State Update: Infusion Downcoding Concerns
posted: April 1, 2016
The OAR has been reviewing complaints from members about changes to complex chemo codes by Ohio’s MAC carrier, CGS. CGS and other MAC’s around the country have recently been unilaterally deciding to downcode many biologics to simple infusion codes without any consideration of the risks or effects of the individual drugs.
Initial reports on this issue are not promising. From the federal side, it appears that MACs are given broad authority to decide how to code these drugs. However, there are some indications that pushback on this issue or directly engaging with CGS may give additional leeway. OAR is currently working with other state and national groups to review the options for our state.
As always, OAR legislative staff will continue to monitor all relevant legislation and will update OAR membership as required.