The Executive Board of the North Carolina Dermatology Association holds the following positions, and demands health insurance carriers to abide thereby. The following practices lead to significant delays in care, denial of necessary treatments, and increased physical, emotional, and financial burdens on patients, caregivers, and medical providers:
- Automatic Downcoding of Evaluation and Management (E&M) Codes Must Cease Immediately
Automatic downcoding of evaluation and management (E&M) codes for outpatient visits is inappropriate and should stop immediately. This practice, often employed by insurers to reduce payments, disregards the clinical complexity and time invested by physicians in patient care. Downcoding devalues the cognitive effort required to diagnose and manage complex conditions, forcing rushed visits, misdiagnoses, or inadequate follow-up, leading to poorer health outcomes and increased long-term costs. - Denial of Treatment Claims Within the Global Period Allows Disease Progression and Must Stop Immediately
Denial of claims for treatment of biopsy-proven cancers within a global period is inappropriate and leads to delays in care and allows malignancies to progress unchecked. The global period, intended to streamline post-procedure care, should not be exploited to deny necessary treatments for life-threatening conditions. Denying claims for life-saving cancer treatments within the global period exploits a technicality to avoid payment, directly endangering patient lives and violating the principle of beneficence. - Prior Authorizations Delay Care and Overutilization Must Stop Immediately
Prior authorizations (PA) for medications on the published formulary should stop immediately, as it leads to delays and abandonment of care. Requiring pre-approval for medications already listed on an insurer’s formulary creates unnecessary bureaucratic hurdles and allows worsening of symptoms or complications due to delays or abandonment due to frustration with the authorization process. This practice disproportionately harms vulnerable populations, introduces unnecessary barriers to care, and prioritizes administrative control over patient health. - Step Therapy Protocols Delay Access to Effective Treatments and Must Stop Immediately
“Fail first” step therapy, also known as step therapy, is a practice requiring patients to try and fail cheaper or insurer-preferred treatments before accessing the physician-recommended therapy, even when evidence supports the latter as more effective. This practice harms patients in several significant ways, and prioritizes cost over clinical appropriateness, disregarding physician expertise and patient-specific needs, and can lead to preventable harm. - Arbitrary Medical Necessity Denials Ignore Evidence-Based Care Standards and Must Cease
Denial of claims by deeming treatments “not medically necessary” through use of internal guidelines that conflict with physician recommendation directly harms patients by ignoring evidence-based standards. These denials prioritize cost savings over patient care, leading to significant harm through delayed treatments, prolonged suffering, and increased health risks. AI driven, often arbitrary denials based on opaque criteria undermine clinical decision-making and patient autonomy, prioritizing profits over evidence-based care.
Call to Action
To protect patients and preserve the integrity of healthcare delivery, insurers must cease placing profits before patients- ending cost-cutting practices that compromise clinical necessity is essential to protect lives and preserve the integrity of our healthcare system. We advocate for:
- Immediate cessation of automatic E&M code downcoding.
- Elimination of claim denials for biopsy-proven cancer treatments within the global period.
- Removal of prior authorization requirements for formulary medications.
- Cessation of step-therapy protocols that serve only to delay care.
- Cessation of denials based on arbitrary and outdated standards of medical necessity.
- Transparent and fair reimbursement policies that reflect the true cost and value of physician services.
- By addressing these issues, insurers can reduce barriers to care, prevent disease progression, and improve patient outcomes. Failure to act perpetuates a system where financial considerations supersede human lives, ultimately harming the very individuals the healthcare system is meant to serve.
If you have questions or feedback regarding this position statement, please contact [email protected].