Reimbursement Strategy

2026 Medicare and Commercial Payer Repricing of Infusion Drugs: ASP + 6%, Sequestration Adjustments, and Contract Language That Protects Margin

When UHC Reprices Your Remicade Claim at ASP + 4%

Last month, one of our rheumatology clients in Texas sent me a UnitedHealthcare remittance. CPT J1745 (infliximab, Remicade) was billed for 400 mg at $965 per 100 mg, matching the Q2 2026 ASP + 6% rate from CMS. But UHC repriced it down to ASP + 4%. Their contract had that vague “Medicare‑aligned reimbursement” language, no mention of the 2% sequestration reinstatement. The result? About $77 lost per dose. Across 25 patients a month, that’s close to $1,900 gone.

We’ve been here before. Payers quietly trim the base reimbursement while insisting they “follow CMS.” The real problem in 2026 is that sequestration is fully active again, and payers are using it as a pretext to keep a little extra margin for themselves. Look, that’s not alignment, it’s underpayment dressed as compliance.

ASP + 6% Isn’t the Same as ASP + 4.3% After Sequestration

Medicare Part B pays most infused and injected drugs at ASP + 6% under Section 1847A of the Social Security Act. Then sequestration applies a 2% reduction to the total allowed amount, including the add‑on. So an $800 drug with a 6% add‑on ($848) actually pays $831.04, an effective ASP + 3.88%.

Commercial payers like Aetna and Anthem Blue Cross reference CMS rates in their 2026 fee schedules, but they rarely clarify which side of sequestration they’re using. If a contract says “ASP + 6% aligned with CMS,” they’re often mirroring the post‑sequestration end result. That’s where practices get squeezed.

CMS hasn’t changed its statutory formula. Sequestration is still a separate payment reduction, not part of the pricing method. So don’t let payers fold it into your rate. Protect yourself with explicit language: “Reimbursement for physician‑administered drugs shall be based on CMS‑published ASP + 6%, exclusive of sequestration.” It’s that simple.

Infusion Claim Headaches: Codes, Units, and PTP Edits

Coding errors can kill infusion revenue faster than any payer‑side repricing. CMS’s Q3 2026 NCCI file added new bundling edits between therapeutic and biologic infusions. Per the latest AAPC update, these edits affect pairings like CPT 96365 (initial therapeutic infusion, up to 1 hour) and 96367 (each additional hour). Practices billing hydration (96360/96361) in the same encounter are getting denials when modifiers aren’t used correctly.

For infliximab (J1745), vedolizumab (J3380), and ustekinumab (J3358), sequencing matters. If your EHR pushes infusion time under the wrong level of service, you lose the entire administration fee. And no, payers won’t reprocess it for you. Fix it before submission or eat the denial.

  • Missing or invalid units, especially common on weight‑based biologics for pediatric Crohn’s disease
  • Wrong PTP modifier when hydration and therapeutic infusions appear on the same claim
  • Diagnosis mis‑match between ICD‑10 codes (K50.80 vs K50.90) triggering UHC clinical edits

CMS’s Q3 2026 NCCI dataset added new modifier 59 discriminator flags across multiple infusion pairs. Ignore them and you’ll see line‑item denials with zero review rights. Clean coding isn’t optional anymore, it’s survival.

Contract Language to Fix Before July 2026

If you’re renegotiating payer agreements, and you should be, get your Part B drug language right. Three recurring traps we’ve seen this spring:

1. “Reimbursement aligned with CMS.” That phrasing lets payers apply post‑sequestration rates. Replace it with a pre‑sequestration definition of ASP + 6%.

2. “Most recent published ASP.” CMS ASP data lags two quarters. Require the payer to use the same effective quarter CMS uses, not a stale table pulled from last winter.

3. “Lesser of billed charge or payer fee schedule.” If your charge master sits below current ASP + 6%, that clause locks you into permanent underpayment. Audit charges every year, no excuses.

We just saw Anthem knock bevacizumab (J9035) payments down 4% after its April 1, 2026 update. Their defense? “CMS sequestration alignment.” Sure. That’s wordplay, not alignment. And it cost the practice thousands.

Monday Morning: What You Actually Do

Grab your top 10 J‑codes from Q1 2026. For each drug, line up your billed charge, allowed amount, and effective add‑on percentage against CMS’s ASP + 6% table. Anything netting under 5.5% deserves a contract review.

Then call your payer rep. Ask only this: “Is our ASP + 6% rate based on pre‑ or post‑sequestration values?” If they hesitate, you already have your answer.

Finally, check your EHR. Make sure the modifier 59 logic for infusion‑plus‑hydration follows the new Q3 2026 NCCI PTP list. CMS posted it in the practitioner section, and that’s exactly what commercial plans mirror. Do the homework now so you’re not back‑appealing in August.

ASP + 6% is still the law. But contracts drift, edits change, and payers test the waters every quarter. Stay loud about it, document everything, and keep your reimbursement where Congress actually put it.

Sources

Claims Assistant