Four Ways to Navigate Reimbursements for Advanced Technology—And Why It’s Worth It

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By Blair Lock and Erica Karlson

"Nothing worth having comes easy."

Theodore Roosevelt certainly didn't have health insurance reimbursements in mind more than a century ago. But his sentiment applies just the same, and harnessing that can-do spirit has propelled the O&P profession forward to improve the lives of countless people in the limb difference community.

When it comes time to cover the costs of constantly evolving medical devices, however, we know that payers regularly deny compensation submissions for advanced O&P devices—regardless of how effective these devices are at enabling users to return to work and their daily activities.

Prosthetic clinics that deliver advanced medical devices deal with denials every day. From helping our partner clinics obtain reimbursement for our technology, we have learned how to guide preparation—and successful submission—of claims for a variety of device configurations. This includes the difficult-to-navigate arena of upper-limb technology.

Whether you're a member of a national or regional billing department, or the owner of a boutique practice, here are four helpful ways you can approach and submit for reimbursement success.

1.    Understand your client's insurance benefits.

Even with a rock-solid, well-documented claim, payers will almost always deny a first submission for advanced prosthetic device reimbursement. Their reasons for denials differ—sometimes even when rejecting similar claims—which can be frustrating for the submitting practitioner.

You can get ahead of the game by understanding the payer's medical insurance policy for your patient from the beginning. To gain an advantage early on and understand if there are policy exclusions, look for opportunities within the policy's services and benefits to which the patient is entitled. Unfortunately, policies vary widely; you need a broad knowledge base and distinct experience in this world of reimbursement management to crack the code.

Payers may write exclusionary language into their policies, such as declarations that they won't cover a myoelectric-controlled hand with multiple moving digits—before they even consider individual cases. Or, they'll deem that such technology is investigative or experimental, with no awareness of the multiple peer-reviewed studies that support increases in patient's abilities to perform activities of daily living with these advanced devices.

Complicating matters, the Centers for Medicare & Medicaid's establishment of new DMEPOS codes does not always keep up with the modern pace of technological development. In contrast, the US Food and Drug Administration (FDA) monitors and assures the safety and efficacy of advanced prosthetic devices more every day. So waiting for a new code may not be a reliable plan and is likely to lead to a disservice to your patients who could benefit from—and in fact, need—that device that falls under the miscellaneous L-Code.

To address this complicating factor, leverage your resources as you navigate the stormy waters of health insurance policies. Determine what materials will help your case. You may need detailed guidance, checklists, academic backup, or coding insights, or a range of ever-updating forms and filings. On the bright side, some policies entitle patients to a dedicated case manager who can validate and advocate on behalf of the patient to the insurance company.

2.    Document in advance; anticipate a denial.

It's likely you've worked diligently with your patient and the physician care team to determine when an advanced device is the ideal option for the patient's function and lifestyle. Unfortunately, health insurance carriers frequently overlook that thinking and, very often, automatically deny the claim. Do not be discouraged when your comprehensive pre-authorization submission is denied. Start promptly on your appeal and consult with the experts to craft it.

Once you receive any denial, the clock starts ticking. You'll have a limited time (often 30 days) to file an appeal. This is where another side of preparation comes into play. Careful planning can help you prepare for that first denial. The following items will benefit your appeal:

Remember that many manufacturers will offer pre-submission review services to ensure your paperwork is thorough and complete before you start pre-authorization communications with the insurer.

Even though you can expect an initial denial, these materials are mandatory for a complete submission. Anticipate payer questions by setting this expectation with your patient and the prescribing physician, so you can all navigate these bumps in the road together.

3.   Seek specific guidance from reimbursement specialists

Reimbursement specialists can be the difference between an authorization and an ultimate denial. Many of the advanced prosthetic devices you're submitting for have manufacturer or third-party team members who are experienced in providing guidance through the process. The sooner you connect with these specialists, the better the results can be.

If you find yourself stuck at any part of the process, a reimbursement specialist can help guide you to the next step, based on past success. A specialist can provide advice on how to overcome the obstacle you are facing, according to your individual needs, including suggesting specific language to use based on peer-reviewed facts about the device and its FDA clearances, for example.

The specialist will ensure you're equipped to advocate for your patient. He or she understands the importance of knowing your patient's story and articulating the positive impact the device can have on function and quality of life. That information can be an important piece in making the difference to a payer in authorizing a claim.

And, even if a device seems new to you, any legitimate prosthetic technology will likely be backed by significant academic lineage. The manufacturer's reimbursement specialists will know what devices have been under academic development for a significant amount of time, and will have high-quality, peer-reviewed literature that can go a long way in supporting your case.

A call or an email to the manufacturer can add a helping hand to the reimbursement journey.

Whether or not you have already established a partnership with the device manufacturer, they'll be able to guide you on preparation of the justification materials that the denied claims may be lacking. In our experiences in advanced technology reimbursement, we've seen that more claims are ultimately authorized when the clinic works closely with us and the resources we can provide.

4.    Commit and be tenacious. It's worth it.

The difficulty of navigating payment for advanced devices may leave you wondering why you should deal with another complicated reimbursement: Because it's worth it.

Your patients deserve to use the tools most appropriate for them to help them navigate their lives. The current environment requires that we advocate for our patients to justify this life-changing technology where applicable.

It's important to be honest with yourself and with your patient that this isn't a quick fix. Successful reimbursement is a journey we take together, and it can take many months. There will be setbacks, but you can help power through them. Giving up—or not starting out—can mean your patient doesn't have access to the technology that will best fit them; or if they do get that device, they'll pay much more for it out of pocket.

So we do the work. We're in it together—prosthetists, physicians, therapists, device manufacturers—we're all partners in providing the best outcomes for our patients.

Your hard work to secure funding for advanced medical devices opens doors not only for your practice and your current patient, but for countless future patients as well.

It may not be easy, but it's worth it.

Blair Lock, CEO and cofounder, and Erica Karlson, director of sales, lead the team at Chicago-based Coapt, a developer of human-machine interfaces and the first company with FDA Class II clearance to provide intuitive control technology for advanced prosthetic upper limbs. For more information, visit www.coaptengineering.com.