The world in which we currently practice is not the same one we knew five to 10 years ago. Insurers second-guess our decisions and create numerous hurdles for us to overcome before our patients can be treated. Government agencies are seeking ways to reduce healthcare expenditures and improve what they perceive as a lack of quality and consistency in healthcare delivery. These groups, as well as Congress and employers (who purchase benefits for their employees), have begun a concerted effort to grade rheumatologists on the basis of what they perceive to be quality and efficiency and then pay us according to those criteria.
Recognizing these trends, the ACR has changed its priorities in the last several years, putting advocacy and practice support at the top of its goals.
In November 2004, the Regional Advisory Council (RAC) was formed as a subcommittee of the ACR Committee on Rheumatologic Care. Ten RAC advisors assist physicians across the country. The ACR also hired two professional coders to help members resolve coding and insurance questions. The RAC’s mission is to advocate on behalf of ACR members on local and regional issues, serve as a two-way communication link between the ACR and its members, and facilitate the advocacy efforts of state societies and individual practitioners.
Since 2005 RAC has developed several lines of communication with members. RAC advisors, members of the ACR board of directors, and others have given presentations on ACR activities to state societies throughout the United States. Our coders have given numerous CME talks on coding and reimbursement at state society meetings, and will do so again in 2007. RAC initiated regional list serves for physicians and one list serve for office managers so that problems can be shared and solutions provided by ACR staff and others.
RAC has been in continuous dialogue with the Physicians Regulatory Issues Team of Centers for Medicare & Medicaid Services (CMS) along several issues—most significantly the confusion about drugs that can be covered by either Part D or B of Medicare. The ACR has challenged the continued preauthorization requests by insurers for drugs such as methotrexate, azothioprine, and prednisone. CMS has agreed to allow these drugs to be covered by Medicare if the diagnosis and “Part D” are written on the script. Although not an ideal solution to the problem, it will eliminate countless hours of frustration and staff time spent handling these issues. Some insurers and pharmacists have been slow to adopt this system, but RAC representatives continue to speak with CMS about ongoing problems and the agency has resolved to fix any that we bring to their attention.
In late 2004, the Technology Evaluation Committee of Blue Cross determined that there is no value for vertebral fracture assessments, and therefore Blue Cross plans across the country as well as Trailblazers, Aetna, and others have refused reimbursement. In 2006, the ACR has worked closely with other medical societies to respond to this problem and will present new data to Blue Cross this fall in the hope of reversing this determination.
On a similar note, the ACR has joined with International Society for Clinical Densitometry to protest the planned cuts in reimbursement for DXA scheduled to be phased in over the next four years. Through a blast e-mail message, the ACR has encouraged members to complete surveys on the work components in performing and interpreting scans. The College has also crafted a letter to Congress to be included in the Congressional record, written CMS directly, and asked members to contact their legislators. (See “Payments Cut to the Bone” on p. 18 for more on DXA reimbursement cuts.) Other accomplishments include:
- Persuading a major insurer in Washington State not only to reverse a decision to pay physicians for simple infusion codes when administering infliximab, but to reimburse them retroactively. This has amounted to more than $5,000 for one office of three rheumatologists;
- Inducing the Government Employee Hospital Association to reverse a policy of mandated brown bagging, which penalized patients who purchased infusible medications through their physicians rather than a specialty pharmacy;
- Getting Palmetto GBA to reimburse a South Carolina rheumatologist $60,000 to $70,000 for infliximab infusions rather than withhold reimbursement pending repeated requests for further documentation; and
- Convincing John Deere Health to discontinue a requirement for increased documentation whenever the -25 modifier was used.
Ongoing issues include reimbursement for IV ibandronate, restriction of rheumatologists from performing and interpreting some routine X-ray studies, the use of sildenafil for scleroderma patients, and unreasonable medication prerequisites.
RAC identifies problems that need to be addressed through the ACR membership. Help us help you by contacting your regional advisors (please visit the ACR Web site to find your advisor) or contact Melesia Collins, CPC, ([email protected]) or Resaee Freeman, CPC, ([email protected]) if you are encountering problems in your area.
Dr. Fohrman is the immediate past chair of the ACR Regional Advisory Council.