Relationships With Major Insurance Carriers—Integral to the PAPR committee’s private payer advocacy success are our proactive relationships with major insurance carriers. In 2021, the PAPR committee established quarterly dermatology-specific meetings with the major national carriers. In nurturing these relationships, the PAPR committee has been able to expand on opportunities to provide payer policy reviews as well as identify dermatologists as subject matter experts available to payers to assist with physician panels or policy reviews. These regular contacts also have proved beneficial in addressing issues raised by members; a few such examples include when one major payer reversed its denials on dermatologists’ claims for Current Procedural Terminology code 88304 (surgical pathology, gross and microscopic tissue exam) after it was brought to their attention by the AADA (AADA, unpublished data, 2021). This payer worked with its external vendor to correct the denials. When the AADA learned that another major payer was improperly denying payment for claims for 1 stage of Mohs micrographic surgery reported using Current Procedural Terminology code 17311, we worked with contacts at this payer to resolve the issue. They were receptive to our concerns and readily researched the issue. Leadership of the PAPR committee continued working with the AADA coding team and this payer to develop training guidance to prevent future denials, and the payer has reviewed prior denials and reprocessed claims for payment (AADA, unpublished data, 2021).
E/M Coding Issues
Another issue under consideration by several national insurers is E/M-level reassignment. Payers are reviewing claims from providers who are identified as coding at a higher E/M level as compared to their specialty peers. Some insurance carriers are using proprietary algorithms that attempt to link specific diagnoses to certain levels of E/M, triggering claim edits within their claim processing systems (AADA, unpublished data, 2021). The carrier will then either deny the claim or adjust reimbursement to a lower-level E/M service. In discussions with a national carrier on its E/M Leveling Program, the AADA has offered to work with them on appropriate E/M documentation and reporting (AADA, unpublished data, 2021). The AADA also has extensive member resources for guidance on E/M reporting as well as preparing for audits and appealing payer downcoding developed by the coding staff in conjunction with the Coding and Reimbursement Committee.
Recent Efforts From the AADA
Within the AADA, the PAPR committee works closely with the coding, practice management, and regulatory teams to address payer issues and develop resources for members. Recent examples include resources for dermatology practices on the No Surprises Act and what practices need to do to comply (AADA, unpublished data, 2021). The PAPR committee also works collaboratively with other AADA committees and task forces on payer issues as needed; for example, the PAPR committee has been working with the Dermatopathology Rapid Response committee to address member concerns regarding access to the pathology laboratory of their choice. Many payers are seeking to consolidate and save money by requiring the use of preferred laboratories, which impacts patient access to physician office laboratories and physician-recommended reference laboratories. The AADA, along with other medical specialties, has advocated for payers to not create a restrictive network of pathology laboratories within their provider networks and to support dermatologists’ laboratories of choice (AADA, unpublished data, 2021).
Within the payer space, the role of employers in impacting payment and coverage policies continues to rise. In 2021, the AADA leadership approved the employer outreach strategy to engage employers. The overall objectives are to advocate to employers on the value of dermatologic care and access to care provided by board-certified dermatologists. This is a long-term project that is just getting underway (AADA, unpublished data, 2021).
Payer Resource Center for AADA Members
To ensure that AADA members have the resources they need to advocate with payers as well as to keep the PAPR committee aware of emerging payer issues, the AADA created a new private payer resource center for members (https://www.aad.org/member/advocacy/priorities/payer-advocacy), which assists AADA members with common dermatologic concerns with insurers as well as contracting issues. The website also includes an email address for members to report payer issues (privatepayer@aad.org). This information helps the PAPR committee identify and prioritize issues of concern.
Final Thoughts
Given the control that private insurance companies exert over the health care that dermatology patients can access, the AADA in general and the PAPR committee specifically play a valuable role in advocating access to care for dermatology patients.