A similar issue is maximum fair price, in which prices set under the federal Inflation Reduction Act are used as a cap for reimbursement that providers can seek. Again, Mr. Henderson said, these federal limits don’t consider administration payment or other payments related to furnishing the medication.
There also have been hiccups with gold cards, or exemptions from prior authorization requirements for physicians who have exemplary track records for getting approvals of their medications.
One of the challenges is that, while a physician might be exempt from prior authorization, they are still obligated to follow step therapy rules—“so you’re left in this weird space where you have to follow the protocol, but you’re exempted from the means by which they enforce the protocol.” This is an issue that needs to be resolved, he said.
Another snag is that it is proving to be difficult to obtain gold cards for medications, because physicians need to have a minimum number of cases with that particular drug in a particular health plan—a threshold that can be hard to reach.
Mr. Henderson emphasized how important it is for physicians to make themselves heard by state legislators. For the most part, he noted, “they don’t understand the diseases you treat, they don’t understand your businesses.”
Is your practice facing a challenging payer issue? The ACR has staff dedicated to payer advocacy and practice support, and the ACR’s Insurance Subcommittee is ready to assist members with individualized support on policy and reimbursement issues. ACR/ARP members who need assistance are encouraged to complete the health plan complaint form or write to [email protected]. Additional resources are also available at ACRInsuranceAdvocacy.org.
Thomas Collins is a freelance medical writer based in Florida.
