The College’s Advocacy Council has taken a multi-faceted approach to payers’ burdensome and unreasonable requests and policy changes that hinder the ability of patients with allergic conditions to obtain relief. We launched the Payer Education Campaign (PEC) to help you – our members.
Breaking News:
The College’s Advocacy Council has secured a meeting with CMS to discuss changing its definition of a dose. Watch College Insider for future updates!
First, we developed a consensus paper on CPT 95165, which guides payers on what are reasonable documentation requests to support the reporting of services you’ve provided to patients: Guidance for the evaluation by payors of claims submitted using Current Procedural Terminology codes 95165, 95115, and 95117. (This Annals article has open access.)
Second, a letter, accompanied by the guidance, was sent to the top 25 health insurance carriers. A separate communication was sent to more than 200 media contacts, stressing the serious access-to-care issues patients face when their allergists are not paid and/or face long payment delays.
Third, we’ve sent multiple letters to Anthem of California expressing our serious concerns regarding their excessive audits and improper pre-payment denials of allergen immunology claims. We urged “…Anthem to amend its current medical review process and, instead, evaluate claims for allergen immunotherapy services described by CPT codes 95165, 95115, and 95117 in accordance with the guidance…” mentioned above.
Fourth, we’ve contacted UnitedHealthcare (UHC) about their recent policy change that follows a version of Medicare’s definition of a dose of antigen extract for immunotherapy, but still uses the CPT relative value. We’ve requested that they rescind the policy and revert to CPT’s definition of a dose. We spoke with legislators on Capitol Hill during our recent Strike Force meetings and Congressman Robert Onder, MD (R-MO-03) has met with UHC about this issue on our behalf.
Fifth, we’ve been successful with three Medicare Administrative Contractors (MACs) – Palmetto (Alabama, Georgia, North Carolina, South Carolina, Tennessee, Virginia (excluding Arlington County, Fairfax County, and Alexandria), and West Virginia), Noridian (Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Montana, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington (state), and Wyoming) and National Government Services (Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin), and we are confirming by email with a fourth MAC that has verbally agreed to cover dilutions. Once confirmed, Medicare will have agreed to pay for dilutions in 42 states! There are only two MACs left to approach, and we have begun our engagement with one of them.
While much has been accomplished, there is still so much more to do! We’ll continue to fight for you (and the fair reimbursement you deserve), the specialty (to keep it sustainable) and our patients (to provide access to the care they so greatly need and deserve).
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
