Payment advocacy spotlight: Wins and recent actions

June 2018 – Vol. 37, No. 5

The AAO-HNS ramped up its private payment advocacy efforts this year due to increased actions by payers to reduce/eliminate physician reimbursements or limit their coverage decisions. Strategic efforts were re-aligned to more actively advocate for full coverage and appropriate payment for patient procedures. After Anthem announced its decision to rescind its draft policy on Modifier 25, the Academy also was notified of another payment advocacy win from United Healthcare (UHC)!

Last November, the AAO-HNS submitted a comment letter in response to UHC’s review request on its “Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable” medical policy. The Academy asserted the inaccuracy of the policy being reviewed, given that the use of bilateral bone-anchored hearing aids is proven and medically necessary for sensorineural hearing loss in both ears. The AAO-HNS requested that UHC revise its Coverage Rationale to provide clear and accurate clinical indications for the appropriate use of bone-anchored hearing aids. UHC updated its policy this spring, integrating the Academy’s recommendations and removing inaccurate coverage criteria language in the policy. The policy became effective April 1, 2018.

As part of these intensified efforts, since January 2018, the AAO-HNS also has worked on many other payer advocacy efforts, submitting comment letters to multiple private payers, including Anthem, various Blue Cross Blue Shield plans, and UHC. The following coverage topics have been the focus of our advocacy efforts:

  • Balloon Dilation of the Eustachian Tube
  • Cochlear Implants
  • Drug-Eluting Devices for Maintaining Sinus Ostial Patency
  • Antibiotic Therapy
  • Sex Reassignment Surgery
  • Cone Beam Computed Tomography Reimbursement
  • Tapering of Fee-for-Service Rates

The AAO-HNS is awaiting responses from the private payer community on the above-named issues and will notify Academy membership if a change in coverage is confirmed. To read more about these and other payment advocacy wins, visit http://www.entnet.org/content/advocacy. If you have questions regarding private payer advocacy efforts or your local challenges, contact pmtadvocacy@entnet.org.