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.

UnitedHealthcare Discontinuing Payment for Consultation Services

UnitedHealthcare announced in the March 2019 that they will discontinue payment for consultation codes (CPT 99241-99255) later this year. Implementation of the policy will occur in two phases. On June 1, 2019, UHC will eliminate the consultation codes for practices whose contracted rates are based on a stated year 2010 or later Medicare fee schedule. As of October 1, 2019, they will completely eliminate the consultation codes for all practices.

UHC proposed a similar policy in 2017 and 2018. In both of those cases the payer subsequently delayed the policy after meeting with strong opposition from the ACR and other provider organizations. UHC’s stated goal is to bring their policy into alignment with Medicare; however, when CMS eliminated consultation codes in 2010 they offset the cut by increasing the value of the codes for new and established patient visits. This argument was the main reason for UHC’s previous delays as some practices’ contracted fee schedules are still based off rates from 2009 or earlier. Before moving forward with implementation later this year, UHC will make an effort to ensure that all practices’ contracted rates are based on a 2010 or later Medicare fee schedule. Members are encouraged to review their contracts with their UHC provider reporesentative and make the best decision for their individual practice.

The ACR is very concerned about the impact of this change on rheumatology practices particularly in the current climate of proposed Medicare changes to E/M codes. We continue to advocate against elimination of these codes and support appropriate recognition and compensation of rheumatologists’ expertise and training.

ACR Letter to UnitedHealthcare on the Elimination of Consultation Codes

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In early 2018, Anthem Blue Cross announced and eventually rescinded a policy that would have reduced reimbursement for E/M services when billed with modifier 25 by up to 50%.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.

The ACR sent a letter to Independence Blue Cross in spring 2018 underscoring the College’s opposition to their misguided modifier 25 policy and requesting further investigation into related reports of claims processing errors. The ACR has also engaged Health Net, a California-based payer, and UnitedHealthcare regarding modifier 25 payment reduction policies. Health Net’s policy went into effect in May 2018 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 proposed a policy that would reduce payment for E/M services by 25% when billed with modifier 25. The UHC policy was originally scheduled to go into effect October 1, 2018; however, the payer decided to indefinitely delay this policy after consideration of stakeholder feedback. In addition to the ACR’s direct advocacy efforts, we have also been 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

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/ARP 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 position statement, Programs Limiting Copay Assistance, the ACR opposes insurance restrictions that prevent application of funds from assistance programs toward patients’ deductibles and out-of-pocket maximum payments.

Coverage for Remicade and Infliximab Biosimlars

Health plans across the country have begun enacting policies on the coverage status of Remicade (infliximab) and the biosimilars, Inflectra (infliximab-dyyb) and Renflexis (infliximab-abda). Many plans are designating either the originator or biosimilar as their preferred products and limiting coverage for patients who are new to therapy.. Several plans have also attempted to force-switch patients who are currently stable on therapy. 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.

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