Molina notes that “payors such as United Healthcare, Regence, and WellPoint have sent their policies to the subcommittee to review and provide input from the rheumatologist perspective.” This has led to positive outcomes for rheumatologists. Due to input from the subcommittee, WellPoint changed its rituxumab policy to include neuromyelitis optica as an off-label indication for the use of rituxumab.

The subcommittee also works on national, state, and local insurance issues. For example, last year an ACR member in New York informed the subcommittee that various payors were denying payment for ultrasound guidance procedures for rheumatologists—code 76881 or 76882. After a letter was sent to the payors, HIP Health Plan of New York responded that they approved the procedure using CPT code 76942—ultrasound guidance for needle placement. Dr. Molina states that this is of great concern for the rheumatology community because the use of diagnostic ultrasound is a reliable method of early detection of joint disease. For example, with ultrasound, synovitis was detected in 7 of 8 patients (88%) in whom clinical assessment failed to detect synovitis that was seen arthroscopically.¹

However, HIP will not approve the use of CPT code 76881 or 76882 for rheumatologists, and therefore the subcommittee is sending a second letter with additional literature on the benefits of using ultrasound imaging for disease management. The ACR will continue to fight for approval of code 76881 or 76882 for rheumatologists.

If you have an insurance issue, contact the ACR Insurance Subcommittee for assistance. To do this, download the Health Plan Complaints Form from the ACR website at www.rheumatology.org/practice, and submit your completed form online.