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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.
Some payers have denied claims billed with the diagnosis of M05.79 (rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement) indicating that it does not meet medical necessity. In ICD-9, one code (714.0) denoted the condition of rheumatoid arthritis. However with the implementation of the ICD-10 diagnosis coding system, rheumatoid arthritis has greatly expanded with three different family of codes to choose from – M05, M06 and M08. Since the clinical diagnosis of active RA is included in these three families of codes, the ACR requests all payers and third parties, including specialty pharmacies and pharmacy benefit managers recognize these codes for coverage and payment purposes.
Below is a template letter from the ACR that members can use to respond that all ICD-10 codes within the family of codes for RA should be approved for treatment.
Many rheumatology practices have reported receiving prior authorization requests from Medicare Part D for all methotrexate prescriptions. When methotrexate is used as a chemotherapeutic drug it is covered by Part B but when it is used as an oral agent for rheumatoid arthritis it is covered by Part D. Early in the evolution of Part D, CMS suggested that rheumatologists writing a prescription for oral methotrexate write the words "Part D drug" on the prescription as documentation for the Part D plan.
Although CMS has instructed the plan(s) to stop requiring prior authorization for methotrexate prescriptions this has not been resolved. The ACR continues to work on eliminating this issue but to minimize denials, it is very important for rheumatology practices to continue writing the words "Part D Drug – for Rheumatoid Arthritis" on every prescription for drugs that are sometimes covered by Part B. keep in mind that the Part D plans are not permitted to pay for drugs that should be billed to Part B and this statement is to inform them that the prescription is a valid Part D prescription.
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.
Some carriers have been compelling providers to prescribe biologic drugs for home infusion rather than under the direct supervision of a physician. Biologics are complex molecules that require a safety checklist and patient evaluation prior to administration by rheumatology providers. Given the increased risk for serious infusion reactions and serious infections, the safest location for administration is under the supervision of the physician immediately prior to and during the point of care. The ACR believes home infusion for the sake of cost-cutting for the payer undermines patient safety.
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.
UnitedHealthcare implemented a pilot lab benefit management program in Florida. Under this program, administered by Beacon Laboratory Benefit Solutions, physicians are required to order certain lab tests through an application called Physician Decision Support from a network provider authorized to perform them. Among the 85 Decision Support Tests are antinuclear antibodies (ANA), human leukocyte antigen (HLA) B27, and systemic lupus erythematosus profile. Physician Decision Support is only integrated with a few EHR systems and physicians not using one of these systems are required to log into the application through a separate online portal to order labs for each covered patient. The ACR opposes this program on the grounds that it creates barriers that will increase administrative costs for the practicing clinician.
On January 1, 2015, UnitedHealthcare implemented formulary changes preventing patients on non-preferred therapies from using co-pay assistance programs. The ACR feels strongly that this action limits access to these critical treatments and jeopardizes patients’ well-being. Furthermore, we believe that any step therapy policy must be supported by high quality studies, research, and be in accordance with best clinical practices. It must also make exceptions for patient characteristics and current remission status. Policies related to biologic choices must include a “grandfather” provision that allows stable patients to continue on their current treatment with continued access to co-pay assistance programs.