Practice Page: The ACR’s Insurance Subcommittee Facilitates Better Communication With Health Insurers for Rheumatology Practices

Dealing with the administrative requirements for health plans costs not only time, but also money for physicians and their practices. A 2009 study published in Health Affairs, “What Does It Cost Physician Practices to Interact with Health Insurance Plans?”, reported that physicians and their supportive staff spend approximately four or more hours each week interacting with insurance plans.¹ Medical staff spends an increasing amount of time on the phone requesting prior authorizations, confirming medical necessity, completing redundant forms, and appealing denials for treatments. When time is converted to dollars, it is estimated that interactions with health plans cost practices between $23 billion and $31 billion each year.

In response to the growing challenges related to insurance companies, the Insurance Subcommittee (ISC) of the ACR Committee on Rheumatologic Care was created in 2009. The subcommittee’s purpose is to coordinate and engage in all activities that improve the practice environment of rheumatology as it is affected by health insurers. The committee works to improve patient access to treatment, support its members, and improve relationships with all stakeholders.

Rheumatologists want to be able to provide efficient care to their patients and to manage their workflow effectively. Coding and reimbursement issues create hurdles to achieving these goals. Practices face frustrations such as payment timeliness, procedural and service denials, claims edit, and claims accuracy. In addition, offices are burdened with an overwhelming volume of prior authorizations and confusing drug approval processes. Like their providers, the health insurance plans cannot afford to compromise patient care by limiting access to care or procedure choices. Thus, it is imperative that providers and payers improve their dialogue and find a middle ground on their common goal of providing excellent, affordable care.

The ISC hopes that coordinating meetings with key decision makers in health plans will promote an honest and candid dialogue regarding the needs and operational systems of both parties, with the expectation of streamlining administrative processes to reduce resource exhaustion and effectively deliver the right care to our patients.

Individual and system-wide insurance issues are among the many areas in which the ISC is working to develop policy and programs to assist ACR members in their interactions with health plans. ISC chair Elizabeth Perkins, MD, says, “The goal of the subcommittee is to build strong relationships with medical directors and policy makers to address our key issues. We want equal access to our medically necessary treatments, standardized prior authorizations, and an open, collaborative approach to efficient, affordable, quality healthcare. The ISC hopes to raise up rheumatologists, despite many of the strongholds weighing them down. We also believe the ACR needs to strengthen state-level [efforts] and legislative efforts, and better engage patients and others in the necessary reform ahead.”

The ISC has been busy this year dealing with issues such as denials for musculoskeletal ultrasound, unnecessary prior authorizations for generic medications and methotrexate, inappropriate step treatment programs, policy and formulary reviews, infusion questions, evaluation and management coding queries, and much more. “These are collective issues affecting rheumatology practices nationwide, and the subcommittee is dedicated to tackling these undue burdens aggressively,” says Dr. Perkins.

Payer Relationships

Since 2010, the ISC has worked diligently on building relationships with health insurance plans to improve the quality and cost effectiveness of healthcare for our patients. The ISC would like to continue having progressive and frank conversations with payers in all matters. The healthcare system is complex, and ensuring that the care provided is both high quality and cost effective is never straightforward. The ISC remains committed to providing input, advice, and expertise on medical policies affecting our membership.

The ISC has been instrumental in contributing to and providing feedback on medical policies on a monthly and quarterly basis with health plans such as WellPoint Health Network Inc., Regence BlueCross BlueShield, and United Healthcare.

In an effort to assist our members with insurance problems and inquiries, insurance resources have been created for members and their staff on the ACR website:

• Health Plan Complaint Form—The ACR developed this standardized complaint form to assist members in addressing both individual and system-wide insurance issues.
• Letter templates—Hot topics for members to communicate to insurance carriers.
• Medicare—Information such as Medicare fee schedules, information about Medicare Part D, and letter templates relating to Medicare issues are available to guide you and your staff.
• Model Biologics Policies—The ACR’s Model Biologics Access and Treatment Policies can be used nationwide to reduce administrative burden among rheumatologists, patients, and insurers, and allow you to properly treat patients without administrative delays. In an effort to make sure that the best care is provided to patients, the ACR also developed a standardized prior authorization form.

If you have an insurance issue, do not hesitate to ask the ISC for help! Keep in mind, the ISC cannot negotiate contracts for physicians, but is willing and able to investigate unfair practices from insurance companies that would put a patient or physician at risk. Join the ACR’s designated list serve to participate in insurance, coding, and payment discussions.

We look forward to serving you! If you have any insurance questions or issues, contact the ACR’s insurance and coding specialist Melesia Tillman, CPC, CPC-I, CRHC, CHA, at [email protected] or (404) 633-3777, ext. 820.

Reference

1. Casalino LP, Nicholson S, Gans DN, et al. What does it cost physician practices to interact with health insurance plans? Health Aff (Millwood). 2009;28:w533-w543.