In late 2004, the Technology Evaluation Committee of Blue Cross determined that there is no value for vertebral fracture assessments, and therefore Blue Cross plans across the country as well as Trailblazers, Aetna, and others have refused reimbursement. In 2006, the ACR has worked closely with other medical societies to respond to this problem and will present new data to Blue Cross this fall in the hope of reversing this determination.
On a similar note, the ACR has joined with International Society for Clinical Densitometry to protest the planned cuts in reimbursement for DXA scheduled to be phased in over the next four years. Through a blast e-mail message, the ACR has encouraged members to complete surveys on the work components in performing and interpreting scans. The College has also crafted a letter to Congress to be included in the Congressional record, written CMS directly, and asked members to contact their legislators. (See “Payments Cut to the Bone” on p. 18 for more on DXA reimbursement cuts.) Other accomplishments include:
- Persuading a major insurer in Washington State not only to reverse a decision to pay physicians for simple infusion codes when administering infliximab, but to reimburse them retroactively. This has amounted to more than $5,000 for one office of three rheumatologists;
- Inducing the Government Employee Hospital Association to reverse a policy of mandated brown bagging, which penalized patients who purchased infusible medications through their physicians rather than a specialty pharmacy;
- Getting Palmetto GBA to reimburse a South Carolina rheumatologist $60,000 to $70,000 for infliximab infusions rather than withhold reimbursement pending repeated requests for further documentation; and
- Convincing John Deere Health to discontinue a requirement for increased documentation whenever the -25 modifier was used.
Ongoing issues include reimbursement for IV ibandronate, restriction of rheumatologists from performing and interpreting some routine X-ray studies, the use of sildenafil for scleroderma patients, and unreasonable medication prerequisites.
RAC identifies problems that need to be addressed through the ACR membership. Help us help you by contacting your regional advisors (please visit the ACR Web site to find your advisor) or contact Melesia Collins, CPC, ([email protected]) or Resaee Freeman, CPC, ([email protected]) if you are encountering problems in your area.
Dr. Fohrman is the immediate past chair of the ACR Regional Advisory Council.