She also coordinates with volunteer members serving on the CORC and ISC, who apply their knowledge and experience as practicing rheumatologists to inform outreach with payers and strategic alliances with other physician groups.
Current ISC Chair Dr. Shepherd works closely with Ms. Strozier and ACR insurance advocacy staff experts. Together, these advocates target specific coverage and reimbursement issues to help address concerns about the impact of payer policies on the practice of rheumatology at the local, regional and national levels.
“Essentially, we are a collective voice for our members,” Dr. Shepherd says. “We are ready and able to help provide support to practices and providers as they undertake the difficult work of caring for patients while navigating third-party payer issues.”
Celebrating Recent ACR Insurance Advocacy Wins
In addition to the continuing work to secure adequate reimbursement for biosimilars, the ACR has been working on appropriate reimbursement for the complex care rheumatologists provide. The ACR also advocates against excessive step therapy requirements and other utilization management concerns, such as lengthy prior authorization processes, unwarranted denials and lack of peer-to-peer review in appeals.
“Our shared goal is to reduce administrative burden on practices,” Ms. Strozier notes. She highlighted several updates on these fronts.
Improved recognition and reimbursement for code G2211 from commercial payers. This year, the Centers for Medicare & Medicaid Services (CMS) introduced the G2211 code for outpatient office visits to recognize the specialty training and work that goes into managing complex and chronic rheumatic diseases. The ACR continues to advocate for reimbursement of the G2211 code in the setting of the Modifier 25 code for outpatient office visits. The College has initiated conversations to encourage private payers to follow suit and has successfully worked with Medicare Advantage plans to appropriately reimburse G2211.
Dr. Shepherd, Ms. Strozier and their team recently led a multispecialty sign-on letter to UnitedHealthcare urging the payer to reconsider its decision to discontinue reimbursement for G2211 for commercial plans as of Sept. 1.
Target payer policy/utilization management concerns. The ISC routinely contacts commercial payers regarding policies and formulary requirements that create significant, unpaid administrative work for practices and result in reduced access to treatment for patients.
For example, the ISC reached out to payers regarding excessive step therapy requirements. In one recent case, a payer required a patient to fail to respond to three tumor necrosis factor (TNF) inhibitors before approving a drug from another class. In other cases, the ACR team has advocated against payers requiring patients to fail to respond to a non-FDA-approved therapy before approving coverage for FDA-approved treatment.
