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Let me start by saying that it's wonderful to be back at WPS!
As an introduction for those of you I haven’t had a chance to meet yet, and a reintroduction for those I have, I am originally from Wisconsin and majored in economics as an undergraduate at the University of Wisconsin-Madison.
I received a doctor of medicine (M.D.) and a master of healthcare administration (M.H.A.) degree from Virginia Commonwealth University, completed graduate
medical training at the University of Virginia and am board certified in physical medicine & rehabilitation.
Outside of clinical medicine, my experience includes leadership roles within healthcare provider organizations, insurers and professional services firms. I look forward to communicating with the provider community on a regular basis and hope you find these newsletters to be valuable.
This issue includes information on:
- Shifting from Low-Value to High-Value Specialty Drugs:
A Path to Better Outcomes
- Reimbursement Policy Update: Diagnosis Coding for Radiology and Laboratory Services
- Medical Policy Updates
- Chiropractic Management Services
- BetterDoctor
- Portal Education
- Provider Manual Schedule Update
- Last Quarter Holiday Schedule
If you have questions related to content within the newsletter, or would like to get in touch for any reason, please feel free to contact me at Jonah.Fox@wpsic.com.
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Jonah Fox, M.D., M.H.A.
Chief Medical Officer
WPS—A health solutions company
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Shifting from Low-Value to High-Value Specialty Drugs: A Path to Better Outcomes | | |
In today’s rapidly evolving healthcare landscape, specialty drugs play an increasingly central role in treating complex conditions such as cancer, autoimmune disorders and rare genetic diseases. However, not all specialty drugs deliver the same value. A growing focus on patient outcomes, cost-effectiveness and long-term health benefits has highlighted the importance of shifting from low-value to high-value specialty therapies.1,2
Understanding Value in Specialty Drugs
Low-value specialty drugs often come with high costs but offer limited clinical benefit, uncertain long-term outcomes or significant side effects. In contrast, high-value specialty drugs provide meaningful improvements in patient health, reduce hospitalizations or complications and demonstrate a strong return on investment for payers and providers. Evaluating drug value involves considering both clinical efficacy and the total cost of care, including ancillary services and potential hospitalizations.
The Case for Transitioning
For patients, this shift can mean better disease management, fewer adverse effects and improved quality of life while reducing financial strain, improving treatment adherence and minimizing the risk of skipped doses.
Reduced Financial Distress
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The Problem: Expensive medications (such as brand-name drugs or specialized
biologics) can cause severe financial stress, which negatively impacts a patient’s
quality of life.3
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The Value: Transitioning to therapeutic alternatives—or high-value generics or biosimilars that offer similar clinical benefits—removes this barrier.2
Improved Medication Adherence
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The Problem: High out-of-pocket costs force some patients to ration doses or avoid filling prescriptions entirely.1,3
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The Value: The use of high-value generics or biosimilars can fit more comfortably within a patient’s budget. When a medication is affordable, patients are far more likely to take their treatments exactly as prescribed, leading to better long-term disease management.3
For healthcare systems, investing in high-value specialty drugs can lower long-term costs by preventing complications and reducing unnecessary interventions.1,2
How Healthcare Leaders Can Help Drive this Shift
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Data-Driven Decision-Making: Leverage real-world evidence and clinical trial data to identify therapies with the highest clinical and economic impact. Utilize comparative effectiveness research (CER) to help inform prescribing decisions.
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Patient-Centered Care: Align treatment choices with individual patient needs, ensuring both effectiveness and adherence.
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Formulary Optimization: Adjust formularies to favor high-value specialty drugs, incentivizing prescribers and patients to choose therapies that deliver measurable outcomes.
Conclusion
Shifting from low-value to high-value specialty drugs is not just a cost-containment strategy—it is a commitment to better patient care and sustainable healthcare.
By prioritizing therapies that deliver the greatest clinical benefit and economic efficiency, healthcare stakeholders can achieve improved outcomes for patients
and a more resilient, value-driven system.
References
1. https://pmc.ncbi.nlm.nih.gov/articles/PMC10388011/
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC4031694/
3. https://accessiblemeds.org/resources/blog/skyrocketing-drug-prices-whats-driving-costs/
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Reimbursement Policy Update: Diagnosis Coding for Laboratory and Radiology Services | | | |
Effective for dates of service on or after November 1, 2026, laboratory and radiology services will be denied when Z00.00 or Z00.01 is submitted as the primary line-level diagnosis on a CMS-1500 claim form. For CMS-1450 claims, these services will be denied when Z00.00 or Z00.01 is reported as the only diagnosis on the claim.
Diagnosis codes Z00.00 and Z00.01 describe an encounter for a general adult medical examination, with or without abnormal findings. While these codes may be appropriate for a preventive examination, they do not identify the specific reason a laboratory or radiology service was ordered or performed.
Providers should report the diagnosis code that supports each separately billed laboratory or diagnostic radiology services, consistent with the medical record and current ICD-10-CM coding guidelines.
More broadly, diagnosis codes should accurately reflect the reason for the service, be supported by documentation in the medical record and reported in accordance with applicable ICD-10-CM coding guidelines. Accurate diagnosis coding supports timely claim processing and appropriate reimbursement.
Check out our Reimbursement Policies on our website under Resources > Provider Resources > Support and Education.
We also encourage providers to use the Claim Edit System (CES) application available within our provider portal to view “edit results” and “rationale” that will be applied to specific code combinations. The CES application is available to all contracted providers through our provider portal. If you do not currently have a provider account, please complete a Request for Provider Access on our website.
For questions regarding medical coding related to policies, you may contact the
Code Governance Committee at codegovernance@wpsic.com.
For questions regarding the policies outside of medical coding, you may contact Provider.Reimbursement@wpsic.com.
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| Medical Policy updates and review | Please note these changes and their effective dates. | |
At their most recent meeting, the Medical Policy Committee approved several new medical policies and completed scheduled annual policy reviews. Please take a few moments to review these updates and their effective dates to determine how they apply to your practice.
Medical Policy updates
Please be sure all doctors, other clinical staff and office staff are aware of these changes before submitting requests for coverage for services and issuing referrals.
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A library of our medical policies can be viewed online at WPS Medical Policy.
Specific questions or comments regarding development of policy content may be directed to the Medical Policy Editor at medical.policies@wpsic.com.
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| Chiropractic Management Services | |
WPS has entered into a partnership with Chiropractic Management Services LLC to administer the health plan's new chiropractic network for commercial group members effective July 1, 2026. This transition was prompted by the March 2026 announcement of WPS' chiropractic network (Fulcrum) that it would
be ending operations later this summer.
Chiropractic Management Services LLC administers the largest network of chiropractic management services in Wisconsin and is led by Dr. Bryan Gerondale, a licensed chiropractor who is well-respected in the chiropractic community. Chiropractors who are interested in continuing in or joining the WPS Statewide network can contact drgerondale@cmservicesllc.com for more information.
As a result of this transition, Chiropractic Management Services LLC will replace contracting and credentialing responsibilities previously conducted by Fulcrum. Claim submission processes will not be affected by this change, as providers may continue to submit claims directly to WPS for processing and payment. WPS Medical Guidelines for Spinal Manipulation will also continue uninterrupted and are available for review at https://www.wpshealth.com/resources/files/spinal-manip-chiro-services.pdf.
WPS stresses that this transition will NOT affect providers who are reimbursed for Medicare Supplement claims.
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| Provider Directory Verification Reminder | |
To help ensure members can access accurate provider information and to support compliance with federal and state regulations, including the No Surprises Act, we continue to partner with BetterDoctor for provider directory verification activities.
Contracted providers will be contacted quarterly by BetterDoctor to verify directory information such as practice locations, contact details and provider availability.
Providers are encouraged to review and confirm their information or submit updates as needed.
Please note that requests to add or remove practitioners or locations must still be submitted through the appropriate Practitioner Data Sheet or Facility Data Sheet process for contracting and credentialing purposes.
We appreciate your continued partnership in maintaining accurate provider directory information. For questions regarding directory verification outreach, please contact providernetworksolutions@wpsic.com for assistance.
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The WPS Provider Portal saves your practice time by providing 24/7 self-service access to critical patient and claim data. Instead of waiting on the phone, you get real-time answers right when you need them.
What You Can Do in the Portal
The portal is your one-stop resource for quick, convenient access to:
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Claim Status: Track submissions from start to finish.
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Eligibility: Verify patient coverage instantly.
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Network Status: Find participating providers and facilities easily.
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Copayments/Deductibles: Review patient financial responsibilities
before appointments.
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Secure Messaging: Communicate directly with Customer Service without holding on the line.
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Code Combination Simulation Tool: Test codes to ensure accuracy and prevent claim denials before you bill.
If you want to optimize your portal usage, let me know:
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Would you like step-by-step instructions on setting up staff accounts?
- Are you interested in troubleshooting a specific tool, such as the CodeCombination Simulator?
Let us know what you need help with!
- WPS Provider Contact Center: 800-765-4977,
Monday–Friday, 7:30 a.m.–5 p.m. CT
New and unregistered providers click here to register!
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| Important Provider Manual Schedule Update | | Moving to Bi-Annual Update Schedule | | |
We are updating our provider manual schedule to serve you better. Starting this year, the provider manual will transition from its previous schedule of annually to a fixed,
bi-annual update cycle.
Going forward, all official revisions and procedural changes will be published twice a year on January 1 and July 1.
Why This Change Matters
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Predictability: Knowing the exact release dates allows your administrative staff to plan ahead.
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Efficiency: Consolidating updates reduces the time you spend tracking changes throughout the year.
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Compliance: Fixed dates make it easier for your practice to review, implement and remain compliant with the latest guidelines.
What You Need to Do
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Mark Your Calendar: Note January 1 and July 1 as the key dates for manual releases.
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Review Bulletins: We will continue to keep you informed of any WPS updates in the WPS Provider Newsletter.
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Access the Manual: Always download the latest version directly from our provider portal to ensure you are using current guidelines.
We appreciate your continued partnership and dedication to providing high-quality care to our members.
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Upcoming Holiday Schedule
While our offices will be closed on the following dates, providers will still have access to benefits, patient information, claim status and other key information via the Provider Portal.
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