Insurance Advocacy Current Issues

Insurance advocacy


The ACR Insurance Subcommittee and staff are dedicated to working on regional and national insurance issues to secure patient access and fair and consistent reimbursement for providers. Below is information on some of the issues we are currently working on.

Modifier 25 Payment Reduction Policies

In early 2018, Anthem Blue Cross announced and eventually rescinded a policy that would have reduced reimbursement for E/M services when billed with modifier 25 by up to 50%. While the ACR was part of a successful advocacy effort to overturn the Anthem policy, several other payers have unfortunately moved forward with implementing similar reimbursement cuts.

In April, the ACR sent a second letter to Independence Blue Cross underscoring the College’s opposition to their misguided modifier 25 policy and requesting further investigation into related reports of claims processing errors. The ACR is also engaging with Health Net, a California-based payer, and UnitedHealthcare regarding modifier 25 payment reduction policies. Health Net’s policy went into effect on May 16 affecting their Medi-Cal, Medicare, and Cal MediConnect plans. This policy reduces reimbursement for E/M services by 50% when billed with modifier 25. UnitedHealthcare also recently proposed a policy that would reduce payment for E/M services by 25% when billed with modifier 25. The tentative effective date for the UHC policy is October 1; however, no formal announcement has been made as UHC is in the process of considering early feedback from stakeholders. In addition to the ACR’s direct advocacy efforts, we are also part of an issue-specific coalition of state and specialty medical societies that are working together to oppose these cuts.

Site of Service Restrictions for Infused Biologics

Since 2015, the ACR has engaged with ten different health plans regarding policies that limit the site of service for patients receiving infusions. The payers implementing these policies have the stated goal of moving infusions from hospital outpatient facilities to other, less costly settings. The policies permit patients to receive their infusions at home, in a physician’s office, or in another non-hospital based infusion center. Most grant exceptions for initiating or reinitiating therapy as well as patients with a history of severe infusion reactions or other medical risks or comorbidities. The ACR continues to dialogue with these health plans as we advocate for patient access in a monitored health care setting with on-site supervision by a provider with appropriate training.

ACR Position Statement on Patient Safety and Site of Service for Infusible Biologics

Hyaluronic Acid Injection (Viscosupplementation)

Blue Cross Blue Shield companies in several states are eliminating coverage and payment for hyaluronic acid injections for knee osteoarthritis. The ACR opposes this policy change which is based on AAOS guidelines. In the ACR’s 2012 osteoarthritis guidelines, the College reviewed all of the available literature and supported a recommendation to use hyaluronic acid injections for follow up therapy for knee OA patients without adequate response to full-dose acetaminophen.

Co-Pay Accumulator Programs

The ACR has begun to see several health plans implementing copay accumulator programs to counter the use of manufacturers’ copay assistance programs and shift costs to the patient. These programs prohibit the application of copay assistance funds toward the patients’ deductible or out-of-pocket maximum. When the funds from the assistance program run out—typically in the middle of the plan year—the patient must go out of pocket until they reach their deductible or out-of-pocket maximum. ACR/ARHP members report that patients are caught off guard by the resulting increase in out-of-pocket costs, and some may feel forced to discontinue treatment due to cost. Per the ACR’s 2018 Health Policy Statements, “The ACR opposes insurance restrictions that prevent application of funds from assistance programs toward patients’ deductibles and out of pocket maximum payments.” The ACR Committee on Rheumatologic Care (CORC) is in the process of developing a new position statement addressing this issue and outlining the College’s concerns. We will continue to monitor this issue and engage with health plans and pharmacy benefit managers to advocate for patient access.

Coverage for Remicade and Infliximab Biosimlars

Several major health plans have enacted policies on the coverage status of Remicade (infliximab) and the biosimilars, Inflectra (infliximab-dyyb) and Renflexis (infliximab-abda). Most of these plans are limiting coverage for the biosimilar products to very specific circumstances. Some have also begun denying claims for biosimilars and instructing patients to switch to Remicade. The plans implementing such policies include Cigna, Humana, UnitedHealthcare, and several Blue Cross and Blue Shield companies. Members should refer to each plan’s coverage policy for additional information including exceptions criteria. The ACR is actively reviewing this issue and will continue to advocate for coverage policies that allow providers to choose the most clinically appropriate treatment for each patient.

Complex Chemo Coding for Biologic Drugs

Complex coding and reimbursement of biologic drugs continues to be a top priority for the ACR. Several Medicare contractors have begun downcoding administration of certain biologics from complex (96401-96549) to simple (96360-96379). The ACR is aware of 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 had the opportunity to discuss this issue with administrators at CMS. We explained the need for consistent, uniform coding and compliance with CPT guidelines, regardless of payer or region. Arbitrary downcoding between regions is unacceptable and creates geographic discrimination by reducing patient access to these medicines in certain parts of the country. The ACR requested CMS issue a national ruling directing contractors to reimburse all biologics as complex.