Both private and academic rheumatology practices face payer challenges that put the health of their patients and their practices at risk. To make sure the rheumatologist perspective is heard by payers, “the ACR’s Insurance Subcommittee (ISC) serves as the interface between payers and our members and ACR colleagues,” explains Sean Fahey, MD, a rheumatologist in Mooresville, N.C., and outgoing chair of the ISC.
“We get involved with any policies that restrict access to care and treatment for our patients, and work to minimize administrative burden for our member practices,” he says.
Over the past three years, Dr. Fahey has led the ISC in addressing payer proposals and decisions that threaten to decrease reimbursement and limit options for infusible biologics, as well as to protect the choice of medications based on a patient’s best interests.
He is working closely with incoming ISC chair Christopher Phillips, MD, and other members of the ISC to continue successful progress on several fronts.
Modifier 25 Payment Reduction Policies
Several health plans have introduced policies that would reduce reimbursement for E/M services when billed with modifier 25 by up to 50%. This policy is based on the view that insurers may be paying for duplicative services. The ACR and other specialty medical societies believe the AMA Relative Value Update Committee (RUC) has already addressed overlap by reducing the value of codes frequently billed with modifier 25.
For Dr. Phillips, who leads an individual rheumatology practice in Paducah, Ky., if these policies go through, he would have to choose whether to perform a procedure, such as administering a joint injection after a routine visit that day and accept reduced reimbursement, or ask the patient to leave and return a different day for the procedure.
“Given the rural setting where I practice and the shortage of rheumatologists in my region, a patient may have a 90-minute drive to my clinic. How can I ask them to make a second trip? Meanwhile, our profit margin is tight; if we see these cuts go through, it will impact our bottom line,” he says.
The ISC and many physician advocates have been vocal in opposing these policies, leading to positive results for rheumatology practices.
Through ongoing dialogue with Anthem Blue Cross Blue Shield, the ISC, in partnership with other physician groups, has had a victory with this payer, which first proposed a 50% reduction, then reduced to 25%, then rescinded the modifier payment reduction policy all together.
Right now, the ISC is working toward a similar goal with UnitedHealthcare (UHC) and Medicare, and is waiting to see if Medicare’s final rule will include removing its proposed modifier payment reduction policy. Regarding UHC’s position, after some advocacy efforts made by the ISC and others, UHC has put on hold a decision regarding modifier 25 payment reduction policies, saying it will wait to see what Medicare decides and will then reevaluate, Dr. Phillips shares.
Site-of-Service Restrictions for Infused Biologics
Over the past several years, the ACR has engaged with 10 different health plans regarding policies that limit the site of service for patients receiving infusions. The payers implementing these policies have the stated goal of moving infusions from hospital outpatient facilities to other, less costly settings. The policies permit patients to receive their infusions at home, in a physician’s office or in another non-hospital-based infusion center. Most grant exceptions for initiating or reinitiating therapy, as well as for patients with a history of severe infusion reactions or other medical risks or comorbidities.
“We have firsthand accounts from members who have shared cases where patient harm occurred due to these policies and decreased access,” Dr. Phillips says. The ACR’s position is to advocate for safe administration of infused biologics in a monitored healthcare setting with on-site supervision by a provider with appropriate training in biologic infusions; the ISC continues to successfully dialogue with payers for this.
Downcoding Administration of Certain Biologics by UHC
Following continued advocacy from the ISC and other physician and patient stakeholders, UHC announced on Nov. 1 that a policy to downcode reimbursement for administration of four drugs is “undergoing additional evaluation” and will not be implemented on Dec. 1 as planned. No future effective date has been announced. This policy would have ended reimbursement of the complex administration codes (96413 and 96415) for four drugs—Actemra, Entyvio, Orencia and Simponi—instead requiring providers to use the therapeutic codes: 96365 and 96366.
UHC previously stated this policy could be expanded to include other drugs. As such, this issue is still very much a priority for the ISC, and the committee will continue to advocate against implementation, Dr. Phillips stresses.
The ACR’s position statement notes that all biologic drugs are complex and present risks of complications. To emphasize this reality and the risks associated with this policy, the ISC sent several letters to UnitedHealthcare and spoke to the insurance company’s leadership via conference call in October, sharing the detrimental effects this policy would have on rheumatologists’ ability to provide patients with access to these treatments.
Many factors make these drugs more complex than antibiotics, which is what this policy was originally intended to address, Dr. Phillips shares. “With tight margins, administration codes are a large part of what allow us to pay our nursing staff and have the facility and qualified staff to infuse these medications, which is another pressure against the bottom line.”
The Realities of Payer Policies
Dr. Phillips and Dr. Fahey agree the voice of the ISC is made stronger by members who share their concerns and complaints about payer policies that threaten rheumatology care. They encourage members to share payer experiences and concerns with the ISC.
In the year ahead, Dr. Phillips will lead the ISC in continuing advocacy work on the payer front. Stay current with these activities through ACR@Work and follow Insurance Advocacy Current Issues to find updates on pertinent policy changes and advocacy victories that impact your practice and your patients.
Carina Stanton is a freelance science journalist based in Denver.
