RheumWATCH Archives


Read the RheumWATCH archives on topics such as rheumatology advocacy, policy updates, insurance advocacy, and practice management.


ACR Fights Down Coding of Biologic Drugs

ACR Fights Down Coding of Biologic Drugs

Complex coding and appropriate reimbursement of biologic drugs continues to be a top priority for the ACR. In early March, WPS Health Insurance began denying payment for complex administration of certain biologics. The carrier advisory committee was not involved in this decision, nor was there any advance notice of the change.

Like Noridian and Cahaba, which were already down-coding certain drugs, WPS suggests they will instead reimburse these drugs as simple infusions. The ACR is aware of several other contractors considering similar changes and has reached out to all contractor medical directors to educate them on the complexity of all biologic drugs.

The ACR also recently had the opportunity to discuss this issue with Sean Cavanaugh, Deputy Administrator and Director of the Center for Medicare at CMS. We explained the need for consistent, uniform coding and compliance with CPT guidelines, regardless of payer or region. Arbitrary down-coding between regions is unacceptable and creates geographic discrimination by reducing patient access to these medicines in certain parts of the country. The ACR has requested that CMS issue a national ruling directing contractors to reimburse all biologics as complex.

If you are experiencing problems with down-coding in your region, the ACR wants to hear from you. Please contact Meredith Strozier at mstrozier@rheumatology.orgor 404-633-3777. 

Repeal of SGR Could Move Forward; March 31 Deadline to Stop Cuts

With less than two weeks remaining before massive cuts to physician payment will kick in due to the broken Sustainable Growth Rate formula, leading members of Congress have shifted talks on permanent SGR repeal back into high gear.

Late last week Republican and Democratic leaders of the House Ways & Means and Energy & Commerce committees confirmed they are in negotiations on a permanent SGR repeal. Legislation may come this week in the House. The deal is expected to cover permanent SGR repeal, implementation of a new payment system, CHIP reauthorization and entitlement reforms. The legislation is likely to contain positive annual payment updates for physicians, opportunities for bonuses and sunsetting of existing penalty programs as it sets up a new physician payment system developed with input from the ACR and other medical societies. It is expected that the deal may move forward without a full “pay-for.” Finding funding sources for SGR repeal has been the perennial challenge in getting the SGR repealed.

The ACR strongly supports efforts to permanently repeal and replace the SGR, and we are encouraged by this late movement toward an agreement before the current SGR “patch” expires on April 1. We’re closer than ever to reaching a deal for permanent SGR repeal, but we need your help. Use the ACR Legislative Action Center to contact Congress today. Ask your members of Congress to pass bipartisan SGR reform this month and to do so without further cuts to vulnerable Medicare physician payments.

Ask Your Patients to Sign up for Grassroots Advocacy

The Arthritis Foundation is a strong and effective partner in advocacy with the ACR. Like the ACR, the Arthritis Foundation believes it is critical that patients have access to quality care and to the treatments critical for successfully managing arthritis. Amplify the collective voice of the rheumatology community by asking your patients to join the Arthritis Foundation’s grassroots Advocate network.

The Arthritis Foundation has established an effective and committed patient advocacy network to address key issues on both the state and federal levels with lawmakers, insurers and regulators. Enlisting patients to speak out and advocate is critical. Patients who sign up as Advocates are key resources for making positive changes in Washington, and it’s easy for them to sign up. All that is asked is for Advocates to respond to action alerts by emailing their lawmakers. Urge your patients to register simply by visiting this link: http://www.arthritis.org/advocate/sign-up-to-be-an-e-advocate.php.

You can make a difference by sharing this opportunity with all of your patients and asking them to sign up for the Arthritis Foundation Advocate program today.

Message from the Government Affairs Committee

 Dr AngusWorthingDear Advocates,

Last week, a patient with longstanding RA in remission called me in tears because she couldn't afford her new Humira co-pay of $2,000/month. “I don’t want to become disabled!” she pleaded. We all have patients who lack access to specialty medicines. Even in the high-rent areas of Chevy Chase, Md. and the K Street corridors of power, where my offices are located, patients struggle. But after years of gnashing teeth and forcing a smile in this situation, this time I could try to give the patient some hope.

A few months ago, I emailed my city council member about this issue, and she introduced a bill to limit specialty drug co-payments in the District of Columbia. Through my ACR volunteering, I had seen similar state bills and the Patients' Access to Treatments Act, which the ACR helped craft in the U.S. House of Representatives. Other rheumatologists, and colleagues in other specialties and patient advocacy groups, have begun to push against unfair insurance policies.

Unfortunately, introducing a bill appears to be the easy part. The local D.C. bill may languish in committee. But luckily, with the strong support of my local medical society and the ACR, a coalition of advocacy leaders is now pushing to obtain a hearing. Meanwhile, I give patients the email and phone number of their city councilman who can advance the bill.

It's simple: when you encounter a systemic issue, email Starla Tanner at the ACR (stanner@rheumatology.org) or your local state rheumatology or medical society. Get the ball rolling on a solution!

You can read a news article about our local effort in D.C.

Angus Worthing, MD

Member, ACR Government Affairs Committee