The ISC monitors insurance policy changes and assists with member requests for support when an insurance carrier’s decision negatively impacts a member’s practice. Through letters and face-to-face meetings with insurance carriers, the ISC advocates on behalf of rheumatologists and their patients to change insurance policy.
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Dr. Phillips believes he is well equipped for his role as ISC chair. “Like me, most private practice rheumatologists are on the front line of insurance battles. We are looking closely at our bottom line, and the amount of time and staff required to deal with insurance requests, such as prior authorization.”
This frontline experience gives Dr. Phillips a personal perspective on the insurance advocacy issues he leads the ISC in fighting. “I have something of a disdain for the way some insurance companies make our decisions for us, and it’s important to me to put in the time to work on these issues.”
Participating in ACR meetings as a member for the past decade inspired Dr. Phillips to take a more active volunteer role in the College three years ago when he joined the Committee on Rheumatologic Care (CORC). Last year, the committee nominated him to chair CORC’s ISC, and he said yes enthusiastically.
Over the past year, the ISC has successfully achieved a long list of wins for rheumatologists on the insurance carrier front, including:
- Influencing a turn against Modifier 25 payment reduction policies by Anthem and UnitedHealthcare (UHC);
- Delaying the elimination of consultation codes by UHC;
- Advocating with several carriers regarding sites of service for patient-infused biologics;
- Advocating for compendia inclusion of mycophenolate to treat scleroderma, paving the way for Medicare Part D coverage; and
- Advocating against downcoding of administration codes for several infused biologics by UHC and several Medicare contractors.
In the year ahead, the ISC will continue to work with Medicare Advantage (MA) plans regarding step therapy protocols and is in discussion with commercial carriers regarding reimbursement for consultation codes, as well as co-pay accumulator programs.
“We [remain] vigilant [in responding to] any member concerns and experiences [that have to do] with insurance carriers,” Dr. Phillips says. “Direct communication with our members helps connect us to challenges on the front line that we can raise concerns about and work to change.”