Blizzard

[Andrea Zlatkus]

Many of us have felt the full force of Blizzards from Texas to the Northeast. But Biologic Coordinators also faced a different type of blizzard. The blizzard of reverification of benefits for all our patients on biologics. Many changes were put in place this years with requirement changes of Biosimilars for UHC. However, many have been successful in keeping stable patients on therapy. Please share your best tips here or any questions.

Thank you for all you do to have our patients stay on their treatment plans. You are their hero.

[Mark Post]

Forum : Biosimilars — This is a follow on from the Regular NORM Forum that I think is compelling in the Biologic Coordinator’s Forum
(Original Topic : Changing from Remicade to Inflectra for Regence’s patients)

11/22/2021 ** Disclaimer: I am not an Attorney but must deal with apparent legal issues regularly. Nothing that I allege or conclude constitutes legal advice, but rather Administrative & Regulatory channels & alternatives**; MP

To ** others in this boat. We have fought all year with Cigna over 1 Pt they want to switch from Remicade to Preferred Biosimilar. I even used Julie & Dr. S. Baak’s letter to them & Cigna’s approval for them in what I deemed an Equivalent case; I alleged it’s cause of Julie’s greater market clout which is based on viewing her Staff on line. Thereby I claim it is capricious rather than clinically sound or safe. I have alleged possible: Fraud, Bribery, Extortion, Violations of Licensing Standards for Cigna HCP’s, and so on. It’s more fun than throwing spaghetti at a wall where some of it will stick.
Bribery? $500. incentive for Pt to make a clinically sensitive decision based on the $$; Extortion? They will harm our patient if we don’t do what they say; remember Quid Pro Quo? Our Rationale for their Avsola P.A. says it’s under Duress & because Cigna refused approving Remicade; if they approved it may be the Pro to go with the Quid; I did not attend Law School though. Then they falsified an Approval dated 5 months before we asked for Avsola. For more Latin, they will plead Nolo Contendere! Phys. Med & Rehab. (PMR) Phyn was assigned to deny Remicade, & she did without proofreading the denial that states you must have contraindication to Remicade to approve Remicade. Also, Fam Med doctor did a Peer to Peer for which she is not qualified. Licensing standards? Not for Cigna. Julie got Dr David Moser, DO, Rheum. who approved for them. They approved Remicade for years without a P.A. for our Pt, then disapproved P.A. in Jan 2021 for faulty protocol that we corrected, then approved it again (for 1 year) then disapproved in July 2021, then under pressure from Employer-Sponsor, approved for 90 Days in Aug. 2021, then disapproved for extension. If you have an ERISA case like ours that entails obvious blatant violative practices, please report to USDOL OIG FRAUD hotline, it’s easy: https://oigportal.oig.dol.gov/eCasePortal/InvestigationsCaptcha.aspx?ReturnUrl=%2feCasePortal I also called our area U.S. Attorney to alert him. Please consider (with permission) cross referencing TDI (Texas Dept of Ins.) complaint #320257 from 9/24/2021; same case. This case crosses lines such that they can get dinged in 2 venues, then if your related cases can be bundled a greater multi-state or national case (in theory) might ensue.
Thanks.

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