Regulatory Update: CSRO Advocacy Prompts Pause on "Down Coding" Policy by MACs
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Late Friday, June 10, 2022, after ongoing meetings over the past year with different departments of Centers for Medicare and Medicaid Services (CMS), CSRO was notified by senior staff at the CMS that the agency has given “technical direction” to its Medicare Administrative Contractors (MACs) across the country to stop sending additional documentation requests (ADR) after June 10, 2022, when physician practices submit claims for chemotherapy administration services for the following drugs:
- Cimzia® (J0717)
- Orencia® (J0129)
- Simponi Aria® (J1602)
- Stelara® (J3358)
- Prolia® (J0897)
From a practical standpoint, rheumatology practices that submit claims for chemotherapy administration services (CPT 96401-96549) when the aforementioned drugs are administered should expect those claims to be processed and paid without receiving ADR letters. Per CMS, “This is a temporary pause in medical review while CMS reviews all of the various manuals and policies and determines the appropriate steps forward.”
CSRO continues to work with the agency on a long-term solution.
Practices that receive ADR letters dated after June 10, 2022, when they submit claims for chemotherapy administration services for the aforementioned five drugs should notify CSRO at info@csro.info.
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Update: FTC Launch Inquiry into PBMs
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On June 7, the Federal Trade Commission (FTC) announced it will conduct a detailed study into six major pharmacy benefit managers (PBMs). The announcement follows the FTC’s solicitation of public comments on the business practices of the PBM industry, on which CSRO submitted detailed comments. In that comment letter, we urged the FTC to conduct a comprehensive study that includes issues related to formulary design and utilization management by the PBMs, so we were pleased to see the FTC include these topics in its announcement.
As for what’s next, the PBMs will have 90 days from receipt to respond to the FTC’s information requests. It may take the Commission some time to review that information, so the final study may not be completed before the end of this year.
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On June 16, CSRO and its advocacy partner, Hart Health Strategies Inc., hosted an informational webinar to provide an overview of the No Surprises Act and its impact on rheumatology practices.
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Alliance of Specialty Medicine: Virtual Advocacy Day
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Each Member of Congress provided introductory remarks before taking live questions from the physicians. Among the lawmakers that spoke during the event, all but one was a health care provider, including 11 physicians. Speakers included Rep. Kim Schrier, MD (D-WA), Sen. Bill Cassidy, MD (R-LA), Rep. John Joyce (R-PA), and Rep. Ami Bera (D-CA), among others.
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Legislation Around the Country
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What's Happening in the States
CSRO tracks legislative activity relevant to the rheumatology community and their patients. Check out the list below to see the status of CSRO priority bills from the past two weeks. For a full status report on all the bills CSRO tracks, click here.
Be sure to check out our interactive legislative map tool for additional information about current policy in your state. Plus, don't forget to add your state to your email profile here to receive state-specific updates and action alerts via email.
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CALIFORNIA
Step Therapy
- AB 1880: Approved by Senate Committee on Health
DELAWARE
Accumulator Programs
- SB 267: Passed by the Senate, referred to House Economic, Development, Banking, Insurance, and Commerce committee.
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LOUISIANA
Prior Authorization “Gold Card”
- SB 112: Transmitted to the Governor (Pharmacy Services amended out of legislation)
Massachusetts
White Bagging
- SB 695: Ordered to study by Joint Committee on Healthcare Financing
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Register Now:
Save the Date:
Find all of CSRO's event dates by visiting our Upcoming Events page, and check out past events and webinars in our Library.
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