VIDEO: ACR criticizes Medicare contractors for ‘inappropriately low reimbursement’
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Medicare administrative contractors are circumventing the normal policy process related to complex drug administration codes, leading to “inappropriately low reimbursement,” according to the American College of Rheumatology.
Rebecca M. Shepherd, MD, MBA, FACR, FACP, chair of the ACR insurance subcommittee, told Healio the issue is playing out in rheumatology as Medicare administrative contractors (MACs) are releasing policies without stakeholder input that prevent the use of complex chemotherapy codes for biologic drugs, and instead require simple therapeutic codes.
“The lack of reimbursement means that rheumatologists may no longer be able to afford to provide these infusions in-office,” Shepherd said. “Patients will then have to miss doses, proceed with long travel plans, potentially incur higher costs, possibly have to discontinue their medication, and this can lead, as we know, worse outcomes and poor disease control.”
MACs are private insurance carriers that have been given jurisdiction by CMS to process Medicare part A and B claims. MACs use local coverage determinations (LCDs) to describe criteria and coverage limitations that apply to certain services. According to Shepherd, MACs are required to introduce new LCDs, or change old LCDs, through specific guidelines, including pre-publishing their intend, giving 45 days’ notice, requesting stakeholder input, and considering expert opinion.
“These steps help ensure transparency and the interests of the beneficiaries are thus served,” Shepherd said.
MACs can also publish local coverage articles (LCAs), which provide coding and billing guidelines to providers. According to Shepherd, these are meant to complement existing LCDs.
“They should not be standalone policies,” she added.
In addition, LCAs do not require the same regulatory steps as LCDs.
The problem, according to Shepherd, is that MCAs are issuing LCAs in place of LCDs, effectively shutting rheumatologists and other physician and patient stakeholders out of the process of crafting these policies.
“This means that unilateral decisions are made that directly affect patient care, and this can be in a negative way,” Shepherd said.
In rheumatology specifically, MACs have been issuing LCAs on complex drug administration codes that prevent the use of complex chemotherapy codes for biologic drugs, and instead require simple therapeutic codes, according to Shepherd.
“This leads to inappropriately low reimbursement,” she said. “By circumventing the process, rheumatologists and patients were not given the opportunity to present the data that demonstrate that biologics have significant risks, as do the chemotherapy drugs. Those risks can include things like infections and infusion reactions — and they require expertise from both the providers and from the nursing staff.”
The next steps for the ACR on this issue include raising awareness and working toward compelling MACs to follow the intended practice.
“We are also working very closely with CMS to compel MACs to use the LCD process as it was intended,” Shepherd said.
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