In response to ACR members expressing frustration with denials from two payers, the ACR’s Insurance Subcommittee (ISC) took action, leading to system corrections that restored set reimbursements for common rheumatology practices, according to ISC Subcommittee Chair Chris Phillips, MD, and ACR Practice Advocacy Director Meredith Strozier.
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In one correction, the ISC reached out to Aetna after members reported denials for corticosteroid injections for patients with osteoarthritis. Aetna fixed the system error causing these inappropriate denials, acknowledged the error, and sent an updated explanation of benefits and payments to impacted providers.
In a separate complaint, the ISC reached out to CGS, a Medicare contractor, after being made aware that CGS was not reimbursing for advanced-practice providers administering certain in-office treatments. CGS agreed that these services should be covered and made the necessary adjustments in their payment system.
“These two wins highlight the ability of the ISC to advocate on behalf of individual practices regarding payer issues, which might be very regional, might not be system-wide, but could negatively impact bottom lines of small practices if not remediated,” notes Dr. Phillips. “The ISC targets large, system-wide issues, but is equally equipped to assist with individual practice issues if it seems insurance carriers are misbehaving.”
Ongoing ISC Priorities
Based on input from members and early awareness through Ms. Strozier and the ACR’s practice advocacy team, the ISC is currently advocating on behalf of rheumatologists and their patients across several fronts.
UnitedHealthcare (UHC) consultation codes policy
UHC is discontinuing payments for consultation codes (CPT 99241–99255), with implementation to occur in two phases. As of June 1, 2019, UHC eliminated the consultation codes for practices whose contracted rates are based on a stated year 2010 or later Medicare fee schedule. On Oct. 1, 2019, UHC will eliminate consultation codes for all practices.
UHC proposed a similar policy in 2017 and 2018; however, in both cases, the policy was subsequently delayed after strong opposition from the ACR and other provider organizations.
After addressing the issue of practices with older fee schedules, UHC is now committed to moving forward and aligning their policy with Medicare. The ISC has continued to oppose elimination of these codes and advocate for appropriate recognition and compensation of rheumatologists’ expertise and training.
“UHC is moving forward with these changes, in spite of vocal opposition by the ACR and others,” Dr. Phillips says. “We will monitor for and advocate against similar changes by other carriers, and work with the American Medical Association [AMA] and its CPT/RUC committees to advocate to the CMS on behalf of adequate valuation for cognitive care provided by rheumatologists.”