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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.
Several commercial insurance companies and pharmacy benefit managers (PBMs) have begun implementing policies mandating that physician-administered drugs be purchased through specialty pharmacies instead of the traditional “buy-and-bill” system. Many of these changes are being implemented at the individual plan level and impact patients on specific employer plans.
Most recently, BCBS TN announced that all specialty drugs would have to be acquired through the BCBS TN specialty pharmacy network as of January 1, 2020. After hearing significant opposition from stakeholders, including the ACR, BCBS TN pushed back the implementation date of the policy to July 1, 2020.
The ACR is very concerned about the impact of these policies on patients’ access to critical in-office treatments. We are providing education to patients and employers regarding the potential harm of these policies and will continue to advocate against the policies proposed by BCBS TN and other payers.
Rheumatology Letter to BCBS TN - December 2019
Multi-Specialty Letter to BCBS TN - February 2020
As of October 19, 2019, payers will implement a new policy on Evaluation and Management (R30) which will deny claims billed with CPT codes for consultation services as not valid. Impacted CPT codes include 99241, 99242, 99243, 99244,99245, 99251, 99252, 99253, 99254, and 99255.
Cigna is the second major payer to discontinue payment for consultation services in 2019. UnitedHealthcare announced earlier this year that they would also eliminate the consultation codes in two phases. On June 1, 2019, UHC discontinued payment for practices whose contracted rates are based on a stated year 2010 or later Medicare fee schedule. As of October 1, 2019, they completely eliminated reimbursement for consultation codes for all practices. Medicare previously discontinued payment for consultation services in 2010.
The ACR is very concerned about the impact of these changes on rheumatology practices. The undervaluation of cognitive care is a serious issue. CMS recently acknowledged this by proposing an increase in reimbursement for many evaluation and management (E/M) services in the CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule proposed rule. Given that the current healthcare environment is moving towards a more appropriate valuation of cognitive care, it is most alarming that commercial payers would move to stop recognizing consultation services at this time.
The ACR will continue to oppose any payer efforts to eliminate reimbursement for consultation services while advocating for appropriate recognition and compensation of rheumatologists’ expertise and training.
Cognitive Specialty Coalition Letter to Cigna - Elimination of Consultation Codes
ACR Letter to Cigna - Elimination of Consultation Codes
ACR Letter to UnitedHealthcare - Elimination of Consultation Codes
On October 1, 2019 UnitedHealthcare (UHC) announced updates to their policies for Actemra, Benlysta, Cimzia, Orencia, Simponi Aria, and Stelara. The policy changes were effective immediately and required all patients to fail the self-administered formulation of these drugs prior to obtaining authorization for the physician-administered product. An exception would be granted only if the physician could attest that both patient and caregiver were unable to self-administer.
UHC has since delayed the policy changes for Actemra, Benlysta, Cimzia, Orencia, and Simponi Aria. Practices should instead refer to the policies that were in effect prior to October 1 for these drugs. The changes to the Stelara policy remain in effect and have not been delayed. If a valid prior authorization is in place for in-office administered Stelara, it will be honored until its expiration; however, the ACR encourages members to watch these charges closely. UHC has indicated that the delayed policies are still under consideration though no future effective date has been set.
The ACR opposes these changes and is actively working with other rheumatology groups to advocate for the permanent rescission of the policies.
Rheumatology Letter to UnitedHealthcare on Coverage for Physician-Administered Treatments
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
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.
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.