CHICAGO—ACR leaders described a series of looming legislative and regulatory threats to rheumatologists and their patients—including the proposed collapsing of evaluation and management (E/M) coding and potential changes to step therapy rules—and urged everyone in the field to make their voices heard to quash the proposals.
Explore this issueDecember 2018
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They also recounted recent victories in the policy realm by the ACR—among them, changes to reimbursement for biosimilars and the easing of cuts to imaging reimbursement—which they say show stepping into an advocacy role can bring results that matter.
The call to action came in a session at the 2018 ACR/ARHP Annual Meeting.
Among many legislative achievements over the past year, according to Angus Worthing, MD, chair of the ACR’s Government Affairs Committee, three were spearheaded by the ACR. One was to get the federal government to restart premium processing for physicians needing H1-B visas, which apply mostly to foreign-trained physicians practicing or finishing their training and wanting to practice in the U.S.
Also, proposed musculoskeletal ultrasound reimbursement cuts were significantly eased after the ACR argued that it is useful and safe—and often more effective than more expensive imaging.
Another success, Dr. Worthing said, was the start of unique coding for biosimilars, which he said creates a “more providerfriendly environment” in which to prescribe these drugs. Under the new coding, biosimilar reimbursements will no longer be pooled—lumping less and more expensive drugs together—but will be individualized.
E/M Coding Changes
The changes to the E/M codes are ostensibly meant to simplify documentation by blending E/M levels 2 through 5 into a single payment, requiring documentation only at level 2, which is less onerous. But the ACR and other medical organizations say the changes will lower reimbursement for more complex cases.
“What it ends up meaning—and may be an unintended consequence—is reducing access to care for our patients to see us, because it reduces reimbursement pretty severely for rheumatologists,” said Dr. Worthing. “Medicare anticipates a 3% reduction in reimbursement, which translates into a 10% pay cut.” That calculation assumes 70% overhead and 30% take-home, he said.
Several health plans have introduced policies to cut reimbursement for E/M services when billed with Modifier 25—involving distinct services on the same day—by up to 50%, in the belief they’re paying twice for certain fixed costs built into the coding. The counterargument, according to Sean Fahey, MD, chair of the ACR’s Insurance Subcommittee, is that the American Medical Association’s Relative Value Scale’s Update Committee has already addressed this overlap by reducing the value of the codes that are frequently billed with Modifier 25. The ACR and other medical societies have opposed the policy.
The ACR has led the national response to this proposal in partnership with other specialty societies, such as the American Academy of Neurology, including facilitating meetings on Capitol Hill and, with the agency, writing and coordinating a stakeholder letter from more than 130 physician and patient organizations to the Centers for Medicare and Medicaid Services (CMS), and letters from members of the U.S. House of Representatives and the U.S. Senate expressing concerns.
So far, the large national payer Anthem has rescinded its policy, but UnitedHealthcare recently announced a policy to reduce the reimbursements, Dr. Fahey said.