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How practices deal with injectable administration denials; UnitedHealthcare among focus areas

Medicare & Reimbursement Advisor Weekly, December 4, 2009

As you approach your commercial accounts, keep these trends in mind that are hurting your physician customers. Cheris Craig, MBA, practice administrator at Atlanta Women’s Obstetrics & Gynecology, has seen a double-digit percentage increase in inaccurate eligibility denials, particularly for plans out of the area, even though the Women’s Obstetrics & Gynecology’s practice verifies each patient’s benefits before an appointment. Craig has also seen an upsurge in payer denials for injectable administrations. For example, take the vaccine Gardasil. “When we administer the injection during a patient’s annual, several large insurers ... especially UnitedHealthcare, bundle the services by paying us for the injection, but denying the [current procedural terminology] code for the exam. We’ve had to appeal every one of those ... and we’re not the only practice. We have the same trouble if we bill for flu vaccines, so we don’t. We require cash up front,” Craig says. The practice does not have a large Medicare population and does not accept Medicaid patients, so the flu vaccine issue is not a problem. To deal with the Gardasil issue, Craig’s team initially required patients to return for an additional visit, but many did not show up, so now they simply do not bill the injection code. “With such a popular medication that’s given in a series, by the time you figure out insurers are not paying for the visits, you’ve already given two shots,” Craig says.

Tier position, specialty pharmacy a focus for PBM

Editor’s note: MRAW will be running a series of PBM and Medicare Part D plan interviews in August and September. The following is a look at a recent interview that 25 Part D plan pharmacy directors, and 52 commercial health plan pharmacy directors asked for copies of.

Using the Academy of Managed Care Pharmacy dossiers and clinical guidelines, such as the American Diabetes Association, and the United Kingdom’s Parkinson’s Disease Society as a pharmacoeconomic guide, PBM HealthTrans puts pharmaceutical products into three buckets. “We have a clinical bucket, where your drug is considered a significant advancement in therapy; so, in this case, we must make sure it’s available on a preferred basis. The second bucket is for products that are clinically inferior in some way—maybe they don’t have outcomes—so they’re nonpreferred. The third bucket is for me-too products,” says Ryan Haynes, RPh, pharmacy director and rebate director.

Like other commercial plans and PBMs, HealthTrans is trying to figure out what it can do to better manage its specialty medication spend. “We have all the [prior authorizations] and step therapy edits in place, but we’re considering other avenues,” says Haynes.

Under consideration are these options:

• A specialty-only formulary, featuring different tiers focused on specialty products
• Benefit design: 2% copay or a percentage copay for preferred, 10% for nonpreferred

“There are a few growth hormones for example, all quite expensive with similar indications and similar administration routes, so maybe we can drive utilization [by managing] that category,” Haynes says.

HealthTrans does build other types of formularies and benefit designs for plans and employers. Some of the union groups typically provide more robust benefits, including more brands, Haynes says, so we’re helping them shift less responsibility to their members.

Haynes previously worked with CareMark Advance PCS and McKesson Specialty. “I’m looking to start establishing relationships with pharmaceutical manufacturers,” he says. Asked what HealthTrans’ major needs from pharmaceutical account managers are at this stage, Haynes lists:

• Educational opportunities for our pharmacists
• Therapeutic review support
• Pipeline presentations
• Disease education

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