DigitalDerm, Inc - Total Body Photography Coding

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Insurance: The Industry Process

Policy Type

Every year you must evaluate the insurance policy provided by your employer or individually through your health insurance sales representatives. To keep a competitive edge, most insurers offer a myriad of products: indemnity, PPO, POS, HSA, HMO, etc. To address every type of policy from the possible 20,000 US insurance providers is not practical. But here is a rule of thumb regarding insurance policies and Total Body Photography:

Indemnity – If you have this type of policy, you want the best that medical care can provide. This policy type lets you decide your treatment options. The tradeoff is higher priced premiums. Because of this, odds are you are covered – they want to keep you happy!
PPO and POS – The insurer wants to provide you a decent insurance level, but has a keen eye on costs. If your deductible is $500 or less, you have a good chance of obtaining reimbursement. $500 to $1000 deductible – plan to use the appeals process and be persistent. Once you get over the $1000 deductible range, the insurer may become less willing to reimburse if you’ve met your deductible or they’ll approve it if your deductible hasn’t been met.
HSA’s – They’ll probably say it’s a covered benefit – but with the high deductible limits – you’re paying anyway! At least you’re paying with pre-tax monies and you’re moving closer to meeting your deductible.
HMO’s – The nature of HMO’s precludes payment for any service not contracted directly with the HMO. DigitalDerm is not contracted with any HMO’s at present. However, you may want to check with your benefit’s administrator. They may provide a rudimentary form of the service internally (less pictures, lower resolution, snapshots, etc), or you may be able to appeal to obtain the MoleMapCD out of network.

Procedure Classification

In an effort to limit procedures to the proper subset of patients (For the MoleMapCD, see Insurance: Total Body Photography page) insurers will focus on procedure classification. If an insurer plans to deny or delay reimbursement, they will list the procedure as:

Investigational/Experimental – As the title indicates, the insurer does not believe there is sufficient scientific evidence to prove the procedure is beneficial to the patient. Be aware that the evaluation process to prove benefit is not an open forum. You, as the consumer have little or no recourse but to accept their verdict. The technical panel who evaluate procedures for the insurer can “pick and choose” reference articles and studies to underwrite their position. They will use the term “evidence based medicine” to limit the information they consider valuable. However, when bolstering their position not to pay, they will accept non evidence based medicine arguments, while ignoring these same types of articles that indicate the benefits of TBP. Your first step is to obtain a written copy of their Medical Policy. In the case of Total Body Photography, do not be surprised if the validation for denial of coverage is based upon other skin imaging techniques such as dermoscopy, ELM, DELM or ultrasonography. Although Total Body Photography is a baseline set of images documenting the whole skin area and utilized by both the physician and patient, the others involve the physician evaluation of a single mole or a magnified view of a single mole – two wholly different techniques! By combining these procedures into a single category the insurers can minimize the efficacy of Total Body Photography. Your only recourse is to utilize their stated appeal process. In addition to submitting medical notes from your physician, supporting reference articles and materials may also be required.

Medically Not Necessary – The insurer does not believe this procedure to be critical or necessary to your care. This does not mean they will not consider it for reimbursement. With the submission of a properly documented patient medical history and a note of medical necessity from your physician, they may reimburse some or all of the cost. However they will only pay your claim if you appeal their initial denial. In some cases you may also have to go further and utilize their complete appeal process. Overall, the odds are greater for reimbursement with this classification versus Investigational/Experimental.

Precertification of Benefits

Precertification of benefits – This is another insurance tool to “insure” patient compliance. Many imaging procedures, i.e., X-Ray, CT, MRI, etc., require precertification of benefits before the patient is scheduled for the procedure. This is necessitated because of the insurer’s multiple policies with varying benefits and payment schedules. DigitalDerm previously had provided this service, until we realized the awful truth. If you listen closely to your benefits coordinator when stating whether a procedure is a covered benefit, they will always make a disclaimer to the effect: “Procedure approval is not a guarantee of payment. All decisions of actual payment of a claim will be determined only after the claim has been filed.” In essence they are telling you that even if they say a procedure is covered, they can deny payment at any time after you submit for reimbursement. In the case of Total Body Photography, we found that over 30% of precertification approvals were denied and accompanied by one or several of the possible 4000+ denial codes the insurance industry has at its disposal. As with all denials, you must utilize their appeal process to gain reimbursement.

Insurer's Philosophy

After dealing with insurers for many years, a few have disclosed some internal (and unwritten) “business practice guidelines” that are common to health insurance providers:

Evidence Based Medicine (EBM) – EBM can be a tool or a weapon. If you are a well funded entity with millions available for R&D and large scale, multi-center clinical trials, then EBM can work to your advantage. This assumes your product or device meets or exceeds accepted efficacy and safety benchmarks. However, if you cannot afford to conduct these large scale trials, then you are basically out of luck. In essence, the insurers are telling you that they will only pay for a sure thing. Total Body Photography (TBP) could not conduct these large scale efficacy trials because no one entity was large enough nor had enough capital to underwrite them. The reason for this is simple: melanoma is not common. And because it is not common, it has been estimated that 50,000 to 100,000 patients would be needed for a conclusive trial. And some experts estimate as many as 500,000 patients would be needed. This is an unrealistic and unattainable number. Therefore, TBP has relied on smaller trials and observations that involved a few hundred or a thousand patients. Their conclusions pointed to increase efficacy in detecting melanoma earlier with higher patient involvement and better compliance with sun protection measures. At this point, you can guess the rest. Yes, insurers believe obtaining a quality, baseline set of images makes good common sense if you are trying to detect future changes. And yes, they agree future change is one of the major parameters leading to early melanoma detection. But no, the insurers cannot pay for this because you haven’t proved your point with a large scale clinical trial. And no, the insurers can’t help you conduct a trial of this magnitude because the benefit of doing so far outweighs the financial commitment. Final conclusion: whenever you must deal with these catch-22 scenarios – you will be the final payer. Common sense is no longer reimbursable, and therefore becomes your responsibility.

Appeal Mechanism – This is a mechanism of diminishing return for you and increasing return for the insurer. It applies to those procedures they consider Investigational, Experimental and Medically Not Necessary. Here’s how it works: Assume we have 100 claim submissions and the insurer initially deny 50% of them. Of these 50 rejected claims, they expect another 50% won’t bother to appeal their decision. Of the 25 remaining, they will deny another 50%, forcing the remaining 13 to file a second time. At this point, they feel that for procedures under $500, you’ll probably not consider it worth your time and effort and pay for it yourself. But if you do, you’ll not go beyond two filings, because most insurers have slipped in a little clause in your policy that states they will ultimately evaluate all denials internally for amounts less than $500. So the question becomes why appeal? The answer is simple: Insurers will only change policy if the liability and cost of not paying for the procedure outweighs the cost of doing it. At a minimum, your willingness to appeal gives you a fifty-fifty chance of being reimbursed after the first denial. But the overall cost of the appeal process for everyone who appeals will eventually cause them to change their policy. Remember: The insurer is betting you will lose interest and absorb the cost before they will have to pay.

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