Insurance Committee Report

THERE ARE A LOT OF COMPANIES COMING AROUND WITH REGENERATIVE WOUND CARE PRODUCTS. MY QUESTIONS ARE -WHAT HAPPENS WHEN THE INSURANCE COMPANY DOES NOT PAY FOR THE PRODUCT AND SHOULD YOU USE THE APPLICATION CODE ALONG WITH A DEBRIDEMENT CODE ON EACH VISIT?

These Regenerative Products (Q code products), although very beneficial to the healing process of most of your wounds, they are quite expensive. You must prior authorize all of these products with the Insurance Company BEFORE you apply the product. When you Prior Authorize, you should take advantage of the prior authorization procedure that is available through the company that you are using for the product. Therefore, if there is no payment from the Insurance Company, there should be some type of agreement with the company that can relieve you from the cost of the material. Please be cautious that in the Prior Authorization Process that you use the same coding and diagnosis that you will be using on the billing of the treatment. The Insurance Companies can delay payment or refuse payment stating that the coding was not consistent. It is also strongly suggested that you repeat these Prior Authorizations monthly if you are still using the product on a patient.

Also, it is important to note, if you have a patient that has questionable coverage for the regenerative products, you can always use them in a hospital setting if the company has authorization through that Hospital Network—this way you will not be responsible for the bill associated with the “Regenerative Material.”

You should only use the debridement code or the application code. Technically they are the same under most CMS LCDs—Therefore, you should not use 11042 for the debridement of an ulcer when you are applying a graft etc, and you are using 15275,2-etc coding.

I HAVE BEEN BOMBARDED RECENTLY WITH CHART REVIEW REQUESTS? WHAT DID I DO WRONG?

More than likely, you did nothing wrong.  All of the Medicare Advantage plans are allotted monetary stipends per patient from CMS that can be increased when they are taking care of a patient with several co-morbidities.  When you have Chart Reviews, they are usually only seeking the diagnostic portion of your note.  In some cases, they will pay you for the notes that are requested at a reasonable fee per chart. There are several third-party companies that are conducting these reviews and they usually send the requests over a fax machine.  I do not suggest that you ignore these requests but just be aware that if you have a large Medicare Advantage population, you will be receiving these requests.

THE DREADED OPEN SEASON IS HERE, WHAT ARE YOUR SUGGESTIONS ON NAVIGATING THROUGH THIS PERIOD?

Depending on your patient population, it is not uncommon that a patient will return to your office knowing that they have switched insurance carriers and do not mention it to your front desk personnel—It is a good idea to ‘run’ eligibility benefits every time a patient comes in—many offices conduct this verification on the day before a patient comes in so that if there are any foreseeable problems, the patient can be alerted before the visit. There is going to be a lot of ‘bouncing around’ over the next couple of months.  In a lot of cases, even the patient does not fully understand the type of coverage that they have.  The booklets that they give out to seniors are very confusing and many of the seniors have difficulty understanding their coverage.

Dr. Jondelle Jenkins

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s