By providing employers with these data and an assessment of the access issues their employees will see, we hope employers will choose to opt out of specialty pharmacy plans. We have seen several employers in Tennessee back out once they understood the implications for their employees’ access to care. Stay tuned for more details and let us know if you see carve-outs on buy-and-bill treatments. The ISC can advocate on your behalf and provide you with literature to share with your local employer groups.
Physician-Administered Drugs
Many of you may recall the policy UHC announced and quickly rescinded on Oct. 1, 2019, that would require patients to document failure of the self-administered version of certain treatments before in-office treatment would be covered. We have talked with UHC, and it plans to re-introduce this policy, with modifications, possibly on July 1.
We are working with UHC on revisions to this policy, and we are pushing it to grandfather in stable patients and to include a reasonable list of exclusions for patients who may be better served by in-office treatments due to weight, compliance, frail health or other reasons we have provided to them. We are hopeful UHC will integrate our feedback to make this policy more manageable.
Modifier -25 Policies
A modifier -25, as defined by the American Medical Association Current Procedural Terminology book, is used to report a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” It requires documentation that satisfies the relevant criteria by payers for billing an evaluation and management (E/M) service and a procedure, such as an injection or infusion, on the same day.
Although both Medicare and Anthem pulled back plans in 2017 to reduce E/M reimbursement by 50% when billed with a modifier -25, this policy keeps rearing its head. We are now seeing Anthem implement prepayment reviews of such claims, which we worry may be burdensome to practices, and stating it will deny the payment altogether if the “same or similar” ICD-10 code has been billed in the previous two months. Anthem has not provided clarity on what “similar” means and as yet has been not been open to reconsidering this policy.
Additionally, Cigna will implement a plan on March 16 requiring review of documentation for medical necessity on E/M claims billed with a joint injection or aspiration. At this point we are unsure if this will trigger a burdensome records request on all such claims or only some, nor do we know how much payment delay may result. If your practice experiences adverse results of such policies, reach out to us at [email protected] with specifics so we can provide these payers with objective data on the administrative hardships such policies create.
