Payer coverage policies
Ask the Expert
By Victoria Houghton, Managing Editor, December 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 initiative to review private payer coverage policies.
DermWorld: The AADA has developed a process to facilitate dermatologist review of carrier policies. Tell us why you developed this initiative to review private payer coverage policies?
Terranova: As part of the AADA’s payer advocacy strategy to promote access to dermatology services through appropriate benefits coverage and payment, this is considered an opportunity to provide dermatologist input to carrier coverage policies. It is primarily an opportunity to evaluate the medical policy to determine if there is any clinical variation with AADA policy or evidence-based medical standards.
DermWorld: How does this review process work?
Terranova: In facilitating physician review, as a first step in the review process, we seek to identify dermatologists who are subject matter experts on the topic at hand. The Academy’s science and quality staff help identify dermatologists who have authored studies or clinical guidelines related to the topic, and conflicts of interest are noted. Leadership from the Patient Access and Payer Relations Committee (PAPRC) reviews the list of subject matter experts and authorizes requests for individual physician review. The comments from the individual physician reviewers are then collected and forwarded to the requesting carrier. Staff will then follow up with the carrier on the outcome of the policy review and inform PAPRC who will then determine whether any additional advocacy or member education is warranted. It is important to note that in facilitating individual dermatologist review, it does not indicate endorsement by the AADA nor does the commentary provided serve as any Academy endorsement or repudiation of the policy under review.
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Aware of an insurer’s coverage or change? Contact privatepayer@aad.org or fill out our form.
DermWorld: What happens if the carrier disregards the comments/recommendations provided?
Terranova: That can, and sometimes does, happen because ultimately the carrier is making the final decision on their policy. The carriers that we have worked with to date have acknowledged the input provided ideally to afford a perspective as well as published studies that may have been overlooked but are germane to the topic under review. As a tactic in the overall AADA strategy to influence decision makers on the value of dermatologic care, this is an opportunity to enhance dialogue and build relationships with payers. Should a carrier not take into account the comments provided, at the very least, we are given advanced notice of a carrier’s policy impacting dermatologists and can be proactive in guiding our members on any forthcoming changes.
DermWorld: What are some of the policies that you’ve reviewed so far?
Terranova: Currently, Anthem, UnitedHealthcare, and the Blue Cross Blue Shield Association (BCBSA) Evidence Street® program have shared their policies impacting dermatology with the AADA for input. While not an endorsement of a carrier’s policy, this process does allow for comments from dermatology subject matter experts. Recently, Anthem and the Blue Cross Blue Shield Association Evidence Street program have requested dermatologic input on the following:
Anthem policy on Technologies for the Evaluation of Skin Lesions: including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography
BCBSA Evidence Street Report on Liposuction for Lipedema and Lymphedema
DermWorld: It sounds like many payers are proactive in engaging specialties like dermatology. What are you doing to reach out to the payers who don’t actively pursue dermatologic input on their coverage policies?
Terranova: As part of the PAPRC strategy of carrier engagement, we have targeted regular meetings with the largest national carriers collectively providing insurance coverage to over 150 million covered lives. Quarterly calls have been arranged with the largest carriers: Anthem, Aetna, and UnitedHealthcare (UHC) and bi-annual calls with Cigna. While Aetna and Cigna have not yet proactively engaged specialty societies in their policy reviews, our strategy of engagement is another way to provide dermatology input to those carriers. Our recent engagement with the Blue Cross Blue Shield Association Evidence Street program presents an opportunity to facilitate dermatologist input to the evidence-based reports that the Blue Cross plans use to guide their individual health plan policies. Also, often in coordination with state dermatology societies, we will work with those state societies as needed to address any regional carrier issues.
Modifier 25 advocacy
Read more about the Academy’s advocacy activities on modifier 25.
DermWorld: What are some of the biggest payer-related issues currently facing dermatologists and how will these reviews help?
Terranova: Treatment advances via technology and pharmacology are at the forefront, especially as payers look to control costs. In addition to providing clinical expertise and access to current medical literature and studies, these types of reviews are helpful in presenting the total cost of care perspective. This is especially true with new therapeutic indications on the horizon. Oftentimes, payers are looking narrowly at the unit cost of treatment or drug and may not fully account for the total cost of care and the efficacy and efficiency of treatment. That is, the overall return on investment beyond the acute episode, so to speak, in terms of reduced sick time or health care utilization, or enhanced productivity.
Additional DermWorld Resources
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