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Victory! UHC changes Mohs prior authorization and multiple procedure payment reduction policies

Illustration for Impact Report Fall 2022

As a direct result of our advocacy efforts, UnitedHealthcare (UHC) has agreed to amend its policies on prior authorization for Mohs and adjacent tissue transfer, and multiple procedure payment reduction. These changes will improve payment for dermatologic services for appropriately reported services, which were being inappropriately reduced under UHC policy.

The AADA pointed out that UHC’s prior authorization requirement for Mohs and adjacent tissue transfer is burdensome and unproductive for both payer and physician. UHC agreed to change its policy and will waive the prior authorization requirement if adjacent tissue transfer is billed in association with a Mohs procedure code. UHC plans to implement the change in early 2023.

UHC will also adjust its multiple procedure payment reduction policy after AADA Patient Access and Payer Relations Committee leadership argued that the insurer’s policy does not fully align with that of CMS. Under Medicare, the payment reduction does not apply if surgeons of different specialties are each performing a different procedure (with specific CPT codes). In such cases, neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). However, UHC had been applying the multiple procedure payment reduction when procedures were performed by two physicians of different specialties, but under the same Tax Identification Number (TIN), on the same patient on the same day.

The revised UHC policy will no longer apply a payment reduction when a Mohs surgery (CPT codes 17311-17315) and a claim for a surgery service from a different CPT code range are submitted by different specialties, regardless of the TIN.

UHC will complete its claims edits by the end of the first quarter of 2023. In the interim, UHC will monitor impacted claims for an override; however, if a payment reduction is applied for surgeries by different specialties as described above, dermatologists should appeal through the UHC appeal process. If the appeals are not resolved, AAD members should report it to privatepayer@aad.org.