Payer Advocacy in Dermatology
Frustrations with payers is a common source of annoyance among dermatologists. Payment rules can seem arbitrary, ever-changing, and not uniform among the various payers. Keeping track of payer requirements can be nearly impossible.
To assist members in handling these concerns, the American Academy of Dermatology Association (AADA) created the Patient Access and Payer Relations (PAPR) committee, which seeks to promote patient access to dermatologic care by addressing issues that may arise with private payers. The committee utilizes a multipronged approach to develop strategies to educate payers on the value of dermatology, addressing systematic payment issues as they arise over time, and building relationships with insurers and employers to promote coverage and payment policies allowing for the highest quality of dermatologic care. The committee is comprised of practicing dermatologists who meet regularly to help guide and implement the AADA’s payer advocacy initiatives.
Identifying payer contacts and forging working relationships is a cornerstone of payer advocacy. In addition to patient access to quality dermatologic services, fair reimbursement is always a primary concern.
Hot Topics in Payer Advocacy
How to Use Modifier −25 Appropriately—The AADA has been advocating for appropriate coverage and reimbursement for services billed by dermatologists; recent examples include assuring appropriate payment for services reported with modifier −25, which is used when a procedure such as a biopsy is performed on the same day as a separate and unrelated evaluation and management (E/M) service, such as psoriasis management. Some payers claim the concurrent nature of the services results in an overlap of office expenses such that these claims should be paid at a lesser amount; however, when procedure codes are frequently billed in association with an office visit, that overlap has already been accounted for as part of the code valuation process, negating the need for additional reduction.
The AADA PAPR committee has created numerous resources for our members to ensure they are using modifier −25 appropriately, particularly now that the US Department of Health and Human Services Office of the Inspector General (OIG) has announced a work plan to audit dermatologists claims reporting modifier −25.1 The AADA immediately formed a work group, including PAPR committee members, to develop and employ a strategy to educate key decision-makers on the correct use of modifier −25 and highlight appropriate resources to guide members. An introductory call was held with the OIG audit team to discuss the appropriate use of modifier −25 in dermatology as the OIG prepares to develop the parameters of its audit sometime in the future (AADA, unpublished data, 2021).
Working With Dermatology Societies on Payer Issues—The American Academy of Dermatology Association PAPR committee works collaboratively with members of the American Academy of Dermatology, 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. Collaboration with state dermatology societies is essential to address payer issues that impact their members and provide guidance on effective engagement with their state payers. Recent examples include working with dermatology societies in Massachusetts, Rhode Island, and Florida on strategies to advocate against modifier −25 payment reductions by insurance carriers (AADA, unpublished data, 2021). Additionally, the AADA PAPR committee has been able to provide guidance and technical support as needed to state dermatology societies, such as to the Rhode Island Dermatology Society and the Pennsylvania Academy of Dermatology and Dermatologic Surgery to address payer quality metrics and access to laboratory services, respectively (AADA, unpublished data, 2021).
Patient Access to Affordable Treatments—American Academy of Dermatology Association payer advocacy is anchored to published position statements and clinical guidelines. To strengthen AADA advocacy on payer-mandated drug substitutions for nonmedical reasons and to preserve patient access to medications, the PAPR committee collaborated with the American Academy of Dermatology’s Drug Pricing and Transparency Task Force to update the AADA Position Statement on Patient Access to Affordable Treatments2 to address this issue. Essentially, patients who are stable on a medication should be allowed to keep using the same medication without payers changing their coverage for nonmedical reasons or by offering financial incentives to switch.