The ACR Insurance Subcommittee (ISC) of the Committee on Rheumatologic Care has had a busy start to 2024, advocating to payers on behalf of the ACR and its members. Following is an update on some of the work this group has been doing to help address concerns about reimbursement and administrative burden while ensuring continued access to critical therapies for rheumatic disease patients.
G2211 Reimbursement
The ISC has been communicating with Medicare Advantage and commercial payers to ensure appropriate reimbursement for the new G2211 add-on code. After hearing feedback about denials, the ISC began outreach to Medicare Advantage and commercial payers to advocate for coverage. In response to this outreach, UnitedHealthcare (UHC) confirmed that its Medicare Advantage claims platform was updated on Jan. 24 to allow reimbursement for G2211. Similarly, Aetna confirmed that its system was updated on Jan. 28. Both updates are retroactive to Jan. 1, 2024, and the payers will be reviewing and adjusting claims for any date of service after Jan. 1. The ACR anticipates that other Medicare Advantage plans will implement similar updates, and outreach is ongoing to confirm these details.
Formulary Requirements & Reimbursement for Biosimilars
The ISC has been engaging with both commercial payers and the Centers for Medicare & Medicaid Services (CMS) regarding formulary requirements that would leave practices underwater when treating patients with biosimilars infliximab-axxq (Avsola) or infliximab-dyyb (Inflectra). Numerous payer formularies require patients to use these specific infliximab biosimilars, despite reimbursement falling below acquisition cost for many independently owned rheumatology practices. The ACR supports biosimilar use and is encouraged by their overall impact on reducing drug costs; however, requiring practices to infuse any drug at a loss undermines financial solvency and is unacceptable.
In response to the ISC’s ongoing advocacy efforts, Aetna has responded that both commercial and Medicare Advantage fee schedules were updated in July 2023, increasing reimbursement for the underwater drugs. UHC has also confirmed that it is pursuing both short- and long-term solutions. In addition to these efforts with commercial payers, ISC and CORC leaders recently had the opportunity to meet with the CMS and discuss the ACR’s concerns.
Prior Authorization Requirements for Mandated Switches to a Biosimilar
The ISC has received numerous complaints about payers requiring patients to switch from an originator to a biosimilar drug, then requiring a new prior authorization. These changes are impacting many patients simultaneously, which is causing significant administrative burden for practices, particularly in cases where the payer requests medical records. The ISC is reaching out to payers to advocate for a more streamlined process to help alleviate the burden on practices and ensure timely and undisrupted access to treatment for rheumatology patients.
Specialty Pharmacy & Home Infusion Mandates
The ACR continues to see select health plans introducing policies that would require specialty pharmacy acquisition of in-office treatments. These policies prohibit the traditional buy-and-bill method of obtaining drugs, limiting practices’ ability to continue providing these critical therapies. Most recently, the ISC sent a letter to Blue Cross Blue Shield of Massachusetts about a new policy that only permits specialty pharmacy acquisition or home infusion for certain biologics. The ISC will continue to advocate against this misguided policy and against all policies that would limit patients’ access to receiving provider-administered treatments in their rheumatologists’ office.
Working for Members
In addition to the issues outlined above, the ISC has received numerous health plan complaints that occurred with the start of the new year. These include changes in step therapy criteria, formulary adjustments, prior authorization issues and payer coding and reimbursement errors. These issues continue to disrupt patient care and add to the workload of rheumatology practices. As complaints are received, the ISC continues to investigate and reach out to the health plans to help ensure resolution.
The ISC is available to help members with issues related to insurance policies and payers. For more information about the issues above or to request ACR’s help on other payer issues impacting your practice, reach out to [email protected].
