Insurance Advocacy

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The ACR is working to ensure that insurance policies impacting coverage and payment for rheumatology services are fair and appropriate. The volunteer members of the ACR Insurance Subcommittee help lead this effort by educating payers and advocating for policies that prioritize access to rheumatology care and treatment. Below are updates and resources on key insurance advocacy priorities and information on requesting assistance with an insurance concern.

Insurance Issues

See resources to help with insurance grievances, complaints, and denials.

Medicare Contractor Directory

Members-Only Resources

The ACR is here to help your practice navigate challenging insurance issues.

 

Filing a State Insurance Department Complaint

 

 Health Plan Complaint Form

G2211 Reimbursement

Medicare implemented the G2211 add-on code for outpatient office visits on January 1, 2024, to acknowledge the complexity of care for services related to ongoing care, for a patient’s singular chronic or complex condition. The ACR is communicating with Medicare Advantage and commercial plans to ensure appropriate reimbursement for the new complex care add-on code, G2211. UnitedHealthcare (UHC) confirmed that their Medicare Advantage claims platform was updated on 1/21/2024 to allow reimbursement for G2211. Similarly, Aetna confirmed that their system was updated on 1/28/2024. Both updates are retroactive to 1/1/2024. Outreach is ongoing to other Medicare Advantage plans to ensure implementation of similar updates ensuring appropriate reimbursement. Additionally, UHC’s commercial platform was updated on 1/1/2024 to allow reimbursement of G2211 on commercial claims. The ACR applauds UHC’s leadership in recognizing the value of this code and will continue working with other commercial payers to advocate for reimbursement.

Formulary Requirements and Reimbursement for Biosimilars

Numerous payer formularies require patients to use certain infliximab biosimilars despite reimbursement falling below acquisition cost for many independently owned rheumatology practices. The ACR is engaging with both commercial payers and CMS regarding these formulary requirements that would leave many practices underwater when treating patients with biosimilars infliximab-axxq (Avsola) or infliximab-dyyb (Inflectra). The ACR supports biosimilar use and is encouraged by their overall impact on reducing drug costs; however, requiring practices to infuse any drug at a loss undermines financial solvency and is unacceptable. In response to the ACR’s ongoing advocacy efforts, Aetna has responded that both commercial and Medicare Advantage fee schedules were updated in July 2023, increasing reimbursement for the underwater drugs. UnitedHealthcare has also confirmed that they are pursuing both short- and long-term solutions.

Prior Authorization Requirements for Mandated Switches to a Biosimilar

Many health plans have implemented policies that require rheumatology patients to switch from an originator drug to a biosimilar. In addition to mandating the switch, they are also requiring the practice to complete a new prior authorization for the drug. These changes are impacting numerous patients within a practice which is causing significant administrative burden, particularly in cases where the payer requests additional medical records. The ACR is reaching out to payers to advocate for a more streamlined process which would help alleviate the burden on practices and ensure timely and uninterrupted access to treatment.

Specialty Pharmacy Acquisition Requirements

Commercial insurance companies and pharmacy benefit managers (PBMs) have implemented policies mandating that in-office treatments be purchased through specialty pharmacies instead of the traditional “buy-and-bill” system. In some cases, employers are being given the choice to include these requirements as part of their employee health plan without fully understanding the impact on patient care and access to treatment. These policies threaten patients’ access to critical in-office treatments and the ACR is committed to further educating stakeholders and advocating against them.

Fact Sheet: Protect Access to Physician-Administered Therapies

Rheumatology letter to Blue Cross Blue Shield TN about advanced specialty benefit management program (December 2021)

Members Only Resources

Letter Template - Practice to Patient Employer: Protect Access to Physician Administered Therapies

Tools & Resources for ACR Members

These template letters can be used to help secure insurance approval for off-label uses frequently seen in rheumatology practices.

Off-Label Drug Use Letters

Adalimumab – Sarcoidosis

Apremilast – Combination Therapy

Infliximab – Uveitis

Rituximab – Lupus Nephritis

Rituximab – Myositis

Rituximab – Scleroderma

Rituximab – Severe SLE

Sildenafil – Refractory Ulcerative Raynaud's Phenomenon

 

Pediatric Letters

Anakinra – Macrophage Activation Syndrome (MAS)

Biologics – Relapsing Chondritis (RP)

Infliximab – Sarcoidosis

MRI – Temporomandibular Joint (TMJ) Arthrtitis

Rituximab and Cytoxan – CNS Lupus

Sildenafil – Refractory Ulcerative Raynaud's Phenomenon

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