Deep roots

By Andrea Niermeier, Contributing Writer, October 1, 2025

Patient care is often a team effort, but rapport sustains that care far beyond the walls of the practice or institution. The American Academy of Dermatology Association (AADA) views its mission in advocacy as an alliance with physicians, supporting and safeguarding their right to deliver timely and quality care without unnecessary obstacles.

Successful advocacy depends on a network of core relationships. Lou Terranova, MHA, the Academy’s associate director of health policy and payment, highlighted, “While our focus is to assist and help our members — to keep them informed on what’s happening in payer advocacy in terms of new policies or procedures — we also work to maintain dialogue and relationship building with the private payers.” He pointed out that the AADA has quarterly calls with national carriers not only to stay abreast of information but also to strengthen those connections.

“The payer advocacy strategy seeks to develop those payer relationships and position the Academy as a resource,” Terranova explained. United Healthcare and Anthem, two of the largest commercial carriers, routinely share with the Academy potential clinical benefits coverage policy changes that may impact dermatology for subject matter review and input. “It is a lot easier to have those types of discussions before a policy is implemented, but it takes a while to develop that trust.”

By engaging with private payers and even employers, along with collaborating with state and local advocacy groups, the AADA strives to build a comprehensive community that fulfills the needs of both dermatologists and their patients, addressing relevant issues related to dermatology, including modifier 25 payment reductions, evaluation and management (E/M) downcoding, prior authorization denials, and immunohistochemistry (IHC) policy, among others.

Partnering with local allies

Modifier 25 reduction is a top issue for the AADA because dermatologists often provide an E/M service and perform a minor procedure in the same visit. David Harvey, MD, FAAD, past member of the Academy’s Patient Access and Payer Relations (PAPR) Committee, commented, “A patient may come to their physician with acne vulgaris, but the physician also sees a mole on their back that should be tested. For some private payers, diagnosing and treating that secondary concern has to be authorized ahead of time. Physicians, who can be booked out for months, must sometimes decide between a delay in care or the risk of not getting paid.” Terranova explained that while dermatologists are frequent users of modifier 25 for efficiency, it has drawn the scrutiny of not only private payers but also the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG).

Payers like UnitedHealthcare (UHC), Elevance Health, and Aetna have in place policies that reduce payment when modifier 25 is used. “Many private payers incorrectly perceive evaluation and management services together with a minor procedure as having overlapping services. However, any overlap of service is already taken into account,” he added. The AADA successfully advocated for Cigna to rescind its proposed modifier 25 project, which would have required submission of office notes every time modifier 25 was reported — adding a significant undue burden on physicians.

“Many private payers incorrectly perceive evaluation and management services together with a minor procedure as having overlapping services. However, any overlap of service is already taken into account.”

Terranova recounted more recent wins with some of the regional Blue Cross Blue Shield plans. Earlier this year, Regents Blue Cross Blue Shield, a carrier for states in the Pacific Northwest, announced plans to implement a modifier 25 payment reduction policy, and the AADA was successful in getting them to rescind the policy before it was implemented. Similar campaigns involving Blue Cross Blue Shield in North Carolina and Blue Shield of California have also been successful.

Despite these victories, Terranova pointed out that carriers may proceed with their policies, and he underscored the need for ongoing advocacy initiatives. Despite strong Academy advocacy, carriers were implementing modifier 25 payment reductions in Massachusetts. The AADA supported the Massachusetts Academy of Dermatology regarding proposed legislation to restrict payers from implementing modifier 25 payment reductions. Additionally, the AADA is actively responding to reports of increased denials and requests for supporting documentation from Aetna and continuing to monitor concerns with UHC’s “Smart” edit program, which may erroneously reduce modifier 25 payments.

“We strive to be vigilant,” Terranova emphasized. “Ideally, we would receive prior notification of changes. We monitor carriers and work closely with our state dermatology societies. Often, they have contacts and relationships at the local level to successfully work with a state-based carrier.” He further suggested that AADA members can be important advocates by using available Academy-developed coding resources and appeal letter templates, and by documenting medical necessity clearly and appropriately. “Advocacy doesn’t exist in a vacuum. When members report issues such as modifier 25 payment reductions or downcoding, they help us identify systemic problems and prioritize our advocacy efforts.”

Engaging private payers

Advocacy efforts built on relationships with private payers are essential for practices to continue delivering high-quality care. Upon learning that Aetna was denying claims using modifier 58 for skin cancer removal, the AADA reached out to the carrier with examples from members of inappropriate denials. The insurance carrier fixed its mistake and implemented training for its claims processing team on modifier 58 to avoid future incorrect denials. Dr. Harvey expressed the importance of bringing these issues to private payers. “Getting the payment physicians are owed is crucial. These are not just payments to the physician. They go to the practice — paying staff and keeping the doors of the practice open.”

Another concern for dermatology advocates regarding proper physician payment is E/M leveling programs and downcoding. E/M coding changes in 2021 allow medical billing for E/M codes for certain levels of care based on time and medical decision making.

However, Dr. Harvey explained that insurance companies often make the judgement of overpayment, at times using pre-2021 E/M policy, and downcode the claim without notifying the physician or reviewing supporting documentation. “Some insurers feel like the work effort isn’t mandating the level of reimbursement, but physicians are following current Medicare guidelines.” In addition to downcoding, some physicians have been flagged and targeted for more frequent review by billing at a higher level more often than peers in their area.

The AADA has engaged the national insurance carriers to ensure they are appropriately applying the standard criteria for reporting the codes in question. Terranova clarified, “Our policy is that payers should not be arbitrarily reducing the level of code without a thorough record review.” Advocacy by the AADA helped temporarily delay the relaunch of Elevance Health’s E/M leveling program, resulting in the carrier revising its program based on identified concerns. While the carrier has launched its program, the impact appears to be much less than it would have been, based on the Academy’s monitoring of the issue. Additionally, the AADA is in ongoing discussions with Aetna and Cigna about their Claim and Code Review programs, as well as UnitedHealthcare’s “Smart” edit program, to ease administrative burden to practices.

Dr. Harvey stressed, “If you document well, you should get paid for your time and effort.” However, he admitted the toll that the appeals process can have on a physician. “If software assesses a claim and issues an automatic reduction, the physician has to pay staff to appeal, costing the practice time, money, and energy.”

Collaborating on systemic challenges

After hearing from a dermatologist member in Iowa about Caremark (the Blue Cross carrier for Iowa and South Dakota) denying immunohistochemistry (IHC), the AADA learned that Caremark issued these denials using guidelines established by EviCore, a utilization management company. This policy deemed IHC stains not medically necessary when associated with skin lesion codes.

After learning about these guidelines, the AADA’s Dermatopathology Committee developed a new position statement on IHC utilization, supporting the advocacy efforts with payers to reverse blanket denials. Dr. Harvey acknowledged, “It is important to preserve the clinical autonomy of dermatopathologists who use the stains to confirm, rule out, or revise diagnoses. By adhering to American Society of Dermatopathology (ASDP) Appropriate Use Criteria, they can apply clinical judgement and diagnostic nuance to patient care.”

Due to Academy advocacy, Caremark agreed to override the EviCore recommendations. The AADA then facilitated a meeting with EviCore resulting in EviCore updating its guidelines, removing the IHC coverage restrictions and rescinding language denying reimbursement. As EviCore guidelines are used by over 20 carriers including several Blue Cross Blue Shield plans, this change impacted many health plans benefiting dermatologists.

Alleviating undue burdens

Terranova noted prior authorization reform is another priority issue for the Academy advocacy. “The Academy’s position regarding prior authorization is that it should be created in such a way that it does not interfere with timely access to care nor create an undue burden for physicians. Often, a broad-brush prior authorization requirement across all cases does not make sense,” Terranova added. In recent years the AADA has had success in advocating to private payers regarding its prior authorization requirement for tissue transfer or repair.

“The Academy’s position regarding prior authorization is that it should be created in such a way that it does not interfere with timely access to care nor create an undue burden for physicians.”

As a result of AADA advocacy efforts on this issue, United Healthcare agreed to amend its policies on prior authorization for Mohs and adjacent tissue repair.

Not only do prior authorization denials affect surgical procedures in dermatology, they also interfere with the drugs that physicians prescribe. When the AADA learned that Blue Shield of California (BSCA) was restricting dermatologists from prescribing omalizumab (Xolair), resulting in prior authorization denials, the AADA successfully advocated for BSCA to reverse this policy.

Providing critical feedback

When Change Healthcare (a UnitedHealth subsidiary) was breached in February 2024, it disrupted pharmacy and practice operations, eligibility determinations, claims processing, and prescription refills with dermatology practices and institutions unable to submit claims or be paid. “Fortunately, because we had established contacts and relationships with UnitedHealthcare, we were able to react quickly on behalf of our members and advocate for workarounds and assistance to physician practices,” said Terranova.

Reaching out

More recently, the AADA built relationships beyond health plan carriers, working with employers who purchase health care benefits. Terranova noted that this is increasingly important as many employers are now self-insured. In this model, employers hire a health plan carrier to pay the bills, but the employer carries the risk and pays for the health care services utilized by their employees. “Carriers will often tell us that they are using a utilization or cost control measure because that is what their clients want. It occurred to us that to effectively advocate for our members, we need to go directly to the employers.”

While there are several thousand more employers than health plan carriers, most employers are part of a nonprofit health care coalition or business group on health. One of the largest is the Midwest Business Group on Health (MBGH) based in Chicago with over 150 companies including McDonald’s Corporation, State Farm, the Boeing Company, and United Airlines. The AADA engaged the MBGH to educate on the nuances of dermatologic care, advocate for access to board-certified dermatologists, endorse benefits coverage for medically necessary dermatologic care, and reveal where their policies may inhibit access to appropriate care.

This resulted in a work group with MBGH that included large, mid-size, and small private and public employers to address concerns regarding skin cancer, psoriasis, and atopic dermatitis. Two new action briefs were developed by the group that explained what employers can do to enhance benefits coverage for these diseases. Terranova acknowledged, “One of the eye openers for the work group panel was the cost of medications and treatments. When an employer has a prior authorization program, they have to look carefully at its impact in terms of the number of appeals and overturned denials because inhibiting access may actually raise costs due to delay in treatment.”

In December 2024, MBGH sponsored a webinar — presented by Dr. Harvey and Alexandra Flamm, MD, FAAD — to MBGH members and guided them on benefit plan design in support of prevention and treatment with board-certified dermatologists. Currently, the AADA is assessing the impact of MBGH resources before reaching out to other regional business groups on health.

This sustained effort includes the contribution of employers and dermatologists as well. “We advocate because we care,” Dr. Harvey emphasized. “We are physicians first and our main goal is to help. We do that by giving a voice to those who can’t speak up, especially our patients. Having bad policies that delay care and hamper our ability to fight for them is like being a boxer with one arm tied behind our back: We can’t be as effective.”

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