ACR Insurance Subcommittee Responds to Payer Policies

The ACR’s Insurance Subcommittee (ISC) of the Committee on Rheumatologic Care reviews payer policies to ensure patient access and fair and consistent provider reimbursement. When the ISC identifies a problematic policy, often via a report from an ACR member, a letter is sent to the payer outlining the ACR’s concerns and requesting corrective action.

The ISC has had a busy start to 2018, sending eight letters since the beginning of the year. Several policy trends the ISC has responded to are detailed below. 

Reimbursement for E/M Services when Billed with Modifier 25
As reported previously in ACR@Work, Anthem Blue Cross announced—and eventually rescinded—a policy that would have reduced reimbursement for evaluation and management (E/M) services when billed with modifier 25 by up to 50%. While the ACR was part of a successful advocacy effort to overturn the Anthem policy, several other payers have, unfortunately, moved forward with implementation of similar reimbursement cuts. In early April, the ISC sent a second letter to Independence Blue Cross underscoring the ACR’s opposition to its misguided modifier 25 policy and requesting further investigation into related reports of claims processing errors.

Site-of-Service Restrictions for Infused Drugs
Blue Cross Blue Shield of Arizona is the latest plan to implement a site-of-service policy that limits coverage for infusions performed in hospital outpatient facilities. It joins a growing list of payers the ISC has communicated with regarding such restrictions since 2015. Other payers with similar policies include Anthem, Cigna, Humana, Medical Mutual of Ohio, Regence BlueShield and UnitedHealthcare. The ACR’s position on this issue is detailed in the position statement Patient Safety and Site of Service for Biologics.

Formulary Changes & Patient Access Issues
The ISC also recently responded to several policies concerning formulary changes and patient access to specific drugs. As described in the Patient Access to Biologics position statement, the ACR opposes step edits, fail-first policies, tiering, forced switching and excessive coinsurance for biologics. The ISC monitors such formulary changes and restrictions, and regularly dialogues with payers to help preserve patient access.

If you have questions regarding these policies or other insurance concerns, contact practice@rheumatology.org.