If the administration proposes a new demonstration project, it will likely happen this spring. My guess is the CMS may move away from the idea of using vendors, but will test a flat-fee reimbursement system.
Medicare E/M proposal modified, postponed
Remember the CMS’ proposal to reduce documentation burdens for doctors while collapsing E/M billing codes so reimbursements for level 2 and level 5 visits would be the same? Well, in November, after a chorus of responses led by the ACR, the administration backed down and finalized a plan to modify and delay the plan for collapsed codes. (Read Medicare’s overview of the final fee schedule.)
Bottom line: Medicare won’t change billing codes until 2021, and plans to keep a level 5 visit code, while collapsing levels 2–4—and for now, as of Jan. 1, 2019, Medicare won’t require repeat documentation of prior historical information. (Read the ACR’s advice on the new documentation rules). The ACR is working with other cognitive specialties on how to make sure the 2021 coding changes work best for rheumatologists and our patients.
Step therapy
No doubt about it: Prior authorization and step therapy are the worst. The ACR opposes step therapy and other utilization management. The Trump administration is allowing more step therapy in Medicare, and Congress is considering helpful reforms. What you need to know right now: Medicare Advantage plans can use step therapy to block coverage for Part B drugs given in the office and at infusion centers in 2019. Although the CMS is promising that plans will cover drugs patients are currently taking—so-called grandfathering and grandmothering—the plans are unfortunately only looking back three to four months to see if a patient is currently taking a drug. So they may not know that a patient is currently receiving a hyaluronic acid injection for knee osteoarthritis every six months or a drug for osteoporosis every six, 12 or 24 months, or a biologic for rheumatoid arthritis is being dosed intermittently.
I met with the No. 2 official at HHS, Deputy Secretary Eric Hargan, in November to express our concerns about this and the lack of other guardrails for our patients going into 2019. I reminded him that utilization management is the worst thing about being a doctor in the U.S. Medicare is currently seeking comments about how to change this in 2020, and the ACR will be weighing in. Send your thoughts, too, before Jan. 25.
Although we’d prefer to remove all step therapy regimes, right now we’re hoping to reform it. Legislation is expected to be reintroduced in the House to regulate step therapy, and we’re hoping for a Senate companion bill this year. The ACR is in a coalition to push this right now. Ask your members of Congress to support commonsense reforms. It only takes a minute on the ACR website, and your message can make a difference.
