Private Payer Advocacy Spotlight: Wins and Challenges

June 2020 – Vol. 39, No. 5

The AAO-HNS is actively engaged in private payer advocacy efforts to ensure coverage and reimbursement of procedures provided by our members to improve health outcomes. The Academy relies on multiple avenues to identify coverage topics for advocacy prioritization. In addition to reaching out directly to the Health Policy Advocacy Team and sharing copies of policies via email or phone, members are also encouraged to notify staff via the online inquiry tool at https://www.entnet.org/content/practice-management-tool. The AAO-HNS Advocacy Team reviews payers’ monthly newsletters announcing changes in coverage and monitors numerous online resources. In addition, staff collaborates with the Academy’s physician leaders, as well as other medical societies to recognize detrimental policies.

Throughout the past year, the Academy has been active on a wide range of private payer coverage and reimbursement issues, including payment issues surrounding Modifier 25, coverage of functional endoscopic sinus surgery (FESS), and the use of balloon ostial dilation for treatment of chronic rhinosinusitis (BSOD). Following an extensive review process by multiple AAO-HNS Committees and the Physician Payment Policy (3P) Workgroup, the AAO-HNS submitted responses to seven BlueCross BlueShield Association (BCBSA) Evidence Street reviews:

  • Implantable Bone-Conduction and Bone-Anchored Hearing Aids
  • Cochlear Implant
  • Eustachian Tube Balloon Dilation
  • Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis
  • Middle Ear Implantable Hearing Aids
  • Steroid-Eluting Sinus Stents
  • Treatment of Tinnitus

By providing clinical input on these evidence reviews, the AAO-HNS had an opportunity to directly impact the clinical evidence that will be assessed in future medical coverage policies by BCBSA member plans.

Functional Endoscopic Sinus Surgery

In November 2019, in response to comments submitted by the AAO-HNS, United Healthcare revised its FESS medical policies. The revisions include the addition of the CT finding of opacified sinus to the chronic sinusitis criteria and the removal of the use of an independent radiologist for interpretation of CT scan findings from documentation requirements. Additionally, in March 2020, Academy staff conducted a telephone meeting with Aetna to discuss our concerns surrounding FESS reimbursement denials.

Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis

In response to outreach by numerous Academy members regarding payer denials of BSOD procedures, the AAO-HNS has been active in fighting policies that deem BSOD to be a noncovered service. On February 5 the AAO-HNS sent comments to BlueCross BlueShield’s Federal Employee Program opposing its medical policy designating BSOD as experimental/investigational. The comment letter highlighted the AAO-HNS Position Statement and Clinical Consensus Statement on BSOD, as well as provided extensive literature support demonstrating the procedure as consistent with the standard of care.

Modifier 25 Policies

Last summer the Academy sent a letter to Anthem expressing our strong opposition to its revised modifier 25 reimbursement policy. According to the policy, Anthem may deny an E/M service with modifier 25 billed on the same day of a related procedure when there is a recent service or procedure for the same or similar diagnosis. The Academy also sent a letter to Anthem BCBS of Virginia expressing our strong opposition to a modifier 25 reimbursement policy that mirrored Anthem’s national policy.

The AAO-HNS comment letters cited flaws with the rationale used by the companies in developing these policies. We called on Anthem and Anthem BCBS of Virginia to immediately reverse their policies by providing full reimbursement for all clinically appropriate E/M services. The letter also requested clarification on two issues: the definition of recent or related procedures and what is considered the same or similar diagnosis.

Members experiencing coverage and reimbursement denials are encouraged to reach out to the Academy’s Health Policy Advocacy Team, so the AAO-HNS can continue to fight for appropriate coverage of otolaryngology-head and neck surgery procedures.

To stay up to date on the latest information from the Academy’s Health Policy Advocacy Team, bookmark https://www.entnet.org/trending-topics.