Seeing eye to eye

By Ruth Carol, contributing writer

First there was step therapy, then physician tiering, and now what looks like care rationing. The latter includes certain insurers not covering treatment for vitiligo, hidradenitis suppurativa, and seborrheic keratosis that is not inflamed, as well as Medicaid in some states excluding treatment for actinic keratosis. Some insurers are not covering specific indications for Mohs micrographic surgery despite their inclusion in the Academy’s 2012 Appropriate Use Criteria for Mohs Micrographic Surgery.

When physicians and insurers don’t see eye to eye about optimal care for medical conditions, it’s the patients who pay the price in more ways than one. “The insurance companies are deciding what treatments they think are effective, reasonable, or cost effective and imposing their decisions on us and the patients,” said Mary Maloney, MD, chair of the Academy’s Ethics and Professionalism Committee. They argue that people can always pay for treatment out-of-pocket or the physician can find alternatives. However, many patients are already paying an exorbitant amount of money for their insurance, so, in effect, the insurers are really limiting access to treatment opportunities. “To me, they are practicing medicine without even seeing the patient,” she added.

Appeal, appeal, appeal

What recourse do dermatologists have when the standard of care isn’t covered?

“There is always an opportunity at the point-of-care to influence coverage decisions through the appeals process,” noted Lindy Hinman, practice director at health care consulting firm Avalere Health. “On a case-by-case basis, payers may make a different decision.”

All health plans have appeals processes, which Lawrence J. Green, MD, chair of the Academy’s State Policy Committee, acknowledges are time consuming, but sometimes do prove fruitful. To help with the process, the Academy provides a prior authorization appeals letter generator and drug denial letter template in its online Practice Management Center at staging.aad.org/practicecenter.

Seemal R. Desai, MD, chair of the Global Vitiligo Foundation’s (GVF) Advocacy Committee and a member of the Academy Board of Directors, sends a customizable template letter that cites studies showing vitiligo is a systemic autoimmune disease with comorbidities and demonstrating the burden of the disease. It’s important to continue educating payers that vitiligo is a disease because those who consider it a cosmetic condition won’t readily cover it without an appeal, he said. Dr. Desai also advocates for the use of home light units as many patients live far away and can’t come to the office a few times a week. “We explain to the payers that it can be more cost effective to have the patient on home light therapy because they’re not paying for the reimbursable office visit to the physician in a situation where the patient may not be able to regularly come to the office,” said Dr. Desai, who provides published papers showing the treatment’s benefit. He has been successful in getting home light units covered by some payers.

Alex Miller, MD, author of the Cracking the Code column in Dermatology World, has been successful using prior authorization appeal requests to get an optimal drug therapy covered when the pharmacist says the patient’s insurance won’t cover it. It’s critical to fill out the form truthfully, but in a way that demonstrates why the drug in question is preferable and how the alternatives offered by the pharmacist don’t favorably compare in efficacy, he said. “That works nine times out of 10,” Dr. Miller stated. “But it takes time away from patient care and creates busy work for my staff.”

Ethical dilemmas

An exhausted appeals process makes for some tough decisions. For example, when treating patients knowing that they will receive a bill, it’s best to be upfront. Dr. Maloney has started giving patients even more alternatives to choose from, citing which ones are covered by insurance and which ones are not. Dr. Maloney’s team has also begun giving their vitiligo patients whose insurance won’t cover light therapy the choice to pay for the treatment out-of-pocket. Most patients will pay for it because they are so stressed by the condition, Dr. Maloney said.

Another option is to set a different price scale for non-covered services. “When we do that, we always go through our legal team,” she said. “You have to be careful. You have to make sure that you are not undercutting the Medicare approved rate.” Those patients must sign a waiver attesting that their insurance doesn’t cover the treatment. Dr. Maloney has treated patients expecting their insurance to cover their treatment, and ended up not getting paid for her services. “That happens from time to time, but I don’t think you should be providing care for free,” she said. “It’s not a long-term solution.”

Dermatologists can choose not to charge patients, even those on Medicare, or charge them less and not bill the insurance for non-covered services, Dr. Miller said. But one can’t just automatically write off copayments or deductibles for Medicare patients because that’s considered inducement or fraud, he said. If one suspects that a treatment may not be covered, it’s best to get an advanced beneficiary notice of non-coverage known as an ABN, Dr. Miller stated. Have the patient sign it prior to the service being performed. The physician can bill the patient as long as the billing to Medicare reflects that an ABN was obtained. “The easiest thing to do for non-covered services is to inform patients that they are responsible for payment and don’t even bother billing Medicare unless the patient specifically requests that insurance be billed,” he said.

Billing a cosmetic service as a medical one is considered fraudulent, especially by Medicare. If Medicare finds out and then sees a pattern of abuse, expect the Department of Justice or FBI to pay a visit, Dr. Miller stated. The other problem with calling a treatment “cosmetic” for one insurer is that other insurers may take notice, said Dr. Maloney, who uses “non-covered service” as opposed to “cosmetic service.”

Although it may be tempting to treat a non-covered service as an add-on service, that begins a slippery slope. “If you make a visit for vitiligo about an existing seborrheic keratosis that you already know is benign, you’re getting into dangerous territory,” Dr. Maloney said. “If you get audited, you could lose that audit. If you don’t put vitiligo in the record, you can really get into trouble because you have to document everything you do.” In the long run, including vitiligo as a supplemental diagnosis isn’t really helpful because the patient will return for additional treatment.

In general, there are enough treatment alternatives to provide adequate care. “Fortunately, in dermatology, it’s rare to have a critical treatment withheld,” Dr. Miller said. If there are risks associated with not providing optimal care, he would appeal until he received approval. “It’s more common to have an optimal or preferred treatment denied with a severe disease, but not a life-threatening one,” Dr. Miller said.

IN PRACTICE: JUST ONE CAN MAKE A DIFFERENCE

Going up against CMS and other major payers may seem like David fighting Goliath, but David did win. And so did Julie Dhossche, MD, who — as a first-year resident at Oregon Health & Science University — advocated for Medicaid in Oregon to cover moderate and severe acne. Dr. Dhossche became increasingly frustrated that she could not provide acne treatment to Medicaid patients because coverage was excluded. “It’s important to offer standard of care to patients no matter what their insurance carrier or economic status are,” she said.

Dr. Dhossche researched online how Oregon’s Medicaid coverage decisions were made. She learned that the health evidence review commission reviews the evidence and scores each disease depending on such factors as: impact on pain and suffering, population effects, effectiveness of treatment, need for treatment, and cost considerations. That score determines the ranking of the disease on a prioritized list, which has a funding cutoff line. The conditions above the line are covered; those below are not. The commission allows patients and providers to nominate topics or diseases for review. She nominated severe scarring acne and was granted permission to present her case. With the help of dermatology colleagues, Dr. Dhossche prepared a document including the latest literature about all treatment options, their effectiveness, impact on individuals, and cost effectiveness. She also helped frame a policy change to propose to the commission. After a year of going back and forth with the commission, Dr. Dhossche presented her case in May 2018. The committee voted unanimously to cover moderate to severe acne, effective January 2020 when the new prioritized list is released.

While she made the case for acne, the commission mentioned that it might be reviewing hidradenitis suppurativa in the future. She followed the same process she did with acne. It took only four months to research and gather the documentation because she knew what the commission was looking for, said Dr. Dhossche, who testified this past January. The commission voted to cover Hurley stage II and III disease as of January 2020.

“Once you understand how the coverage decisions are made, you can build an effective case to reverse them,” she said. It’s also important to recognize that these decisions may be based on incomplete or older information. These committees may not have considered new evidence or have an expert in the field to help them with their policies, said the now pediatric dermatology fellow at OHSU. “I was really surprised how receptive the commission was to my input,” Dr. Dhossche said. “Once the members understood why I was advocating for reprioritization of these conditions, they were supportive of it.”

THE BIGGER PICTURE

Moving beyond their individual patients, dermatologists can affect coverage decisions in myriad ways. One way is to help develop clinical guidelines, which is one of the data points health plans use to make determination decisions (see sidebar.) Working through professional societies, such as the Academy, is always helpful to bring forth consistent policy, Hinman said. She suggested leveraging key opinion leaders and nationally recognized experts to have conversations with payers when there are concerns about specific coverage decisions being made. “Then it comes down to having one-on-one conversations with payers with the intent to influence and inform the decisions they’re making,” Hinman said.

Dr. Green encourages dermatologists to become active in their local and state dermatology societies as well as medical societies. He points to the Academy’s efforts to combat step therapy through legislation that has resulted in 27 states passing step therapy reform laws as just one example of the power of advocating for patients at the state level.

The goal is to limit the hoops that physicians have to go through to get what they think is the best medication for their patients in a timely manner, Dr. Green explained. Dermatologists whose patients have been negatively impacted by step therapy are encouraged to report their experience to the Academy, which uses that information for its state advocacy efforts. On a state and national level, working with the house of medicine carries much more weight with insurers, regulators, and legislators than working with only dermatology societies, Dr. Green added.

Having three or four states pass legislation prohibiting insurance companies from arbitrarily excluding conditions as cosmetic in the face of scientific evidence could cause a snowball effect across the country, Dr. Maloney said. Dermatologists calling out insurers that exclude known autoimmune conditions and a range of treatments for pre-cancers could rally public pressure as could publicizing stories of patients whose actinic keratosis turned into squamous cell carcinoma causing them harm. “These are all avenues we should be exploring,” she said.

PATIENTS CAN BE POWERFUL ADVOCATES

On an individual basis, patients can advocate for themselves by contacting their employer’s human resources department and insurance companies. “The insurance companies don’t care if the doctors call. They just say, ‘Sorry it’s our policy,’” Dr. Maloney said. “But they do care what patients think.” If patients call outraged and start rejecting insurance companies that don’t cover their conditions, she said, insurers will take notice.

Dermatologists can encourage patient advocacy by providing patients with a fact sheet indicating that their insurance company has arbitrarily decided not to cover their medical condition, Dr. Maloney said. The sheet can include steps that patients can take to help reverse coverage decisions. Dermatologists can ask patients to sign a registry of other patients who are equally as concerned. This list could be used to present to insurance companies and/or legislators as part of a grassroots effort, Dr. Maloney noted.

Dr. Desai encourages patients to become part of GVF’s support group in Dallas where he practices. All of the local support groups are affiliates of the Global Vitiligo Support Coalition. As a member, patients can learn about the disease, local experts, clinical trials, and advocacy efforts. Dr. Green noted the importance of working with patients. “The entire step therapy effort has been driven by physicians and patient groups, such as the National Psoriasis Foundation,” he said.

It’s imperative that dermatologists take a stand on these issues now, stressed Dr. Maloney, who believes insurance companies are targeting conditions that are not costly to treat to see what kind of pushback they get. “If we all just roll over, we’re going to see more and more medical conditions being considered cosmetic or insignificant,” she said.