The ACR Insurance Subcommittee (ISC) regularly engages with insurance companies to discuss concerns raised by ACR members and advocate for appropriate coverage and payment policies. The ISC has gotten off to a busy start in 2017, working on a variety of patient access and reimbursement issues. Two recent issues the ISC has taken action on include:
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Regal Medical Group Policy on Home Administration of Biologics
Regal Medical Group sent a letter to providers in California indicating that injectable and infused medications, specifically biologic or “specialty” drugs, should be administered at home and covered under pharmacy benefit and/or Medicare Part D for the purpose of saving money. As the position statement on Patient Safety and Site of Service for Biologics asserts, “The ACR opposes policies that force patients to receive biologic infusions at home because such policies, designed for the sole purpose of cutting costs, undermine patient safety.” The ISC sent a letter to Regal Medical Group providing information on the complexity of biologic drugs and emphasizing the importance of prioritizing patient safety when administering these drugs.
Humana Medicare Advantage Denials for Modifier 25 Use
The Humana Medicare Advantage plan has inappropriately denied coverage for E/M visits that occurred on the same day as a procedure despite use of modifier 25 and appropriate documentation. The ISC recently sent a letter to Humana defending members’ ability to use modifier 25 and receive appropriate reimbursement when significant, separately identifiable E/M services are taking place.
Where to Go for Answers, Assistance
The ISC is ready and willing to assist ACR members by providing support for policy and reimbursement issues. If you have questions about either of the issues listed above or would like assistance with another matter, contact practice@rheumatology.org or complete the online health plan complaint form (ACR login required).