Replies to Medicare Prior Authorization question

I received a few replies to my query:

My query,
Hello all,

I received a few replies to my query:

My query,
>
> As a business owner
for the past 7 years I have done my battles with insurance companies. 
The insurances I have the fewest issues with require prior
authorization.  When I receive an authorization based on the diagnosis
codes and level of service requested (L-Codes) I know they have
considered the claim valid.  That doesn’t preclude possible
complications on the claims side but, in my experience, they are fewer
and more easily appealed.  We always get paid!  We battle until we win
because we know it IS a valid claim.
>
>
I do not see a downside to prior authorizations with Medicare, as long
as they don’t take more than a week or so.  The initial and most
critical decision of diagnosis versus level of service will, or at least
should, be determined.  We all know the rules.  They can request
additional documents on the claims or preauth side, which we all know we
need to have.  We are ready to submit what they need because we have
it.  You’re half crazy to bill or proceed without it.
>
>
If Medicare acts like a professional insurance company and processes
and replies in a timely manner, how is that bad?  I read the e-mail. 
Doom and gloom!!!  Really?
>
> Why is AOPA so vehemently opposed to this???   ???
>
> ***  I will post replies with names attached for credibility, unless you request otherwise.

Replies******************

Kevin, I agree with you. If prior authorization prevents me from buying
 prosthetic components  to build a leg that will be denied for payment
or recouped, I much rather have the denial form the get go and save
myself the expense and heartache. I don’t know how this can be a bad
thing. I have not heard any rational argument against it, have you?

Imelda
****************************

Kevin, I feel the same you do. I fail to see the problem with Prior
Authorization. I think AOPA is against it because it does not prevent
future audits on the same claim…but surely having it pre-authorized
would add validity to the claim during the appeal process. In fact, I
recently had a claim audited by a C2C Solutions..the claim had already
been audited by Medicare (pre-payment audit) and all I had to do was fax
them a copy of Medicare’s approval letter and audit stopped. I don’t
see how an auditing company could overturn something that was
pre-approved (Pre-payment audit..sort of). I too would like CMS to state
there would be no audits on pre-approved claims…but I don’t think
that is a reality. Maybe I’m missing the problem with pre-approval all
together but it seems like a step in the right direction.
Jeremy CPO
******************************

Same here, Kevin. I’d rather have them review and say it’s kosher to go
ahead. NONE of them insurances guarantees payments anyway.

I. Lesko, LPO
*****************************

Kevin,

Thanks for bringing up this important issue!!

As a business owner of 17yrs, I have wished for prior authorizations
from Medicare for the same reasons​ you mentioned. Namely, that prior
authorization validates our claim and shows that the insurance company
agrees with medical necessity, diagnosis codes, etc.

The concerns for Medicare’s prior auth plan as I understand them are:
1. The prior auth will not determine medical necessity or prevent audits for such!
2. The prior auth will not guarantee payment
3. The prior auth will take too long to get, thus delaying care

So, lets be honest here. These concerns sound more like hurdles, not brick
walls. If we can work out these issues, then Prior Auth would be holy
grail for prosthetics we have been searching for to get the RAC audits
off our backs. It will also be a feather in the cap for CMS to have some control over spending.

Seriously, if we can get CMS to agree that the prior auth determines medical
necessity and appropriateness of care and therefore precludes audits
from questioning these things…. then we have a win-win situation!

Of course, we need assurances that payment won’t be questioned for these
things (medical necessity, etc.) and that the approval process will have time limits so as to prevent delayed care.

This Prior Auth idea could be the thing to finally bring relief to these dang audits.

We just need to make sure the Authorization counts as a real Authorization.

Matt Bailey CPO, LPO
Fellow American Academy of Orthotists and Prosthetists
************************************************

I think prior authorization is a good thing. It’s going to take a year
after it is implemented to get the bugs worked out. I just recommend our
profession being able to weather the storm financially.
***********************************************

it is a road block for the patient! Historically the MC pt did not have to
go through that process, and could get their device immediately, the same day,
or at least how ever long the PA process takes sooner. In my facility we do same
day service when appropriate. The more one gives away, the more stuff gets taken
away, and the masses do not notice or care.
 
Until the late 70’s early 80’s people typically paid for our services
at delivery, if they had insurance, then they would fill out the forms and fight
with them if required. (I believe that was a much better system!) At that
time the end user had skin in the game, and now the is an expectation of free
entitlements. It is just another example of giving up control. Frankly, a lot of
us hate handing control to an entity who has a history of inefficacy and power
grabbing.
 
James O.
Young Jr., LP, CP, FAAOP
AmputeeProstheticClinic
Macon, Tifton,
Albany
888FAKELEG
888fakeleg.com
*********************************************************

Kevin,

Hello from Tulsa! I agree, I’d love to see the comments.
*********************************************

Hi Kevin,

AOPA is, essentially, the
manufacturers of components that we use day to day. They also have the
strongest voice of the three organizations (ABC, AOPA, AAOP), because
they are the ones with the most money to spend on marketing and
defending not us, but their own business practices. They have the most
to lose through prior authorization because we, as practitioners,
wouldn’t order that magic carbon fiber foot if we didn’t already have
prior auth. To a certain degree, the manufacturers are banking on us
buying the foot, or knee, or… before we know if Medicare will, or will
not, pay for it. Chances are, by the time a Medicare audit takes place,
the free return period will have ended long ago, sticking you and I
with the cost of the foot, et al.

You
are, I believe, correct about your theory that prior authorization would
only (ultimately) help our cases, moving forward. You can imagine that
Medicare will weight in heavily on the exact components used to
fabricate a prosthesis. If we are told “No” by Medicare before we order
that expensive part, it will save us the time and hassle of trying to
return a foot or knee that won’t be paid for.

The
manufacturers (“AOPA”) have the luxury of being in a position to sell
parts to us without any penalty if Medicare, or anyone else, ultimately
says no to what we have provided to the patient. Perhaps a better
question might be, “Hey, AOPA, why don’t you offer a lifetime return
policy on any items ultimately rejected by Medicare?”

It’s
about time that the manufacturers actually shared the same risk that
practitioners do. Either that, or they need to stop direct marketing to
patients via the internet and industry magazines.

We all serve different masters, it seems.
********************************************

That’s all I received.  It appears there is a majority in favor.  Why is AOPA so opposed?  What does NAAOP think?  They don’t represent manufacturers as far as I know.

Thanks to all that replied and thanks again to you Paul.

Kevin C. Matthews, CO

Advanced Orthopedic Designs
12315 Judson Rd. #206
San Antonio, Texas  78233
(210) 657-8100
(210) 657-8105  fax