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• 86 percent of physicians report PA burdens have increased over the last five years. • The Office of Inspector General found Medicare Advantage Organizations overturned 75 percent of their own denials during 2014-16, overturning approximately 216,000 denials each year. The OIG stated, “The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided.” Evidence suggests that PA and step therapy adversely affect patients… • 37 percent of prescriptions rejected at the pharmacy are abandoned, never to be picked up by patients. • 74 percent of physicians report PA can lead to treatment abandonment. The broad application of PA and step therapy may very well be penny wise and pound foolish… • Studies have shown that while step therapy, for example, decreased drug costs, overall health care costs remained the same or increased. • A review of medical and pharmacy claims of nearly 300,000 Medicaid enrollees found that adherence to medication declined due to formulary restrictions, and total costs increased with formulary restrictions due to increased inpatient and medical costs, as well as, increased pharmacy costs for bipolar disorder.
• Prescription PA implementation for medications to treat diabetes, depression, schizophrenia and bipolar disorder has been associated with worsening disease status.
SB 612 (S-1) DOES NOT prohibit insurers from: • Requiring prior authorization before covering a drug or patient service. • Requiring patients to try a generic drug if it is equivalent to the brand. • Using step therapy, so long as the protocol is not in conflict with the “best interest” of the patient, as defined in the legislation. Sources: 1. Bergeson JG, Worley K, Louder A, Ward M, Graham J. Retrospective database analysis of the impact of prior authorization for type 2 diabetes medications on health care costs in a Medicare Advantage prescription drug plan population. J Manag Care Pharm. 2013;19(5):374-384. doi:10.18553/jmcp.2013.19.5.374 2. Seabury SA, Goldman DP, Kalsekar I, Sheehan JJ, Laubmeier K, Lakdawalla DN. Formulary restrictions on atypical antipsychotics: impact on costs for patients with schizophrenia and bipolar disorder in Medicaid. Am J Manag Care. 2014;20(2):e52-e60. 3. 2019 American Medical Association Prior Authorization Physician Survey. https://www. ama-assn.org/system/files/2020-06/prior-authorization-survey-2019.pdf. 4. CoverMyMeds. 2019 ePA national adoption scorecard. https://www.covermymeds. com/main/insights/scorecard/impact/. Accessed November 29, 2019. 5. Office of Inspector General. U.S. Department of Health and Human Services. Some Medicare Part D beneficiaries face avoidable extra steps that can delay or prevent access to prescribed drugs. https://oig.hhs.gov/oei/reports/oei-09-16-00411.pdf. 6. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150
MSMS REIMBURSEMENT ADVOCATE ALERT MSMS provides periodic updates to members and their offices on new and relevant payer policies. Please find some recent highlights below. For a comprehensive accounting of a health plans announcements, please consult the payer’s official communications.
Evaluation and Management Updates for 2021 Tuesday, December 1, 2020 Presentation: 1 - 4 p.m. Presenter: Jill Young, CPC, CEDC, CIMC Registration Fee: $25.00
Coding Updates for 2021 Tuesday, December 1, 2020 Presentation: 9 a.m. - 12 p.m. Presenter: Jill Young, CPC, CEDC, CIMC Fee: $25.00
For the last two years, we have been talking about the proposed changes to Evaluation and Management codes and that these changes would become effective January 1, 2021. Understanding those changes is key in making any necessary changes in the office flow. It is also important to consider any potential software changes that may be necessary to ensure correct coding of Evaluation and Management services.
The CPT code set continues to be modified to respond to the ever-changing health care field. This year is no different. There are 206 new codes, 54 deletions and 69 revisions to the CPT code set. As you know, there were important additions to the CPT code set for new medical testing services due to the public health response to the COVID-19 pandemic. Jill Young will present an overview of changes for 2021 to help prepare you for the new year. NOTE: Evaluation and Management (E/M) changes for 2021 will be done in a separate session in the afternoon. Register Today
The E/M office visit modifications include: • Eliminating history and physical exam as elements for code selection. • Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time. • Promoting payer consistency with more detail added to CPT code descriptors and guidelines. Jill Young will explain these changes and allow time for questions, to help you prepare for 2021. Register Today
Please contact Stacie Saylor or 517-336-5722 for questions or concerns.
