ATLANTA—From step therapy requirements to infusion center locations to evaluation and management coding, insurance issues bring frequent headaches to clinicians and patients. Experts discussed some of the most recent concerns in a session at the 2019 ACR/ARP Annual Meeting.
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Chris Phillips, MD, chair of the ACR’s Insurance Subcommittee (ISC), and Gary Bryant, MD, delegate to the American Medical Association (AMA) from the ACR, described the ACR’s ongoing efforts to prevent the rollout of potentially harmful new rules, and to push for changes to insurance rules that harm patients and physicians.
The ISC can help ACR members by investigating inappropriate health plan policies or practices. “Feel free to reach out to us—we are happy to advocate on your behalf,” Dr. Phillips said.
From October 2018 to October 2019, the ISC sent letters to payers on a variety of issues: six on formulary and drug access issues, five for nonmedical switching of medications, four regarding consultation codes, and three each on step therapy requirements, Modifier -25 related evaluation and management (E/M) coding.
Rheumatology Insurance Issues
Some of the leading insurance topics affecting rheumatology that Drs. Phillips and Bryant discussed include:
Consultation codes: United Healthcare eliminated consultation codes this year, and Cigna followed recently, saying they were following Centers for Medicare & Medicaid (CMS) guidelines and wanted to simplify their billing and coding processes. A silver lining, Dr. Phillips said, is that the CMS fee schedule to take effect in 2021 includes a 15% increase for rheumatology, but it is not known whether private payers will do the same.
“We would certainly encourage you to examine your contracts to see how they’re structured,” Dr. Phillips said.
Tracking commercial payer policies: Dr. Bryant cautioned the audience that policies are not always kept on websites, so they may require extra diligence to keep them accessible when needed. What’s more, private insurers often communicate policies with paper newsletters, even in the digital age.
“If that’s the case, then it’s very important that when those are received, they be reviewed by the appropriate personnel in the practice,” he said, and then kept on file for future reference.
Step therapy in Medicare Advantage: This practice—requiring a patient to try a medication, typically a generic or low-cost option—specified by the insurer, before moving on to other medications, was allowed in 2019 after regulatory changes. Patients with claims paid in the previous 365 days were grandfathered in, and a turnaround time of 72 hours for appeals is required.
The ACR is working with the AMA to ask for more guardrails to be put in place, such as the provider being able to define failure of treatment, exceptions if a medication is contraindicated or likely to be ineffective or cause harm, and exceptions for patients whose lives or physical function could be irreparably harmed by a delay in appropriate treatment, Dr. Phillips said.
Prior authorizations: The ACR has worked to ease the burden of prior authorization policies, “which can delay or deny care,” Dr. Bryant said.
United has limited prior authorization requirements for certain procedures and radiologic treatments, but reserves the right to review after the fact, which “may be worse,” Dr. Bryant said. “If you provide the service and then they deny it on the back end, that’s going to take appeal time and that’s even more burden,” he said. “And so these are things you need to be aware of about what the prior authorization policies are.”
Biologic therapy: The U.S. Food & Drug Administration recently issued guidance on the interchangeability of biologics, and no biosimilars are currently considered interchangeable to the bio-originator product, Dr. Phillips said.
But several payers and even local hospitals have insisted on force switching patients who are stable on the bio-originator to biosimilars for infliximab, he said. One carrier is even requiring biosimilars for rituximab for all new medication starts, including rheumatic conditions, even though rituximab is only approved for oncologic conditions.
“Our position essentially is that unless these drugs are proven to be interchangeable, the decision to switch should belong to the patient and to the provider,” Dr. Phillips said.
Infusion sites: Anthem Blue Cross has shown data suggesting a 40% cost savings on infusions if they’re moved out of the hospital outpatient setting, so that is a big incentive to move patients to other infusion locations, Dr. Bryant said. And other payers have placed hospital outpatient infusions under close scrutiny.
“We’ve worked with, I believe, one payer this year who wanted to insist on home infusion of rituximab, which we thought was interesting,” he said, although that request was later dropped.
The ACR advocates for safe and timely access to the right treatment and urges the “recognition and mitigation of barriers related to travel for patients with arthritis and other rheumatic conditions.” The ACR also has not endorsed home infusions for complex biologics.
Modifier -25: This is used to report an E/M service on a day when another service was provided to the patient by the same physician. Anthem rescinded a proposed policy to reduce E/M reimbursements by 50% when billed under modifier -25.
“There are still issues around this, however,” Dr. Phillips said.
Anthem Blue Cross recently imposed a policy to deny payment for E/M billed with modifier -25 if the same or similar ICD-10 code was billed in recent months. The timeframe was left poorly defined, and the payer described the similarity of coding as in the “same family tree,” Dr. Phillips said. “I personally don’t know exactly what that means.”
Copay accumulator programs: Traditionally, copays for biologics that were covered by pharmaceutical companies counted toward a patient’s out-of-pocket maximum, but some payers are no longer applying these copays toward that max. When these copay assistance funds are not applied to the deductible, the fixed annual maximum copay assistance may be exhausted before the patient has met their deductible, potentially forcing patients to switch treatments.
This practice is “not prevalent yet,” but could become a bigger problem soon, Dr. Phillips said.
“We would welcome and invite changes in the biologic marketplace—the economic marketplace—to make the system more sustainable,” he said. “But we’re in the system we’re in right now, and we must advocate for patients’ affordable access to treatment they need.”
Thomas R. Collins is a freelance writer living in South Florida.