Right now, the ISC is working toward a similar goal with UnitedHealthcare (UHC) and Medicare, and is waiting to see if Medicare’s final rule will include removing its proposed modifier payment reduction policy. Regarding UHC’s position, after some advocacy efforts made by the ISC and others, UHC has put on hold a decision regarding modifier 25 payment reduction policies, saying it will wait to see what Medicare decides and will then reevaluate, Dr. Phillips shares.
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Site-of-Service Restrictions for Infused Biologics
Over the past several years, the ACR has engaged with 10 different health plans regarding policies that limit the site of service for patients receiving infusions. The payers implementing these policies have the stated goal of moving infusions from hospital outpatient facilities to other, less costly settings. The policies permit patients to receive their infusions at home, in a physician’s office or in another non-hospital-based infusion center. Most grant exceptions for initiating or reinitiating therapy, as well as for patients with a history of severe infusion reactions or other medical risks or comorbidities.
“We have firsthand accounts from members who have shared cases where patient harm occurred due to these policies and decreased access,” Dr. Phillips says. The ACR’s position is to advocate for safe administration of infused biologics in a monitored healthcare setting with on-site supervision by a provider with appropriate training in biologic infusions; the ISC continues to successfully dialogue with payers for this.
Downcoding Administration of Certain Biologics by UHC
Following continued advocacy from the ISC and other physician and patient stakeholders, UHC announced on Nov. 1 that a policy to downcode reimbursement for administration of four drugs is “undergoing additional evaluation” and will not be implemented on Dec. 1 as planned. No future effective date has been announced. This policy would have ended reimbursement of the complex administration codes (96413 and 96415) for four drugs—Actemra, Entyvio, Orencia and Simponi—instead requiring providers to use the therapeutic codes: 96365 and 96366.
UHC previously stated this policy could be expanded to include other drugs. As such, this issue is still very much a priority for the ISC, and the committee will continue to advocate against implementation, Dr. Phillips stresses.
The ACR’s position statement notes that all biologic drugs are complex and present risks of complications. To emphasize this reality and the risks associated with this policy, the ISC sent several letters to UnitedHealthcare and spoke to the insurance company’s leadership via conference call in October, sharing the detrimental effects this policy would have on rheumatologists’ ability to provide patients with access to these treatments.