Both private and academic rheumatology practices face payer challenges that put the health of their patients and their practices at risk. To make sure the rheumatologist perspective is heard by payers, “the ACR’s Insurance Subcommittee (ISC) serves as the interface between payers and our members and ACR colleagues,” explains Sean Fahey, MD, a rheumatologist in Mooresville, N.C., and outgoing chair of the ISC.
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“We get involved with any policies that restrict access to care and treatment for our patients, and work to minimize administrative burden for our member practices,” he says.
Over the past three years, Dr. Fahey has led the ISC in addressing payer proposals and decisions that threaten to decrease reimbursement and limit options for infusible biologics, as well as to protect the choice of medications based on a patient’s best interests.
He is working closely with incoming ISC chair Christopher Phillips, MD, and other members of the ISC to continue successful progress on several fronts.
Modifier 25 Payment Reduction Policies
Several health plans have introduced policies that would reduce reimbursement for E/M services when billed with modifier 25 by up to 50%. This policy is based on the view that insurers may be paying for duplicative services. The ACR and other specialty medical societies believe the AMA Relative Value Update Committee (RUC) has already addressed overlap by reducing the value of codes frequently billed with modifier 25.
For Dr. Phillips, who leads an individual rheumatology practice in Paducah, Ky., if these policies go through, he would have to choose whether to perform a procedure, such as administering a joint injection after a routine visit that day and accept reduced reimbursement, or ask the patient to leave and return a different day for the procedure.
“Given the rural setting where I practice and the shortage of rheumatologists in my region, a patient may have a 90-minute drive to my clinic. How can I ask them to make a second trip? Meanwhile, our profit margin is tight; if we see these cuts go through, it will impact our bottom line,” he says.
The ISC and many physician advocates have been vocal in opposing these policies, leading to positive results for rheumatology practices.
Through ongoing dialogue with Anthem Blue Cross Blue Shield, the ISC, in partnership with other physician groups, has had a victory with this payer, which first proposed a 50% reduction, then reduced to 25%, then rescinded the modifier payment reduction policy all together.