Don't Let Insurance Companies Bully You

“You can no longer inject Avastin in patients who have Aetna Insurance” was the text message I received the other day from my practice manager.

I did a double take. I thought I read it incorrectly. Usually, these types of warnings read the opposite. Usually, I am being told that “Insurance Company X” says that you can no longer use the costlier Lucentis or Eylea (both about ~30 times the cost of Avastin).

That’s what we’ve been used to hearing for last 5 years. Never have I come across a message like this.

“WTF?” I replied.

Here’s the weird part… “They’re denying reimbursement because they consider it a non FDA-approved / investigational drug by their claims processor. Until we appeal this decision, you can no longer use Avastin for your Aetna patients.”

OK. If you don’t know the drama between using the less expensive Avastin (~$60) versus the more costlier Lucentis or Eylea (both, ~$1900), check out my previous blog post.

In short, Avastin is in fact, FDA-approved, but only as a chemotherapeutic for the treatment of colon or kidney cancer given in a 4 ml intravenous dose. It blocks a signal that allows tumor cells to grow.

Used “off-label” in the eye, its activity has prevented blindness from macular degeneration and diabetic retinopathy.

Over the past decade, Avastin has been retinal specialists’ preferred, first-line drug and the most widely used ocular treatment worldwide.

Because it’s compounded and aliquoted into several dozen 0.05 ml doses, the cost of $4,000 for 4 ml now becomes about $60 per dose.

Recently, Avastin has been shown to be a more cost-effective treatment than its FDA-approved “on-label” counterparts, Lucentis and Eylea.

In fact, several insurance companies have required a trial of Avastin treatment prior to using the more costly drugs, a process known as Step Therapy intended to reign in cost.

Until now. Aetna changed the rules but didn’t tell anyone. That’s one reason why physicians are becoming increasingly dissatisfied with the business aspects of clinical practice.

It’s like playing baseball and given only 1 strike without the umpire telling you ahead of time.

Here’s the real rub…

Physicians pay for these drugs up front often times with a line of credit. If there’s a delay in reimbursement or worse, non-payment, doctors’ offices are on the hook with their creditors. In high volume practices, a gut wrenching cash crunch could happen.

So far in the last 3 months, Aetna has denied 32 of these Avastin injections.

Thankfully, our practice has invested in our back-office infrastructure with a highly-trained billing department that quickly picked up this disturbing development with the Aetna claims processing department.

Conspiracy theorists might suggest that claims processors may be incentivized to increase denials of claims, even clean ones like ours.

Fortunately, after a time consuming appeal process, we are likely to get reimbursed.

My recommendation is to always be diligent with your billing and coding and self-audit often. Invest in a well-trained back office. Don’t let the insurance companies bully you.

But most importantly, be an advocate for your patients.

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#avastin #medicare #lucentis #eye #bigpharma #healthcare #Medicare

Robert Wong, MD
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