September Updates from the ACR Insurance Subcommittee

As rheumatologists, we often experience trials and tribulations set forth by insurance payers. I know these challenges all too well from my own practice.

Dr. Shepherd

Rheumatologists are critical to the well-being of so many patients who struggle day in and day out with autoimmune diseases and other joint complaints. We have new medications and interventions that allow us to help our patients, but all too often we spend our limited time justifying our decisions—essentially because of payers’ desires to limit the cost of care. Just last week, I spent time explaining to a payer that apremilast is not a biologic and can be used safely with tumor necrosis factor inhibitors. As chair of the Insurance Subcommittee (ISC) of the ACR’s Committee on Rheumatologic Care, I have the honor of working alongside our knowledgeable and hard-working ACR staff as they advocate for our membership and educate payers on clinical matters.

The ISC serves as a critical force to educate payers as we advocate for policies that prioritize fair and appropriate access to rheumatology care and treatment. I wanted to share the following updates on some of our recent efforts.

Medicare Reimbursement for Administration of Biologics

• As of July 2022, all Medicare Administrative Contractors (MACs) have enacted Local Coverage Articles (LCAs) prohibiting the use of complex chemotherapy administration codes with Cimzia, Orencia, Simponi Aria, Stelara and Prolia. The ACR has spoken with each of the MACs; however, they are unwilling to revise their policies.
• The ACR strongly opposes the downcoding of these drugs. We have also argued that the use of LCAs—as opposed to local coverage determinations (LCDs)—to enact these changes undermines transparency and stakeholder engagement.
• The ACR recently spearheaded a coalition effort to address the flawed policymaking process used to implement these changes. In June, the ACR led a multispecialty sign-on letter to the Centers for Medicare & Medicaid Services (CMS) asking them to compel the MACs to discontinue the inappropriate use of LCAs and invalidate all current LCAs that restrict coverage or patient access.
• The CMS acknowledged the concerns raised and suggested this specific issue may fall under the purview of its Center for Program Integrity (CPI). The ACR has subsequently reached out to the CPI and will pursue additional opportunities for dialogue.

Cigna Modifier 25

This modifier is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.

• In the spring, Cigna announced that effective August 13, claims billed with modifier 25 would be immediately declined unless accompanied by a full set of office notes. In doing so, Cigna would exacerbate the existing administrative burden on rheumatology practices.
• The ACR sent a letter to Cigna expressing concerns that the policy would result in inappropriate denials and/or delayed payments for legitimate services.
• Cigna subsequently delayed the policy indefinitely and we are continuing to monitor for further developments.

Prior Authorization

• We have heard from numerous members about challenges with increasingly burdensome prior authorization processes.
• CVS and Express Scripts were specifically noted for both the overall length of their forms and the irrelevance or redundancy of many questions.
• The ACR has engaged both CVS and Express Scripts in an ongoing dialogue aimed at streamlining prior authorization forms to reduce administrative burden and avoid potential delays in patient care.

The ISC is here to assist practices as they navigate challenging insurance issues. If you have concerns about a payer policy or would like help with an issue impacting your practice, complete the Health Plan Complaint Form or email [email protected].

Thank you for your investment in the greater community of our shared specialty. Together, we remain committed to delivering exceptional patient care.

Rebecca Shepherd, MD, MBA, FACR, FACP, is the chair of the ACR Insurance Subcommittee of the Committee on Rheumatologic Care. She is chief of rheumatology and director of the osteoporosis service line at Lancaster General Health in Lancaster, Pa.