ORA Challenges Regence for Equal Parity, G Code Reimbursement
ORA Insurance Liaisons met with Regence BCBS representatives in January to discuss new reimbursement codes and discrepant data regarding one TNF-blocker's dosing.
Humira
Since last year, Regence has placed Humira on its formulary as a second-line medication, claiming that 30 percent of its Humira patients crept to weekly doses, doubling the cost to the provider. ORA members Peter Bonafede, Dan Fohrman, and Paul Hudson met with Regence medical director Ralph Prows, his assistant Lynn Nishida, and Rob of provider affairs. ORA presented data from a national survey, an ORA survey, and IMS data from Abbott, as well as personal experience and use of Humira by the three physicians and their partners to show that the high percentage of weekly dosing was faulty. An ORA survey showed that only three percent of Humira patients needed the weekly injection.
Regence claimed that in two different surveys of the number of prescriptions it filled in a given period, 19 of 66 and 21 of 73 of its Humira patients used weekly doses. The ORA liaisons pointed out several ways this survey method could skew data. They also presented Regence with a regional and national survey of 20 providers who placed Humira on parity with other TNF-blockers. Dr Prows agreed to review his data and share the results with ORA.
Coding
Rob, who put together the Regence plan, was not aware that CMS had judged that an increased complexity of coding was appropriate for in-office infusions, but was planning to reimburse in-office infusions using hydration codes. Noting that Regence intended to be in sync with CMS, he agreed to amend Regence's coding policy. ORA liaisons suggested that Regence be sure that if it chooses to continue to accept CPT codes, that those codes correspond with the new chemotherapy administration codes. ORA also suggested updating or amending a bulletin to all providers in the region.
Information provided by ORA Liaison Dan Fohrman, MD.