Office of Inspector General: MAOs & Pre Authorization Requests

April 2022: Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care

With there being the potential concern of MAOs having the ability to increase profits by denying payments and access to services to providers, the OIG conducted this review from a random sample of 250 denials of prior authorization requests and 250 payment denials issued by 15 of the largest MAOs during the month of June 2019.

Report in Brief 

2022 Annual Conference

Save the Date: WRA 15th Annual Conference

Dear Colleagues,

We are looking forward to gathering in person for the Washington Rheumatology Alliance Annual Meeting! Once again, we will be hosting the event at the charming Sleeping Lady Resort  in the beautiful Cascade Mountains. Please join us from Friday, September 16th- Sunday, September 18th, 2022.

Attendees and guest speakers are welcomed to stay on site at Sleeping Lady Resort. We request that industry representatives stay at the Icicle Village Resort (just a few miles away from the conference venue) in the Bavarian-themed village of Leavenworth. There will be a discounted room block available.

If you are interested in attending, presenting, or exhibiting at the annual event, please contact Jena Rehm at

We look forward to seeing you this summer! Thank you for your continued support of the WRA.

Jeff Peterson, MD

WRA President

Thank you for attending the WRA 14th Annual Conference

Thank you to everyone who attended the 2021 14th Annual Conference in Leavenworth! If you still need to complete the CME evaluation and/or claim credit, please contact Emily Jones at or 206-956-3621.

Please help us thank our generous sponsors

Bristol-Myers Squibb
Sanofi Genzyme

Thank you to our 2021 exhibitors

Gold Level Exhibitor
Lilly, USA

Silver Level Exhibitors
Horizon Therapeutics
Janssen Biotech

Bronze Level Exhibitors
Aurinia Pharmaceuticals
Boehringer Ingelheim
Scipher Medicine

We look forward to seeing everyone again in 2022!

Introducing Our Stories Rx

As an initial convening, Our Stories Rx is hosting a virtual roundtable conversation with Antonio Ciaccia, who served as the government affairs director for the Ohio Pharmacists Association in 2018, when a state audit revealed a PBM-led spread pricing scheme that overcharged the state Medicaid agency by over $200m.

Our Stories Rx invites you to a virtual roundtable with Antonio Ciaccia, President of 3 Axis Advisors and CEO of 46brooklyn Research, for a discussion on Pharmacy Benefit Managers and his experience unwinding the web of cost and access issues associated with PBM interactions between clinical providers, state Medicaid agencies, and patients across the US. The discussion will be moderated by Karen Ferguson, Practice Administrator at Arthritis Northwest, PLLC. This event will occur on Wednesday, 6/30, from 12p – 1p PST. Register by clicking here.

About Antonio Ciaccia:
Born and raised in pharmacy, Antonio has been involved with pharmacies his entire life.  After three years as a pharmacy technician and two years of pre-pharmacy curriculum, Antonio diverted course, graduating from The Ohio State University in 2007 with dual degrees in communications and political science before moving into the world of association management. Thinking that pharmacy would be in his rear-view mirror forever, he ended up making his way back to his pharmacy home, heading up government affairs for the Ohio Pharmacists Association.

After years of studying the pharmacy marketplace, Antonio became increasingly perplexed and concerned as he saw drug costs spiking while payouts to pharmacies were declining. Knowing something was being lost somewhere in the middle of an ever-growing transaction, Antonio has spent years working to crack the drug pricing code and pull the rug out from what he believes is one of the most dysfunctional marketplaces in the world.

About Karen Ferguson:
Karen Ferguson is the Practice Administrator at Arthritis Northwest, PLLC, the largest clinical rheumatology practice Northwest of Denver, and headquartered in Spokane, Washington. Karen founded Our Stories Rx, and is also the co-founder and CEO of Discus Analytics, Inc., a healthcare IT company addressing the unmet need for organized, discrete, and clinically actionable information supporting the physician and patient’s longitudinal journey together.

As Practice Administrator for Arthritis Northwest, Karen led her organization to earn the national recognition for quality care, “NCQA Patient-Centered Specialty Practice Recognition” which distinguishes practices that communicate, collaborate, and integrate care in ways that demonstrates constant improvement through communication, coordination, and providing access to care.

Ms. Ferguson is past President of the Washington State Medical Group Management Association and the Inland Empire Medical Group Managers Association. She currently serves as ARP/ACR Education Committee, NORM Payer Committee, and CSRO Payer Committee.  Ms. Ferguson received her Master of Science in Health Education/Promotion from Whitworth College, and a Bachelor of Science degree in Physical Education from San Diego State University.

About Our Stories Rx:
Our Stories Rx is a 501(c)4 organization focused on developing an interactive storytelling platform that will advocate for policy outcomes that improve the health and well-being of vulnerable patient populations and the community clinics that serve them. By documenting and publicizing the experiences of patients, clinical providers, and other purchasers of healthcare services, Our Stories Rx seeks to build qualitative and quantitative tools to advance a data-driven, community centered platform with a proactive vision for advocacy and policy reform.

Online Registration Is Closed

Washington Rheumatology Alliance’s
14th Annual Conference

September 17-19, 2021
Sleeping Lady Mountain Resort
7375 Icicle Road
Leavenworth, WA 98826

Online registration is now closed. Onsite registration will be available; please contact Sleeping Lady directly regarding room availability.

Your registration includes the following:

Friday night opening reception with appetizers and hosted bar. Open to all participants and their family members.

1.5 days of educational programming  for physicians (Saturday and Sunday)
Click here to view the Physician Agenda. Topics include:

  • Immunosuppression: Is It All in Your Head?
  • Advances in Treatment for Patients With Systemic Lupus Erythematosus or Lupus Nephritis
  • Improving Recognition and Management of EGPA: A Multidisciplinary Approach to Individualizing Treatment
  • Pulmonary Involvement in Rheumatic Diseases
  • We also look forward to our annual Advocacy Panel, which is open to all attendees.

Please note that the practice manager track has been cancelled. We apologize for any inconvenience.

Registration Details
You can pay your annual WRA dues on the conference registration form in order to get the member rate for the conference.

  • $45 Annual WRA dues
  • $45 conference registration fee for the entire weekend’s programming (including CME credit!)
  • $25 per ticket for guests

Hotel Accommodations
We have arranged for discounted room block for meeting attendees at Sleeping Lady Mountain Resort. You are responsible for booking and paying for your own accommodation. Visit this page for room rates, how to make reservations, and selecting your meal package.  There are a limited number of dog-friendly rooms, so contact the resort as soon as possible to book one of those rooms if you plan to bring your pooch.

Click here for airport and ground transportation information.


For questions about the WRA and its programs, contact Emily Jones, WRA Executive Director, or 206-956-3621.

Help us thank our generous sponsors and exhibitors:


Bristol-Myers Squibb
Sanofi Genzyme


Gold Level 
Lilly, USA

Silver Level
Horizon Therapeutics
Janssen Biotech

Bronze Level
Aurinia Pharmaceuticals
Boehringer Ingelheim
Scipher Medicine

New Medicare Changes

We are providing information that hopefully will help our members understand the 2021 Final WRVU billing codes and reimbursements slated for Rheumatologists.

  1. The final WRVU code values for E & M coding: Please notice that at the end of 2020, the WRVU was set at a lower number, and increased to 34.89 early 2021. Because 34.89 represents the universal conversion factor, it needs to be budget neutral, so you will see other specialties actually have decreased over all. Because the E & M codes are newly defined, rheumatologists actually are increased by approximately 13%.
  2. A cheat sheet for rheumatologists to understand both the E & M coding requirements as well as the time based coding, which includes time spent face-to-face as well as activities that a physician does in review, reporting, dictation, or preparation to see the patient, on the date of service.
  3. Final Medicare Ruling: Add on codes G2211 on hold until 2024, however can still be assigned a PFS payment STATUS INDICATOR of B (bundled) until 2024.

2020 Salary Survey

Dear colleagues,

It has come to my attention that many of the hospital systems are not compensating rheumatologists for any increase in RVU value that CMS has just put in place starting January 1 to help compensate for cognitive specialists and to help increase recruitment into these underserved fields. This was approximately a 15% increase. For those who listened in on the post ACR talk that Karen Ferguson and I did we discussed this issue at that time. Karen had a table that she can share with anyone who is interested that updates the RVU/ code. I have checked with CSRO and there may be no legal recourse unless there is specific language in your contract. One Hospital system stated that they were waiting on data from MGMA which is terribly faulty and seriously under- valued. The last time we did a salary survey in 2017, MGMA was approximately 50% below the actual compensation in our state. However, the hospital systems use MGMA numbers to generate your salary. It is imperative that we collect good data and have a significant number of responders. PLEASE COMPLETE THE SURVEY BY MARCH 31.

Take the Survey NOW

This is completely confidential, and we will not associate names with the data. We need ALL rheumatologists in the state to answer to make the survey valuable to all, especially those who are employed.

Thank you,
Jeff Peterson, MD
WRA President

Save the Date for WRA’s 14th Annual Conference September 17-19, 2021

Dear colleagues,

The Washington Rheumatology Alliance cordially invites you to join us for our outstanding annual conference September 17-19, 2021, which will be held again  at the intimate Sleeping Lady Mountain Resort in the beautiful Cascade Mountains of Washington State.

Click here to learn more about exhibitor opportunities and to register as an exhibitor.

We understand that we are living in uncertain times right now. While we are moving forward with conference planning under the assumption that life will return to relative “normal” this fall, please let us know if you think you are likely to attend our conference in-person this September. Send an email to our executive director, Emily Jones, at We strive to meet the needs of our members and attendees; your input is invaluable as we continue to plan.

Thank you for your support of WRA,

Jeff Peterson, MD
WRA President

Genentech Stance on Most Favored Nations (MFN) Model

On December 15, 2020, Genentech led a discussion about how the Most Favored Nations (MFN) model threatens provider and patient access to existing and future medicines; we share your concerns that this could have a detrimental impact on your practice and ability to treat patients. Genentech agrees that we have to work together across the healthcare delivery system to enable all Americans to receive appropriate and affordable care. As we do this, we must protect and sustain patient access to scientific innovation in the U.S. so that people with serious diseases continue to benefit from the breakthrough medicines they depend on. Never has this need been clearer than during the current COVID-19 pandemic.

Below is more information on the MFN model, Genentech’s position, as well as that of other organizations.

If you would like to independently advocate against this model, I suggest that you reach out to your physician specialty societies and ask them to:

  • Engage policymakers, in Congress and in the current and incoming administrations, to stop the implementation of MFN;
  • Communicate their concern to CMS via written comments; and
  • Consider joining or pursuing litigation challenging implementation of MFN. The most expedient way to get societies involved in existing cases is for them to contact representatives at PhRMA ( or BIO (

Additionally, you can reach out to your federal and state representatives, to request that they weigh in opposing the model with their peers, and existing and incoming administration officials.

Downloadable Resources from the Arthritis Foundation

The Arthritis Foundation has free downloadable brochures and fact sheets through the AF Store​ that you can save to your office desktop. The brochures and fact sheets can be e-mailed to patients or you can print copies in-office and hand out to patients as needed. The downloadable materials are a convenient way to provide your patients, who may not be comfortable taking printed materials from your office as a result of the Covid-19 pandemic, the information they are looking for. Instructions are available here.

If you are in need of a bulk order of printed brochures or fact sheets, please contact your local Arthritis Foundation staff member at for assistance.

The Arthritis Foundation also created a Covid-19 Resources flyer that has a list of great patient resources to help them navigate the pandemic and stay connected.