ACAAI’s Advocacy Council is excited to announce a key partnership with Congressman Bob Onder, MD, FACAAI (R-MO-3) — a practicing allergist and strong ally for our specialty in Congress. Together, we are advancing the Allergy and Asthma Patient Protection Act to address the growing burdens imposed by commercial payers on allergy/immunology practices. The official introduction of this act is expected soon. This legislation, if passed, will help address many administrative and reimbursement issues that are unique to the allergy specialty. The bill will safeguard reimbursement for essential services like allergy immunotherapy (allergy shots), reduce administrative burdens, and ensure patients maintain access to preventive allergy and asthma care that improves outcomes and lowers overall health care costs.
While the bill is still being finalized, building bipartisan support for this legislation in the House and Senate will be the cornerstone of our Strike Force advocacy efforts on Capitol Hill this week. We will be asking for your help to build momentum and secure co-sponsors soon.
Why this matters: Immunotherapy as preventive care
Allergy immunotherapy is the only proven disease-modifying preventive care. It reduces allergic rhinitis symptoms, prevents the progression to asthma, decreases asthma exacerbations, cuts ER visits and systemic steroid use, and lowers downstream health care costs. Yet commercial payers continue to erect barriers, such as arbitrary denials, unfair audits, and slashed reimbursements, that threaten independent practices and patient access.
Without action, more practices will close or limit services, harming patients who rely on us.
Key provisions: Here is what we are fighting for
The proposed bill will outlaw unfair practices and mandate fair coverage and processes. These are some of the provisions we have suggested:
- Require all health plans to follow the CPT definition of 95165.
- Prohibit health plans from discounting reimbursements for CPT Code 95165 if an extract vial – 95165 – contains diluent. Diluent is necessary to ensure that patients’ immune systems gradually build up to the strength of the antigen.
- Require that all health plans pay for the build-up phase of allergy immunotherapy.
- Prohibit health plans from establishing medically unlikely edit (MUE) limits, volume-based reimbursement caps, predetermined aliquot sizes, or other quantitative restrictions that are inconsistent with CPT descriptions or recognized clinical standards of care.
- Ensure consistency with coverage requirements for CPT code 96165, require that all payers allow 95165 to be billed on the date the vial is made, the date it was opened (shot given to the patient), or the date it was shipped.
- Allow clinical decision-making to justify the number of allergens tested for allergy immunotherapy codes.
- Reimburse skin testing and spirometry on the same day as an office visit. These tests are often necessary to inform further treatment of the patient. Limitations of these services force patients to come back for additional visits, delaying care and causing additional burdens for both patients and practices. Insurers commonly deny these services with reasons such as “no medical decision making” or “no interpretation,” even when supportive documentation is present.
- Skin and serum allergy testing are both appropriate when clinically indicated and should not be denied as “duplicate” services.
Additional priorities include limiting recoupments (often automatically deducted), restricting supplemental documentation demands, and prohibiting automatic downcoding of E/M claims.
Take Action: Contact your representatives
The Strike Force needs your voice. Reach out to your representatives in Congress — especially those you know personally — and urge them to co-sponsor this important legislation when it is introduced. We will let you know when the bill is introduced in the House (and eventually in the Senate) so that you may contact a broader group of Congress members, including acquaintances and those you know professionally, asking them to support the Allergy & Asthma Patient Protection Act.
In your messages, share your stories of how payer barriers affect your practice and patients. Emphasize the preventive value of immunotherapy in reducing asthma exacerbations, ER utilization, and costs.
We will update you when we have more detailed information.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
