Payer advocacy 101
Ask the Expert
By Victoria Houghton, managing editor, April 1, 2021
DermWorld spoke to Louis A. Terranova, assistant director of practice advocacy for the American Academy of Dermatology Association (AADA), about the Academy’s private payer advocacy activities and what members can do to get involved.
DermWorld: Briefly, tell us about the AADA’s payer advocacy arm.
Terranova: Dermatology practices continue to adapt to an ever-changing health care environment, which demands optimal patient care at the right time. The AADA payer advocacy team works collaboratively with Academy members, state and local dermatology societies, and private payers to alleviate administrative burdens for dermatologists, maintain appropriate reimbursement for furnished services, and ensure patients can access covered quality care. The AADA’s coordinated approach to payer advocacy works to promote payer policies aligned with everyday practice for dermatologists, so they can focus on treating patients without interruption.
DermWorld: What role does relationship-building play in the work that you do in the Academy’s payer advocacy activities?
Terranova: As the specialty’s greatest advocate, the AADA builds relationships with public and private payers and examines insurer coverage and payment trends affecting dermatology. This critical collaboration helps address immediate needs affecting our members’ ability to deliver care, such as when policy changes affect claims and formulary coverage or payment.
DermWorld: What should a physician do if they are having payer issues such as onerous policy and reimbursement changes?
Terranova: There are several measures members can take for their own practice advocacy, utilizing AADA resources. First, practices should exercise the appeals process with the payer. To assist its members, the AADA has created an appeal letter tool. Members may also report their issue to the AADA, be it a coding-related concern to coding@aad.org, or payer issue at privatepayer@aad.org.
DermWorld: After a physician reports a problem, what are the Academy’s next steps and how does collaboration with membership play a role in the process?
Terranova: When a concern is raised, it is important to obtain as much information as possible in order to determine the level of impact and any mitigating circumstances. For example, why is a particular claim being denied? Is the coding appropriate and is there documentation to support the coding? Are other physicians reporting similar concerns, meaning, how widespread is this issue? Most often, an issue is reviewed in tandem with coding staff and/or the Academy’s Patient Access and Payer Advocacy Committee members and, depending on the carrier, with the state dermatology society. Collaboration is key as advocacy cannot be as successful when it functions in a vacuum. For example, when dermatologists in Oregon notified the AADA that HealthNet Medicare Advantage was implementing a modifier 25 reduction policy, the AADA worked closely with the Oregon Dermatology Society (ODS) to advocate jointly to HealthNet to urge them to reverse the policy. This coordinated effort ultimately resulted in HealthNet dropping the policy change.
Modifier 25 advocacy
Read more about the Academy’s advocacy activities on modifier 25.
DermWorld: Tell us about a recent payer advocacy win. What did that success entail?
Terranova: Advocacy is about building and nurturing relationships such as identifying key contacts among the payers. Having that foundation can lead to productive dialogue and ideally, problem resolution. As an example, when the AADA learned that UnitedHealthCare was improperly denying payment for claims for one stage of Mohs reported with CPT 17311, the Academy worked with contacts at UnitedHealthCare to resolve the issue. UHC was receptive to our concerns, and readily researched the issue. They realized that they had been misinterpreting policy and agreed that the denials were in error. Anthem notified the AADA that they plan to require preauthorization for a series of procedures when provided in the outpatient hospital setting, and the AADA worked closely with them to reduce the impact it will have on dermatology. As a result of these discussions, most dermatologists should not be impacted by the change due to the site of service code that is used when reporting services.
DermWorld: What are some of the biggest payer-related issues currently facing dermatologists?
Terranova: There are a number of factors in the payer arena that will impact dermatologists, from market consolidation as payers expand both horizontally and vertically, movement toward value-based payment, and cost-saving measures such as non-medical switching on formularies. We are hearing from members reporting concerns with denied or delayed payment. Currently, we are closely monitoring modifier 25 payment reductions, when an E/M code with modifier 25 and a procedure code having a 0- or 10-day post-operative period are billed by the same provider for the same date of service, the plan will compensate the E/M service at a reduction of the allowed amount. The AAD/A advocates against these types of policies and has engaged insurers when they are considering this type of policy which has led, in some cases, to a reversal of these types of policies, such as with HealthNet.
DermWorld: What do you expect to see more of in the future regarding issues and/or policy changes?
Terranova: I do think that as we begin to emerge from the pandemic, payers will look to re-initiate implementation of cost-savings measures, such as formulary changes via non-medical switching. As a result of the disruption in care delivery caused by the pandemic, those in a strictly fee-for-service payment model were hit very hard. This could lead to greater movement toward capitation or alternative payment models that are not wholly dependent on a volume-based payment model. Also teledermatology will be another area where we can expect to see policy changes.
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