1. Schaum, Kathleen D. MS

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I recently had the honor of facilitating a wound care-related reimbursement question-and-answer session, during which time the participants had the opportunity to select the topics. Although we discussed numerous topics, I was very surprised that "payer coverage" was the major topic of discussion. Because I try to share "hot issues" with Payment Strategies readers, the following are some of the myths and truths that your wound care peers uncovered about "payer coverage."


MYTH: All private payers follow Medicare's coverage policies.


TRUTH: Private payers typically write their own medical policies. Private payers often refer to Medicare's policies, but they are not required to follow them.


MYTH: Private payers do not publish their medical policies.


TRUTH: Most private payers publish their medical policies. Sometimes they are not publicly available, but can be accessed on their website with your provider number.


MYTH: Medicare Administrative Contractors (MACs) write a local coverage determination (LCD) about every service/product/procedure.


TRUTH: Actually, MACs write LCDs only about services/products/procedures that they are trying to control for various reasons such as overutilization, cost, misuse, and so on.


MYTH: If your MAC has not written an LCD about a particular service/product/procedure, the MAC does not cover it.


TRUTH: If your MAC has not written an LCD, the service/product/procedure may be covered based on medical necessity.


MYTH: MACs do not make their LCDs public.


TRUTH: MACs are required to publish their LCDs on their own website and on the Medicare Coverage Database (MCD) website (


MYTH: If a MAC retires an LCD and a provider is audited for past claims, the auditor uses the LCD that is available.


TRUTH: The LCD that existed on the day the service/procedure/product was provided to the patient is used by the auditor. All retired LCDs can be found on the MCD Archive Database ( according to the following timeline:


* Proposed/Draft LCDs move to the MCD Archive 90 days after being released to the final LCD.


* Retired LCDs and Articles move to the MCD Archive 90 days after their retirement dates.


* Superseded versions of active LCDs and Articles move to the MCD Archive after 1 year.



MYTH: LCDs are updated annually.


TRUTH: LCDs may be updated as frequently or infrequently as the MAC deems necessary. Therefore, wound care professionals should assign someone to review their MAC's LCDs on a monthly basis.


MYTH: Wound care professionals never know when coverage is being changed by the MAC; it is always a surprise.


TRUTH: If the MAC is considering a new LCD or coverage reduction to an existing LCD, the MAC must release a "draft" LCD and must provide a minimum of a 45-day comment period. That is another reason wound care professionals should review their MAC's LCDs on a monthly basis. Always look for "draft" LCDs. If a "draft" LCD is released, give (1) a copy of it to the wound care professional(s) who should submit comments about the "draft," (2) the address (electronic, fax, and mail) of the person/place to whom the comments should be submitted, and (3) the comment deadline.


Wound care professionals should exercise their right to comment on "draft" LCDs because the MAC medical directors value comments from medical professionals and use those comments to prepare the "final" LCDs. This author has seen many "draft" LCDs significantly revised before they became "final" because of the superb comments and clinical evidence submitted by wound care professionals. In fact, some "draft" LCDs were never finalized because of comments received during the "open comment" period.


In addition to accepting and reviewing written comments, the MACs typically conduct quarterly open LCD meetings where wound care professionals can present their testimonials about "draft" LCDs. Those are wonderful opportunities to educate the MAC medical directors about wound care clinical evidence. Once the MAC has considered all the comments and developed the "final" LCD, it must be published on Medicare's coverage website. A minimum notice period of 45 days is required prior to the effective date of implementation.


MYTH: Once an LCD is released, wound care professionals cannot challenge the LCD.


TRUTH: All LCDs can be challenged through the LCD Reconsideration Process. Any interested party may request a reconsideration of the benefit category determination or any provision of an existing LCD by submitting a formal request in writing to the local MAC. A formal request for reconsideration must include either (1) new information that was not considered during the initial determination or (2) arguments that the LCD decision materially misinterpreted the applicable statutory provisions, the applicable regulatory provisions, or the existing evidence at the time the determination was made.


The MACs must consider all LCD reconsideration requests from beneficiaries residing or receiving care in the contractor's jurisdiction, providers doing business in the contractor's jurisdiction, and any interested party doing business in the contractor's jurisdiction. A reconsideration request-once accepted-goes through the same process as an initial LCD. The reconsideration process permits experts to re-evaluate the evidentiary basis for a decision.


MYTH: If a patient provides an insurance card, the wound care professional is guaranteed that the wound care service/procedure/product will be covered.


TRUTH: Nothing could be further from the truth, especially in January and July when patients often change their insurance. Every patient's current insurance should be verified by contacting the payer on the insurance card. In the question-and-answer session, I heard many "sad stories" that happened because this process was not routinely performed.


The most frequent problem stemmed from beginning the conversation with the payer by asking if "prior authorization" was required before the provider verified if the service/procedure/product was covered on the particular patient's plan. In many cases, the payer answered "no prior authorization is required" because it was not covered on that patient's plan (but they did not tell the provider that it was not covered on the patient's plan). In those cases, the providers proceeded with the work, submitted the claims, received denied claims, and called the payers to determine why the claim was denied. That is when the providers learned that they should have verified the insurance coverage before asking if prior authorization was required.


Note: Many wound care providers in the room experienced this exact situation.


Following are a few tips to make the insurance benefit verification process go smoothly:


* Confirm that your facility/office has patient consent to conduct insurance benefit verification.


* Obtain the patient's policy number and date of birth, your tax identification number, and national provider identifier, and call the payer's provider services line.


* Ask about the coverage criteria for the service/procedure/product for the patient's specific diagnosis. Be sure to review the exact International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes, the exact pertinent CPT(R)* code(s), and the exact pertinent HCPCS code(s) with the payer.


* If covered, ask if there are any prior authorization/precertification requirements, how to meet these requirements, and how to expedite the process. If required,


[white circle] Determine what information the payer needs and provide that information in the format required (usually via the telephone, or by fax).


[white circle] Some payers require the completion of a specific form; if so, obtain and use the form.


[white circle] Include a letter of medical necessity when appropriate (include product information, patient information, prior treatment notes, and any other documentation that will "paint the picture" of the rationale for the service/procedure/product).


[white circle] Follow up with the payer until they render a decision.


[white circle] Follow up with an appeal letter if the prior authorization/precertification is not granted.


* Inquire if the patient has any coverage limitations or policy exclusions.


* Verify the reimbursement rate for the service/procedure/product and how much the patient will be required to pay out of pocket.



Note: Medicare will not give a prior authorization or a precertification for most wound care services/procedures/products. That is why your MAC's LCDs are so important, if they exist for a particular service/procedure/product.


Caution: The most amazing finding at the question-and-answer session was that many wound care professionals learned that they were no longer preferred providers with the payers and that their service was not covered at all, or at a much higher co-pay to the patient. That fact must be discussed with the patient before the service is rendered!


*CPT is a registered trademark of the American Medical Association.