Policy Type

Every year you hassle with the insurance renewal process 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, High deductible HSA’s and HMOs. To address each type of policy from the possible 20,000 insurance policies in the US today is not practical. But here is a rule of thumb regarding insurance policies and Total Body Photography:

• Indemnity – The insurer is charging you top dollar. 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. More than $500 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 the service internally, or you may be able to appeal to obtain the MoleMapCD out of network.

The DigitalDerm Response:

With the state of insurance reimbursement today, DigitalDerm evaluated the needs of our patients and developed different methods to make Total Body Photography affordable to everyone. In addition to our insurance filing services, we have enacted a number of payment options to meet your needs:

• Checks and Credit Cards – You may pay for your MoleMapCD with either a personal check or credit card (Master Card, Visa, American Express or Discover) at the time of service.

• Credit Card Installment Plan – This was developed for the individual on a budget. There is no interest charged for either option. The six month option does require us to charge a $3.00 per payment service fee. You can choose your option at the time of scheduling. Here are the particulars:

• Three Month Option – An initial payment of one quarter (1/4) of the total MoleMapCD cost at the time of scheduling, with three equal payments to be charged to your credit card on the 20th of each month. This amounts to $73.75 per payment.

• Six Month Option – An initial payment of one seventh (1/7) of the total MoleMapCD cost at the time of scheduling, with six equal payments to be charged to your credit card on the 20th of each month. This amounts to $45.14 per payment.

Procedure Classification

Insurers in an effort to limit procedures to the proper subset of patients (For the MoleMapCD, see Insurance: Total Body Photography page) 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. Obtain a written copy of their Medical Policy for the procedure. 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, 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 exhaust 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 is does not mean they will not consider it for reimbursement. With the submission of a properly documented patient medical history, they may reimburse some or all of the cost if, and only if, the patient appeals their initial denial. In some cases you may also have to exhaust their stated appeal process. The odds are greater for reimbursement with this classification versus Investigational/Experimental.

The DigitalDerm Response:

In either classification, DigitalDerm believes we have a commitment to you to make every effort to obtain reimbursement for you. Because we absolutely believe Total Body Photography is an essential tool in the early detection of melanoma, we will file your insurance claim for you with any benefits paid directly to you. If coverage is denied, we will assist you in the appeal process by providing you with a tailored package of, appeal letter(s) and supporting articles for you to submit to your insurer. Typically, the appeal process will require you to follow-up with your physician and obtain a detailed medical history and treatment record. After that, dogged persistence is the key to success.

Although filing for an appeal may not guarantee you’ll receive reimbursement, it will increase your chances to the greatest extent dictated by your insurer and benefit levels. A point to consider: insurers know that 50% of all denials are never appealed because the patient lacks the time and will to contest their decision.

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 their associated 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 60% of precertification approvals were denied and accompanied by one or several of the possible 4000+ denial codes the insurance industry has at its disposal.

The DigitalDerm Response:

Since the insurers could not be counted on to deliver on their own precertification approval process, we examined the cost associated with it. We found that the process in some cases required up to eight weeks to complete, with the final outcome being denial of benefits after an initial approval. The only way we could deliver greater value to our patients was to eliminate the process and pass along the associated administrative cost. Therefore, on April 1, 2007 we lowered our service price from $395.00 to $295.00.

And we (still) continue to file your insurance claim for you and assist you in your appeal efforts.