More replies to Medicare Pre-Auth

Hello All,

I understand AOPA’s position a little more, I think.

Hello All,

I understand AOPA’s position a little more, I think.  The new issue of The O&P Almanac discusses this topic more in-depth.  July 2014 Almanac

 
           
July 2014 Almanac
American Orthotic & Prosthetic Association (AOPA) – July 2014 Issue – O&P Almanac
View on issuu.com Preview by Yahoo
 
 
They would like a guarantee of payment without audit if prior authorization is obtained.  All my insurance contracts have the stipulation that prior authorization (PA) is not a guarantee of payment.  I think this will be an impossible hurdle, but it would be nice.

If pre-auths go the way of ALJ hearings then they may end up taking months to get, then Medicare may say they are not taking any new prior authorization requests due to backlog.  One thing I do know is that I hate the feeling in the back of my mind that Medicare could end up auditing all my patients for the past 3 years and decide I owe them $723,947.46.  Can you pay with cash or CC?  Maybe PAs are not the answer, but I would vote to give them a try.  We should attempt make sure they do it in the best way possible and look out for our interests.  This system didn’t work out to well for power wheelchairs, but they’ve always been troublesome for some reason. 

More Replies:

Kevin,

I don’t think AOPA is opposed to prior auth.  I think they just want to
make it the best it can be, if it is going to happen.  I think the
changes they propose would make it a very good system.  As is, it would
be better than what we have currently.  The current medicare proposal
could be better.  I think that AOPA sees that medicare will do whatever they want in the end, as they have done all
along, but if we can influence it to be better, that is better.  I think medicare knows that they can do whatever they want, but if they make
some changes to their plan that we, or AOPA are presenting, later there
will be less chance of complaints from us, or AOPA, because they can
point to it and say, this is what you proposed.  In our state, we did
similar, knowing insurance lobby wouldn’t go for some things in parity
legislation, and then settled on what we were happy to accept anyhow.
 Basically, shoot for that stars, and maybe we will at least end up in
orbit, rather than sitting on the ground where we currently are.

I think you could agree that you would like to see the auth as favorable
to our patients and us as possible.  I think that is reasonable and what AOPA is hoping for.

I don’t think AOPA has the power to have prior auth killed, and they know it.  At least if we can get it improved, it will be better.

I think your actions may hinder the end goal of improved prior auth, as
AOPA’s suggestions would do.  Basically, you are saying, whatever
medicare does to us is fine, just take their lowest offer and be happy.
 Why not push back and try to improve it on the front end, while it may
be possible?

Please don’t include my name, it’s not worth the headache.
**************************************

Kevin,
 
No opposing views to Prior Authorization offered??? I find that
fascinating!
 
I’m on the fence. I’d like to believe that CMS would be efficient in their
PA process, but in reality the only thing they seem quick at is asking for money
back! I believe those who expect a one week decision are a tad overly
optimistic!
 
 
 
Joel J.
Kempfer CP FAAOP
President,
Kempfer Prosthetics Orthotics Inc.
4365
West Loomis Road
Greenfield, WI
53220
414-817-1452
********************************************

Hi Kevin,
 
I frequently do not see the connection of P/A and payment in our practice.
In
our practice we often request and receive prior auths from insurers,
only to get denials on the backside when reviewed by the  “utilization”
dept at the same insurer.
 
Like AOPA
and other professional organizations I do not see adding another
administrative step to the process as being a step forward.   I have
seen nothing in the proposed information the states that P/A is in any
way connected to payment, or decreasing audits.  Unless that connection
is added the P/A process is meaningless.  We have debated the issue
locally with insurers without success.
 
While
the concept of securing P/A seems to indicate warranty of payment (to
us), at least in our cases nothing could be further from the case.  If
P/A is admistered by Medicare as it is here by private insurers the only
change is one more time consuming administrative step.  With as little
positive result as all of the other administrative dances we are doing
now, except because the argument that “we have P/A”,  utilization
denials only increases the frustration.  Change the policy to insure
payment with P/A, and I agree it make sense. I do not think that
Medicare will ever do that.  I think that most of the responders to your
question are making a gaint leap of faith, in regard to payment, with
the present proposal.
 
Alan
 ********************************************

Hi Kevin,

I believe the problem is
based on past experience with the Medicare clinical determinations we’ve
seen through the appeals and audit systems. Anyone who’s been involved
in Medicare appeals and audits, ALJ’s themselves included, will tell you
that the Medicare contractors have many times denied claims for the
most ridiculous reasons. We’ve had many where the claims denial
referenced irrelevant rules or LCD rules and diagnosis requirements for
other devices (this with KOs)! Others where they clearly did not look at
the documentation we provided. The only way to get the claim paid was
through an appeal, and sometimes requiring an ALJ hearing, which is now
taking over a year to schedule. Medicare says they’ll postmark a
response to these prior auths within 10 days. They aren’t able to keep
the deadline for these ALJ hearings due to the shortage of judges and
won’t hire more. What makes us think they’ll be able to take these new
requests and keep it to a deadline?

Also
the initial trial done by Medicare is the ADMC (advanced determination
of medicare coverage) program for power wheelchairs. We have a power
wheelchair division and were just denied a claim for same and similar
even though we had an approved ADMC. The patient needed a different type
of chair due to a change in condition, and we showed that on the ADMC
which was approved. Now they’re denying it anyway for same and similar
forcing us to go through appeals process regardless of the original
determination.

Just a few points I see as problematic. I’m sure others have more.

Shlomo ‘Sol’ Heifetz
Director of Operations

Presque Isle Medical Technologies
o 216-371-0660 x 200 c 814-504-7949 f 866-536-2954 e [email protected]

2440 W 8th St I Erie I Pennsylvania I 16505
2120 S Green Rd I South Euclid I Ohio I 44121
Silver Spring I Maryland I Mobile Services
Chicago I Illinois I Mobile Services
*********************************************

We have PA’s for GA Medicaid, it does not insure payment or prevent
auditing. It slows down the process. Last year  I had 2 PA hearings
before a judge with Medicaid “expert witnesses” arguing against
provision of a particular lower end foot feature. It tools almost a year
to have the hearing, spent days preparing, took a day off each time for
travel, waited weeks for the decision, which was deems not medically
required. I still have not figured out how it saved anyone a dollar. And
in the end everyone lost except the legal team and their “experts”
preventing the few hundred dollars spent to improve the quality of life
for 2 female amputees.
**********************************************

Again, thanks to all respondents.

 

Kevin C. Matthews, CO/LO
Advanced Orthopedic Designs
12315 Judson Rd. #206
San Antonio, Texas  78233
(210) 657-8100
(210) 657-8105  fax