Knowledge is Essential
by Cheryl Nash and AJ Riviezo
Most commercial insurances and Medicare have clinical guidelines they review one to two times per year. It is essential that you are operating under the most current guidelines. As the United example shows, the changes can be dramatic and result in denials.
One way to ensure you are reviewing your top payers on a regular basis is to see if they have a 'Next Review Date' listed on the current guidelines. You can place a note on your calendar to go to that payer's guidelines and see if there is a new publication of the guideline or if the date has been changed. Key elements to review are changes in documentation requirements, changes in medical necessity requirements, and changes in conservative therapy. Be sure to read the fine print. Sometimes the changes are in the addendums or are a few words hiding in the middle of what appears to be an unchanged paragraph.
Tuesday, November 16, 2010
ZPIC Audits
Is Phlebology Being Targeted?
by AJ Riviezzo, MBA
The new Zone Program Integrity Audits (ZPIC), which have been in the making for several years, have really begun to be conducted over the past three months. The goal of these audits is to detect fraud and abuse in Medicare claims. These audits are being done by sub-contractors on behalf of the Medicare Administrative Contractors (MAC). It also appears that these several sub-contractors are paid only on the 'found' dollars. This lends serious concerns regarding their processes and the neutrality of the review.
Further, the rules (like those surrounding the RAC audits) were never formalized by Congress. This is allowing the ZPIC sub-contractors to devise their own rules and regulations regarding the process. These rules are certainly not provider friendly to date. It has also created a significant variance between Zones on how these audits are being conducted. In one area it appears they are being treated much like the RAC audits with thirty charts being reviewed on a retrospective review. In another area, ALL claims are being reviewed with payments being denied prospectively, with virtually no feedback as to the reason why save the standard Medicare denial codes.
Attempts to gain further information have, to date, been difficult. One phlebology provider has basically been told that it is not the ZPIC contractor's responsibility to 'educate' the provider, and yet they are still holding essentially all payments prospectively. Thankfully this provider has a relatively small percentage of Medicare patients as part of their payer mix. For a provider with a large Medicare mix, this is tantamount to a forced closure.
Is phlebology being targeted? The author cannot state that it is. However, two phlebology practices are already in review that we know about. Given the small number of providers in review by these ZPIC contractors and given the even smaller percentage of all providers that perform ablations, it does give one serious pause for concern.
So what is a practice to do proactively? First, we recommend that you re-read your Local Coverage Determinations (LCD) regarding phlebology services for your area. Make sure your patients are meeting the medical necessity requirements outlined in the LCD.
Second, the LCD may also have documentation requirements that are specifically required on each chart or operative note. Please review your documentation against these requirements. You may also want to have an external agency conduct a chart-to-bill, bill-to-chart audit. Yes, you can do these on your own but it is a bit like proof-reading your own work. An outside eye will not overlook 'assumed' elements.
What are the next steps should your practice be contacted by ZPIC? The request from ZPIC will be for copies of your charts. We recommend sending, as quickly as possible, the copies requested. Typically they are requesting for a specific date of service. We recommend sending all of the documentation necessary for that specific date (e.g. Diagnostic Ultrasound, History and Physical, Operative Note, any other documentation). If they request records for multiple dates of service, send the same type of packet for each date of service. Do not assume they will copy the Diagnostic Ultrasound and attach it to each date of service. They will not do so. We also suggest that you immediately contact an attorney in your area with some ZPIC or at least RAC audit experience.
Now to the vaguely good news. Once ZPIC has denied your claims (recent experience shows a denial rate of over 95%), you can then appeal these denials through the Medicare system. Medicare has five levels of appeal that can be attempted. These are:
1. Redetermination. This goes through MAC and is basically to keep the claims open for additional appeal processes. On the average 50% of claim denials are overturned at this stage.
2. Reconsideration. These appeals go through a completely different department, usually a Physician panel, for review. These reviewers do not work for Medicare or the ZPIC contractor, and are not paid by the denial. (this is a completely independent review team).
3. Administrative Law Judge Hearing. Established for any outstanding claims over $130.00. This stage allows for a teleconference with a legal entity to discuss the medical necessity of the services, and functions like a peer-to-peer review. There is a high level of success at this stage of appeals.
4. Medicare Appeal Council Review. This is an independent team of professionals tasked with reviewing the decision made by the ALJ panel. Any contested issues found in the ALJ hearing will be reviewed here.
5. District Court. Established for any claims over $1260.00. You may request a review in district court.
The encouraging news is that at the 3rd level of appeal, if a physician's services may not have exactly met criteria set forth by the MAC, the claims may still be considered for payment if the physician is able to state, in a concrete fashion, as to why the services were necessary and prudent.
In short, these ZPIC audits are looking to be both unpleasant and expensive with few guidelines that are required to be followed. It appears the assumption is that fraud has been committed unless proven otherwise. Review your documentation, medical necessity assumptions, and the Local Coverage Determinations soon.
by AJ Riviezzo, MBA
The new Zone Program Integrity Audits (ZPIC), which have been in the making for several years, have really begun to be conducted over the past three months. The goal of these audits is to detect fraud and abuse in Medicare claims. These audits are being done by sub-contractors on behalf of the Medicare Administrative Contractors (MAC). It also appears that these several sub-contractors are paid only on the 'found' dollars. This lends serious concerns regarding their processes and the neutrality of the review.
Further, the rules (like those surrounding the RAC audits) were never formalized by Congress. This is allowing the ZPIC sub-contractors to devise their own rules and regulations regarding the process. These rules are certainly not provider friendly to date. It has also created a significant variance between Zones on how these audits are being conducted. In one area it appears they are being treated much like the RAC audits with thirty charts being reviewed on a retrospective review. In another area, ALL claims are being reviewed with payments being denied prospectively, with virtually no feedback as to the reason why save the standard Medicare denial codes.
Attempts to gain further information have, to date, been difficult. One phlebology provider has basically been told that it is not the ZPIC contractor's responsibility to 'educate' the provider, and yet they are still holding essentially all payments prospectively. Thankfully this provider has a relatively small percentage of Medicare patients as part of their payer mix. For a provider with a large Medicare mix, this is tantamount to a forced closure.
Is phlebology being targeted? The author cannot state that it is. However, two phlebology practices are already in review that we know about. Given the small number of providers in review by these ZPIC contractors and given the even smaller percentage of all providers that perform ablations, it does give one serious pause for concern.
So what is a practice to do proactively? First, we recommend that you re-read your Local Coverage Determinations (LCD) regarding phlebology services for your area. Make sure your patients are meeting the medical necessity requirements outlined in the LCD.
Second, the LCD may also have documentation requirements that are specifically required on each chart or operative note. Please review your documentation against these requirements. You may also want to have an external agency conduct a chart-to-bill, bill-to-chart audit. Yes, you can do these on your own but it is a bit like proof-reading your own work. An outside eye will not overlook 'assumed' elements.
What are the next steps should your practice be contacted by ZPIC? The request from ZPIC will be for copies of your charts. We recommend sending, as quickly as possible, the copies requested. Typically they are requesting for a specific date of service. We recommend sending all of the documentation necessary for that specific date (e.g. Diagnostic Ultrasound, History and Physical, Operative Note, any other documentation). If they request records for multiple dates of service, send the same type of packet for each date of service. Do not assume they will copy the Diagnostic Ultrasound and attach it to each date of service. They will not do so. We also suggest that you immediately contact an attorney in your area with some ZPIC or at least RAC audit experience.
Now to the vaguely good news. Once ZPIC has denied your claims (recent experience shows a denial rate of over 95%), you can then appeal these denials through the Medicare system. Medicare has five levels of appeal that can be attempted. These are:
1. Redetermination. This goes through MAC and is basically to keep the claims open for additional appeal processes. On the average 50% of claim denials are overturned at this stage.
2. Reconsideration. These appeals go through a completely different department, usually a Physician panel, for review. These reviewers do not work for Medicare or the ZPIC contractor, and are not paid by the denial. (this is a completely independent review team).
3. Administrative Law Judge Hearing. Established for any outstanding claims over $130.00. This stage allows for a teleconference with a legal entity to discuss the medical necessity of the services, and functions like a peer-to-peer review. There is a high level of success at this stage of appeals.
4. Medicare Appeal Council Review. This is an independent team of professionals tasked with reviewing the decision made by the ALJ panel. Any contested issues found in the ALJ hearing will be reviewed here.
5. District Court. Established for any claims over $1260.00. You may request a review in district court.
The encouraging news is that at the 3rd level of appeal, if a physician's services may not have exactly met criteria set forth by the MAC, the claims may still be considered for payment if the physician is able to state, in a concrete fashion, as to why the services were necessary and prudent.
In short, these ZPIC audits are looking to be both unpleasant and expensive with few guidelines that are required to be followed. It appears the assumption is that fraud has been committed unless proven otherwise. Review your documentation, medical necessity assumptions, and the Local Coverage Determinations soon.
United Health Care Update
Positive Change for Once
by Cheryl Nash and AJ Riviezzo
United Health Care, effective October 25th, 2010, has again revised their medical policy guidelines for ablations. The submission of color photographic prints is no longer required. Also, the submission of US prints is no longer required. It appears their system could not handle the massive amount of data they were receiving thus forcing a change.
The best news coming out of the new policies is that compression stockings are no longer required as a part of conservative treatment. A completed questionnaire addressing the degree and severity of pain still must be submitted for authorization. This questionnaire can be found at: https://www.unitedhealthcareonline.com
The bad news is that diameter sizes have not changed... it is still 5.5mm for GSV, 5mm for SSV. Only one measurement is required. If bleeding or ulceration is present vein sizes of a lower diameter will be accepted.
Perforator size for treatment has dropped to 3.5mm. Additionally, the notes must document the presence of venous stasis ulceration for laser or RF ablation of the perforator.
There are some other requirements so please read the policy for some of the various nuances.
by Cheryl Nash and AJ Riviezzo
United Health Care, effective October 25th, 2010, has again revised their medical policy guidelines for ablations. The submission of color photographic prints is no longer required. Also, the submission of US prints is no longer required. It appears their system could not handle the massive amount of data they were receiving thus forcing a change.
The best news coming out of the new policies is that compression stockings are no longer required as a part of conservative treatment. A completed questionnaire addressing the degree and severity of pain still must be submitted for authorization. This questionnaire can be found at: https://www.unitedhealthcareonline.com
The bad news is that diameter sizes have not changed... it is still 5.5mm for GSV, 5mm for SSV. Only one measurement is required. If bleeding or ulceration is present vein sizes of a lower diameter will be accepted.
Perforator size for treatment has dropped to 3.5mm. Additionally, the notes must document the presence of venous stasis ulceration for laser or RF ablation of the perforator.
There are some other requirements so please read the policy for some of the various nuances.
Friday, October 22, 2010
PAD Requirements
A Growing Trend
by Cheryl Nash and AJ Riviezo
Some payers are requiring a rule out of peripheral artery disease to be contained in the history and physical prior to granting an authorization. One way to add this element is through a pedal pulse examination. Another is to have your RVT (or you as the case may be) perform an ultrasound peripheral arterial examination. The codes for these studies are 93925 bilaterally and 93926 for a single leg examination. The relevant diagnosis code is 459.81 - venous insufficiency.
One concern to consider is the amount of time each patient will be spending prior to any real treatment if you couple an ultrasound arterial examination with a venous examination and the history and physical. Some patients may not be willing to spend that much time being 'worked up'. Discussing the reasons for the amount of time and what each elements helps determine will assist in alleviating this concern.
by Cheryl Nash and AJ Riviezo
Some payers are requiring a rule out of peripheral artery disease to be contained in the history and physical prior to granting an authorization. One way to add this element is through a pedal pulse examination. Another is to have your RVT (or you as the case may be) perform an ultrasound peripheral arterial examination. The codes for these studies are 93925 bilaterally and 93926 for a single leg examination. The relevant diagnosis code is 459.81 - venous insufficiency.
One concern to consider is the amount of time each patient will be spending prior to any real treatment if you couple an ultrasound arterial examination with a venous examination and the history and physical. Some patients may not be willing to spend that much time being 'worked up'. Discussing the reasons for the amount of time and what each elements helps determine will assist in alleviating this concern.
Marketing Thought...
Lunch and Learn with Bariatric Surgeons
by AJ Riviezzo, MBA
When establishing your referral base of physicians, one specialty niche to consider targeting is bariatric surgeons. Patients who receive lap band and other bariatric surgeries frequently have venous insufficiency surface as an issue. Their weight issues were masking the signs and symptoms until they have lost a sufficient amount of weight. A course of stockings to meet conservative therapy guidelines may be required as many of these patients have likely not been wearing compression stockings.
There are some bariatric surgeons who also dabble in phlebology so please ensure you are not marketing to a competitor.
by AJ Riviezzo, MBA
When establishing your referral base of physicians, one specialty niche to consider targeting is bariatric surgeons. Patients who receive lap band and other bariatric surgeries frequently have venous insufficiency surface as an issue. Their weight issues were masking the signs and symptoms until they have lost a sufficient amount of weight. A course of stockings to meet conservative therapy guidelines may be required as many of these patients have likely not been wearing compression stockings.
There are some bariatric surgeons who also dabble in phlebology so please ensure you are not marketing to a competitor.
Quick Information Regarding Ablation of Other Elements
Quick Information Regarding Ablation of Other Elements
by AJ Riviezo, MBA
We are frequently asked if one can perform an RF or laser ablation for a tributary, anterior accessory or perforator - and receive payment for the work.
The answer is, like most everything regarding insurance, perhaps.
First, the vein to be ablated must meet the minimum guidelines that are in place by the payer for the saphenous veins. For example, they may require the vein to be at least 3mm in diameter, showing evidence of reflux, and the patient has to have met conservative treatment guidelines.
Second, please note that many payers believe this procedure should be performed concurrently with an ablation of the saphenous vein. The codes for a second insertion/ablation are 36476 and 36479 for RF or laser. You should have a progress note stating why the patient needs this ablation versus alternative treatment, and why you are recommending this to be a staged procedure.
Next, should you determine that there is a need to stage the procedure and not perform it during the ablation of the saphenous vein, we recommend reviewing the patient insurance carrier's guidelines regarding ablations. Some, like Anthem Blue Cross/Blue Shield, are very clear that they will not authorize the service. Their guidelines note usage of sclerotherapy to resolve these issues after an ablation of the saphenous vein. You will not have to review these guidelines every time but we do recommend reviewing them at least quarterly to check for any changes. Some payers, like Blues of Illinois, changes their guidelines at least once per year.
If you have an authorization (if required), the CPT code used for these ablations is the same as for a saphenous ablation - 36475 for RF ablation and 36478 for laser ablation. Documentation of the procedure is essentially the same save for noting as to why this is a staged procedure.
by AJ Riviezo, MBA
We are frequently asked if one can perform an RF or laser ablation for a tributary, anterior accessory or perforator - and receive payment for the work.
The answer is, like most everything regarding insurance, perhaps.
First, the vein to be ablated must meet the minimum guidelines that are in place by the payer for the saphenous veins. For example, they may require the vein to be at least 3mm in diameter, showing evidence of reflux, and the patient has to have met conservative treatment guidelines.
Second, please note that many payers believe this procedure should be performed concurrently with an ablation of the saphenous vein. The codes for a second insertion/ablation are 36476 and 36479 for RF or laser. You should have a progress note stating why the patient needs this ablation versus alternative treatment, and why you are recommending this to be a staged procedure.
Next, should you determine that there is a need to stage the procedure and not perform it during the ablation of the saphenous vein, we recommend reviewing the patient insurance carrier's guidelines regarding ablations. Some, like Anthem Blue Cross/Blue Shield, are very clear that they will not authorize the service. Their guidelines note usage of sclerotherapy to resolve these issues after an ablation of the saphenous vein. You will not have to review these guidelines every time but we do recommend reviewing them at least quarterly to check for any changes. Some payers, like Blues of Illinois, changes their guidelines at least once per year.
If you have an authorization (if required), the CPT code used for these ablations is the same as for a saphenous ablation - 36475 for RF ablation and 36478 for laser ablation. Documentation of the procedure is essentially the same save for noting as to why this is a staged procedure.
Monday, August 30, 2010
United Healthcare Authorization Process Update
More Requirements by UHC
by Cheryl Nash and AJ Riviezo
Over the past few weeks we have obtained further clarification from Dr. Jeff Mason, Senior Medical Director for United Healthcare (UHC). One of the key questions needing clarification was "pictures of what exactly?". UHC, per Dr. Mason, would like to receive the following from the diagnostic duplex ultrasound:
1) Images (black and white, or color) that show the anatomy and size of the vein at sections relevant to the case. These images can be submitted in hard-copy prints, or, preferably, in a digital file. We do not need a record of the entire exam --- several "snapshots' are enough.
2) We need speed and direction of blood flow information, either from a color doppler print(the colors represent direction and speed of flow) or locations (denoted by cursors) where flow readings were taken.
3) We need a report of the exam including results of the above size of vein and degree and timing of reflux, that is signed, hard copy or electronically, by a physician.
UHC has also already modified their policy regarding the surface skin photos. They now want a ruler showing size next to the problem area(s) as well as the patient name. One group is taping the patient name as a flag on the ruler. Another group has the patient stand in front of a white board and the patient name is written on the white board.
If you or your team have questions regarding any of the new UHC processes, do feel free to call us. We are happy to try and explain the processes as we understand them. No charge. We are all in this boat together! Please ask for Cheryl at 719.955.9128 ext. 203.
by Cheryl Nash and AJ Riviezo
Over the past few weeks we have obtained further clarification from Dr. Jeff Mason, Senior Medical Director for United Healthcare (UHC). One of the key questions needing clarification was "pictures of what exactly?". UHC, per Dr. Mason, would like to receive the following from the diagnostic duplex ultrasound:
1) Images (black and white, or color) that show the anatomy and size of the vein at sections relevant to the case. These images can be submitted in hard-copy prints, or, preferably, in a digital file. We do not need a record of the entire exam --- several "snapshots' are enough.
2) We need speed and direction of blood flow information, either from a color doppler print(the colors represent direction and speed of flow) or locations (denoted by cursors) where flow readings were taken.
3) We need a report of the exam including results of the above size of vein and degree and timing of reflux, that is signed, hard copy or electronically, by a physician.
UHC has also already modified their policy regarding the surface skin photos. They now want a ruler showing size next to the problem area(s) as well as the patient name. One group is taping the patient name as a flag on the ruler. Another group has the patient stand in front of a white board and the patient name is written on the white board.
If you or your team have questions regarding any of the new UHC processes, do feel free to call us. We are happy to try and explain the processes as we understand them. No charge. We are all in this boat together! Please ask for Cheryl at 719.955.9128 ext. 203.
Marketing to Males
Or... How to Herd Cats
by AJ Riviezzo, MBA
As the data above shows, very few men are coming in for phlebology services. The reasons are fairly evident and are not unique to phlebology. The question then becomes: "How do we capture a few more of these reticent males?" Below are some ideas for your consideration.
1. Pain and Performance: The bulk of the phlebology marketing tri-folds and brochures are geared towards women in both their look and language. Understandably so. I recommend creating a separate brochure specifically for men. This will typically cause a re-write of your brochure as men will not respond to the aesthetic elements most marketing pieces contain. The men will respond to two elements.
The first is pain. Your services can reduce the pain and swelling in their legs. The information should contain a bit of clinical information describing how that happens. Very straight forward information. Stress that this is an ailment and not a cosmetic procedure. The second element is performance. By having healthier, pain free legs the gentleman will be able to golf, walk their dog, hike, lift weights, bike, and other activities at a higher performance level.
2. Pictures: Consider adding some more male pictures to your website and especially your 'male' brochure. Again, have them focus on performance by showing pictures of healthy legs climbing a cliff, biking, dog walking, and the like. You may want a separate page on your website stylized 'For Men' or similar heading that contains your more male oriented information.
3. Build It and They Will NOT Come: Your male patient is not typically looking for your service. You need to determine how best to go to them. If you have had a few patients that work for a male dominated industry with a union (electrical, pipe fitters, carpenters, meat cutters, etc.) and the patient is happy with their outcome; ask them who you should contact in the union. Many unions have a preferred provider book. They may allow you to do a Lunch and Learn or other speaking engagement at one of their meetings. You may be able to place brochures in the commons areas.
Another possibility is to get your brochures out to various activity venues. Bicycle shops may be willing to keep your information on a brochure rack or on the counter. High end running shoe stores may also be a possibility. Gyms that cater primarily to men may be willing to have you place your brochures. You may even be able to meet with the trainers. A quick review of signs and symptoms with the trainers and you now have three or four people looking at legs for you! Work a reciprocity agreement so to speak by carrying their brochures in your office.
A third possibility is health fairs. Yes, they are sometimes boring and not always much fun. Having information that caters specifically to men will help you at the health fair. The man may or may not be there to meet with you or your team... but their spouse is. Their wife then has something they can take back to them for their review.
by AJ Riviezzo, MBA
As the data above shows, very few men are coming in for phlebology services. The reasons are fairly evident and are not unique to phlebology. The question then becomes: "How do we capture a few more of these reticent males?" Below are some ideas for your consideration.
1. Pain and Performance: The bulk of the phlebology marketing tri-folds and brochures are geared towards women in both their look and language. Understandably so. I recommend creating a separate brochure specifically for men. This will typically cause a re-write of your brochure as men will not respond to the aesthetic elements most marketing pieces contain. The men will respond to two elements.
The first is pain. Your services can reduce the pain and swelling in their legs. The information should contain a bit of clinical information describing how that happens. Very straight forward information. Stress that this is an ailment and not a cosmetic procedure. The second element is performance. By having healthier, pain free legs the gentleman will be able to golf, walk their dog, hike, lift weights, bike, and other activities at a higher performance level.
2. Pictures: Consider adding some more male pictures to your website and especially your 'male' brochure. Again, have them focus on performance by showing pictures of healthy legs climbing a cliff, biking, dog walking, and the like. You may want a separate page on your website stylized 'For Men' or similar heading that contains your more male oriented information.
3. Build It and They Will NOT Come: Your male patient is not typically looking for your service. You need to determine how best to go to them. If you have had a few patients that work for a male dominated industry with a union (electrical, pipe fitters, carpenters, meat cutters, etc.) and the patient is happy with their outcome; ask them who you should contact in the union. Many unions have a preferred provider book. They may allow you to do a Lunch and Learn or other speaking engagement at one of their meetings. You may be able to place brochures in the commons areas.
Another possibility is to get your brochures out to various activity venues. Bicycle shops may be willing to keep your information on a brochure rack or on the counter. High end running shoe stores may also be a possibility. Gyms that cater primarily to men may be willing to have you place your brochures. You may even be able to meet with the trainers. A quick review of signs and symptoms with the trainers and you now have three or four people looking at legs for you! Work a reciprocity agreement so to speak by carrying their brochures in your office.
A third possibility is health fairs. Yes, they are sometimes boring and not always much fun. Having information that caters specifically to men will help you at the health fair. The man may or may not be there to meet with you or your team... but their spouse is. Their wife then has something they can take back to them for their review.
Who Are Your Patients
A Quick Demographic Study
by AJ Riviezo, MBA
A new practice was asking for some information about patient demographics. To that end, I combined the demographic data of three large phlebology practices. None of these practices specifically target Medicare members as their primary market. All of them have primarily commercial payers with some (less than 20%) Medicare in the mix. Total patient sample size is 2,306 patients. The results are interesting and give you some comparison information you can use after reviewing your own practice's experience.
Under 30 - 4%, 30 to 39 - 15%, 40 to 49 - 23%, 50 to 59 - 27%, 60 - 69 - 19%, 71 to 79 - 9%, 80+ - 3%
Almost 70% of the business was 40 to 70 years of age. This age banding was skewed a bit older than what I had expected when reviewing practices that primarily see commercial payer patients.
The male/female ratios were even more significant. Males constituted only 16% of the patient population for these practices.
I recommend giving this data and your own age/sex patient data to your marketing person or company. Armed with this, they should be able to rifle in on a more targeted marketing campaign rather than a shotgun approach.
by AJ Riviezo, MBA
A new practice was asking for some information about patient demographics. To that end, I combined the demographic data of three large phlebology practices. None of these practices specifically target Medicare members as their primary market. All of them have primarily commercial payers with some (less than 20%) Medicare in the mix. Total patient sample size is 2,306 patients. The results are interesting and give you some comparison information you can use after reviewing your own practice's experience.
Under 30 - 4%, 30 to 39 - 15%, 40 to 49 - 23%, 50 to 59 - 27%, 60 - 69 - 19%, 71 to 79 - 9%, 80+ - 3%
Almost 70% of the business was 40 to 70 years of age. This age banding was skewed a bit older than what I had expected when reviewing practices that primarily see commercial payer patients.
The male/female ratios were even more significant. Males constituted only 16% of the patient population for these practices.
I recommend giving this data and your own age/sex patient data to your marketing person or company. Armed with this, they should be able to rifle in on a more targeted marketing campaign rather than a shotgun approach.
Friday, July 23, 2010
How to Make Life More Complicated/United Health Care Changes
by Cheryl Nash
Many of you may have received a letter from United Healthcare recently detailing some significant modifications to their coverage guidelines. With the main topic of discussion being documentation this month, I feel this is an opportune time to review these changes.
The most dramatic change by United is the addition of digital photos and the color flow Doppler results in addition to the interpretation by a physician. This digital media will be requested at the time of notification/pre-authorization. A standard 10 megapixel camera (cost is between $100 and $ 300) should be sufficient. The preferred way of submitting this information will be by digital upload through a secured email. Contact your local United Healthcare provider representative to obtain your personal secured email address. The documentation can also be sent hard-copy, but they freely acknowledge that this will delay processing. We recommend securing a comprehensive way of storing this data in an easily accessible electronic file to make communication with the insurance company as smooth as possible.
Some other significant changes to the clinical requirements is the detail to be documented in the Doppler study as well as in the patient History and Physical. United will require the vein diameter with strict guidelines as to what the diameter must be for different venous issues (including perforators). They will also be requiring the duration of reflux to be written in the report. This is all in addition to the previous requirements of reflux without evidence of DVT/PAD. For patients who exhibit only signs and symptoms they have added a questionnaire to be filled out completely and sent along with a dictated H&P from the provider. This H&P will need to have a complete treatment plan and proposed outcome. As always, a trial of conservative treatment to include compression stockings will be included.
The complete clinical guidelines can be found at unitedhealthcareonline.com under the tools and resources/policies and protocols/coverage determination guidelines. The header has changed and is now listed as Ablative Procedures for Venous Insufficiency and Varicose Veins (this was formerly under Surgical and Minimally Invasive Treatment for Varicose Veins of the Leg).
Unfortunately, practices that treat varicose veins will only have a couple of weeks to get these changes into place as the new guidelines go into effect on August First, 2010.
Many of you may have received a letter from United Healthcare recently detailing some significant modifications to their coverage guidelines. With the main topic of discussion being documentation this month, I feel this is an opportune time to review these changes.
The most dramatic change by United is the addition of digital photos and the color flow Doppler results in addition to the interpretation by a physician. This digital media will be requested at the time of notification/pre-authorization. A standard 10 megapixel camera (cost is between $100 and $ 300) should be sufficient. The preferred way of submitting this information will be by digital upload through a secured email. Contact your local United Healthcare provider representative to obtain your personal secured email address. The documentation can also be sent hard-copy, but they freely acknowledge that this will delay processing. We recommend securing a comprehensive way of storing this data in an easily accessible electronic file to make communication with the insurance company as smooth as possible.
Some other significant changes to the clinical requirements is the detail to be documented in the Doppler study as well as in the patient History and Physical. United will require the vein diameter with strict guidelines as to what the diameter must be for different venous issues (including perforators). They will also be requiring the duration of reflux to be written in the report. This is all in addition to the previous requirements of reflux without evidence of DVT/PAD. For patients who exhibit only signs and symptoms they have added a questionnaire to be filled out completely and sent along with a dictated H&P from the provider. This H&P will need to have a complete treatment plan and proposed outcome. As always, a trial of conservative treatment to include compression stockings will be included.
The complete clinical guidelines can be found at unitedhealthcareonline.com under the tools and resources/policies and protocols/coverage determination guidelines. The header has changed and is now listed as Ablative Procedures for Venous Insufficiency and Varicose Veins (this was formerly under Surgical and Minimally Invasive Treatment for Varicose Veins of the Leg).
Unfortunately, practices that treat varicose veins will only have a couple of weeks to get these changes into place as the new guidelines go into effect on August First, 2010.
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