ATLANTA—From step therapy requirements to infusion center locations to evaluation and management coding, insurance issues bring frequent headaches to clinicians and patients. Experts discussed some of the most recent concerns in a session at the 2019 ACR/ARP Annual Meeting.
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Explore This IssueMarch 2020
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Chris Phillips, MD, chair of the ACR’s Insurance Subcommittee (ISC), and Gary Bryant, MD, delegate to the American Medical Association (AMA) from the ACR, described the ACR’s ongoing efforts to prevent the rollout of potentially harmful new rules, and to push for changes to insurance rules that harm patients and physicians.
The ISC can help ACR members by investigating inappropriate health plan policies or practices. “Feel free to reach out to us—we are happy to advocate on your behalf,” Dr. Phillips said.
From October 2018 to October 2019, the ISC sent letters to payers on a variety of issues: six on formulary and drug access issues, five for nonmedical switching of medications, four regarding consultation codes, and three each on step therapy requirements, modifier -25 related evaluation and management (E/M) coding.
Rheumatology Insurance Issues
Some of the leading insurance topics affecting rheumatology that Drs. Phillips and Bryant discussed include:
Consultation codes: United Healthcare eliminated consultation codes this year, and Cigna followed recently, saying they were following Centers for Medicare & Medicaid (CMS) guidelines and wanted to simplify their billing and coding processes. A silver lining, Dr. Phillips said, is that the CMS fee schedule to take effect in 2021 includes a 15% increase for rheumatology, but it is not known whether private payers will do the same.
“We would certainly encourage you to examine your contracts to see how they’re structured,” Dr. Phillips said.
Tracking commercial payer policies: Dr. Bryant cautioned the audience that policies are not always kept on websites, so they may require extra diligence to keep them accessible when needed. What’s more, private insurers often communicate policies with paper newsletters, even in the digital age.
“If that’s the case, then it’s very important that when those are received, they be reviewed by the appropriate personnel in the practice,” he said, and then kept on file for future reference.
Step therapy in Medicare Advantage: This practice—requiring a patient to try a medication, typically a generic or low-cost option—specified by the insurer, before moving on to other medications, was allowed in 2019 after regulatory changes. Patients with claims paid in the previous 365 days were grandfathered in, and a turnaround time of 72 hours for appeals is required.
The ACR is working with the AMA to ask for more guardrails to be put in place, such as the provider being able to define failure of treatment, exceptions if a medication is contraindicated or likely to be ineffective or cause harm, and exceptions for patients whose lives or physical function could be irreparably harmed by a delay in appropriate treatment, Dr. Phillips said.