Arnold H. Glasow once said, “In life, as in football, you won’t go far unless you know where the goalposts are.” I am not too sure if we can ever be completely certain about the whereabouts of the goalposts in life at all times, but in football, the rules about goalposts are explicitly defined; the whereabouts, the height, and the distance between the goalposts. These rules have certainly evolved over the period of the game’s lifetime but any changes are incremental, well evaluated and agreed upon by all parties. But what if one day you walked out onto the pitch and the size of the field is suddenly a lot bigger and the goal posts look a lot smaller too. Then the coach informs you that any rule can be changed at any time once the referee blows the starting whistle. Chaos would likely ensue.
At The Policy Authority (a subsidiary of The Verden Group), we track changes to health insurance health plan medical and administrative policies. These policies are the ‘rules’ that govern coverage and determine how physicians get compensated for providing medical services. In tracking such changes, we attempt to make order out of the chaos that are the ‘rule’ changes made to such policies every day. As data from scientific literature changes or the criteria developed by specialty societies alters, the insurance companies review and change their medical policies. Take the example of a typical disclaimer: on Wellmark BCBS (Iowa and South Dakota) website, it states that medical policies are “subject to change without notice, except as required by the law” and policies may be added or removed from use “from time to time”. These ‘rules’ are frequently changing but physicians are not necessarily informed when they do. In some cases, a monthly or quarterly newsletter of changes may be emailed to network physicians, but only if you have previously signed up for such communications. If you haven’t, you can look up policies on most plan websites, and those policies may or may not provide you with details about how each policy has changed.
Many participating providers may be unaware of such rule changes, until they receive a claim denial. So it is important to stay on top of such changes or at the least having access to policies to frequently review the ‘rules’ that apply to your services and specialty.
Let me share with you some examples of recent changes and how they may affect physicians.
Aetna has a relatively easy website to navigate and medical policies (known as Clinical Policy Bulletins) are fairly easy to find. Typically included in each policy are the revisions, updates and any additions made and the time stamp that each occurred. This is helpful, particularly in case of a claims denial where rules changed on a certain date and you can either support the request for payment or determine that payment will not be forthcoming (and hence not waste further time on the appeal) due to the new rules. However, from time to time some updates go unrecorded. For example, in their batch of updates on June 3rd, in addition to the typical time-stamped and annotated revised policies, they quietly updated three additional policies; “Daratumumab (Darzalex)”, “Mepolizumab (Nucala)”, and “Talimogene Laherparepvec (Imlygic)”, by adding a note of precertification required in each of the coverages. No other notification appeared on the website. No change to the review date of the policies, as is the usual practice for updates at Aetna, was noted. Now, it may be that pre-certification was always required for these services, and perhaps Aetna was simply making things clearer by adding that requirement directly to the clinical policy, but if not, then this presents a potentially significant impact to physicians that may continue providing services without knowledge of the change, and subsequently will receive denials for such services due to no pre-certification on file.
Major Changes: Genetic Testing
Over the last few quarters, we have seen policies pertaining to Genetic Testing changing for ALL of the insurers that we track and this is primarily due to updated to the scientific literature, the availability of new tests and greater awareness and information about such options. According to the industry, there are more than 7000 different genetic tests now available that can identify genetic variants and about 60,000 testing products developed by different laboratories, and clinical labs are introducing 8-10 new testing products every week with tests ranging in price from $250 to more than $6000. With all of this new technology and testing, it is forcing insurers to find ways to keep up to date on their coverage criteria.
Typically Cigna’s policy changes usually roll out on or around the 15th of every month, and we anticipate anywhere between 10-12 percent policies being revised during each cycle, i.e. around 35-40 policies out of more than 350 policies. However, on February 15th, this payer made changes to 61 policies, removing 25 policies pertaining to different forms of genetic testing alone. Did the removal of such policies mean that these tests were no longer covered? We needed to take a closer and more detailed look, and in doing so we found that they had overhauled their genetic testing policy section by consolidating and merging policies into four existing documents, introducing sections within the coverage policy that explained the coverage for specific tests. Moreover, Cigna has since added a future version of each of the four policies; two on April 15th and two on May 15th, and introduced a comprehensive table with description of tests, indication, related policy and Cigna’s coverage position. However, any updates or changes made in the table or policies would be difficult to capture unless compared with the previous policy, making it tricky for physicians to track movement in coverage.. Cigna does not address either Neurofibromatosis or PALB2 Mutations yet, but we have picked these up as being introduced by other insurers, and so anticipate that Cigna will add those policies in coming months too.
BCBS of North Carolina has 55 policies related to Genetic Testing; and two new policies, Genetic Testing for PALB2 Mutations and Genetic Testing for Neurofibromatosis which were added to the list on April 29th, with the latter having the policy of “may be considered medically necessary”, while the former is “considered investigational”. Similarly, BCBS of South Carolina added “Genetic Testing for Neurofibromatosis” policy on May 4th, also having the policy of “may be considered medically necessary.” Genetic Testing for PALB2 Mutations was introduced by the same company in February of 2015 and despite revisions and updates, is still “considered investigational.”
It’s not an easy job to do, but we figure someone has to track these changes, notify physicians and keep the insurers ‘honest’ with their updates. If you would like more information on how we can help, please visit www.ThePolicyAuthority.com