CMS Pre-Authorization...thoughts, suggestion??
Jim DeWees
Description
Collection
Title:
CMS Pre-Authorization...thoughts, suggestion??
Creator:
Jim DeWees
Date:
8/21/2012
Text:
Hello again,
The message for this morning is this: What do people think about going to a pre-authorization or pre-approval type of system?
This has been the message I have gotten from many people who have replied. I have thought about this as well, and I KNOW it is possible. The very same office that processes my Medicare claims is the same as the Anthem Blue Cross office in Indianapolis (or the sister office in Louisville). We all know that Anthem has the ability and also requires (for many of their contracts or policy holders) a pre-authorization or a pre-approval for prosthetic services. They could easily (well, that is questionable) manage to do the same for Medicare claims. BUT it will take the action of CMS to make these changes and require NGS (who is owned by Anthem...but is the contracted administrator for Medicare in several of the regions/jurisdictions) to implement a pre-auth kind of prgram or system for us to go through.
(Again, from the emails I have gotten, it is still clear that many of us do not fully understand that Medicare or CMS does NOT handle any claims or process any payments at all. They contract there services out to the private sector companies. Many of these companies have a business name, but they are all owned by other larger groups, which are owned by another even larger group....it was not obvious or easy to really figure out who owns the contractor that handles my Medicare claims....NGS, Inc (National Government Services, Inc. is owned by Palmetto GBA....and who in the world is Palmetto...they were the ones that I sent the application to get my Medicare Provider ID number, and they are the ones that sent a contracted inspector to my office to check me out, etc.....BUT then I found that Palmetto GBA was owned by Blue Cross of North Carolina (or South...I can't remember) and then that BCBS of ? Carolina is totally owned by Anthem..... But, now on the NGS website it clearly states at the bottom of the web page in tiny letters, they are a wholly owned subsidiary of Anthem/Wellpoint. ))
So, pre-auth's are not new to the private sector insurance companies, and ALL the Medicare contracted administrators ARE owned by the private sector companies.
It is not the private sector companies that are the hold up, but it is the rules of CMS that would need to change to require this kind of system.
BUT, is it a good idea? I can see where it can hold up the process for a while, slowing down the time that an amputee would be fit with a prosthetic limb. It would definitely have a negative impact there. It would also require us to jump through more hoops BEFORE starting on a prosthetic limb.
On the positive side, we would know before we ever started on a limb that it was approved (but as the disclamer always states, this is not a guarantee of payment, and they are subject to medical necessity before payments are sent), and we will have to fight to get that guarantee disclamer removed. IF they approve this device, then they must guarantee it is payed as long as the patient signs for the device, and accepts the device.
This would prevent a patient from working 2 facilities at the same time, or from going to one place, and then months after receiving a limb, starts at another facility, and WE have no way of knowing this at all!! We must rely on the patient to be honest with us, and tell us what is going on. OR if we are lucky, when asking the physician for the chart notes for the evaluation, they might let us know that they already sent an Rx to another place a few weeks ago, with could raise a red flag.
If Medicare had already given a pre-auth to a facility, then hopefully they would have that marked, and not give another pre-auth for a 2nd office to also provide the same services.
This could be a very good suggestion that is brought to the attention of interested politicians who are looking at how to crack down on the fraud that is in the news.
Let me know what your thoughts are, please.
One last note....I sent my email last night about CMS Emails too soon....I got 2 more after 4:30 pm here. That makes SEVEN emails from CMS in ONE day. Nice!!
Thanks
Jim DeWees
The message for this morning is this: What do people think about going to a pre-authorization or pre-approval type of system?
This has been the message I have gotten from many people who have replied. I have thought about this as well, and I KNOW it is possible. The very same office that processes my Medicare claims is the same as the Anthem Blue Cross office in Indianapolis (or the sister office in Louisville). We all know that Anthem has the ability and also requires (for many of their contracts or policy holders) a pre-authorization or a pre-approval for prosthetic services. They could easily (well, that is questionable) manage to do the same for Medicare claims. BUT it will take the action of CMS to make these changes and require NGS (who is owned by Anthem...but is the contracted administrator for Medicare in several of the regions/jurisdictions) to implement a pre-auth kind of prgram or system for us to go through.
(Again, from the emails I have gotten, it is still clear that many of us do not fully understand that Medicare or CMS does NOT handle any claims or process any payments at all. They contract there services out to the private sector companies. Many of these companies have a business name, but they are all owned by other larger groups, which are owned by another even larger group....it was not obvious or easy to really figure out who owns the contractor that handles my Medicare claims....NGS, Inc (National Government Services, Inc. is owned by Palmetto GBA....and who in the world is Palmetto...they were the ones that I sent the application to get my Medicare Provider ID number, and they are the ones that sent a contracted inspector to my office to check me out, etc.....BUT then I found that Palmetto GBA was owned by Blue Cross of North Carolina (or South...I can't remember) and then that BCBS of ? Carolina is totally owned by Anthem..... But, now on the NGS website it clearly states at the bottom of the web page in tiny letters, they are a wholly owned subsidiary of Anthem/Wellpoint. ))
So, pre-auth's are not new to the private sector insurance companies, and ALL the Medicare contracted administrators ARE owned by the private sector companies.
It is not the private sector companies that are the hold up, but it is the rules of CMS that would need to change to require this kind of system.
BUT, is it a good idea? I can see where it can hold up the process for a while, slowing down the time that an amputee would be fit with a prosthetic limb. It would definitely have a negative impact there. It would also require us to jump through more hoops BEFORE starting on a prosthetic limb.
On the positive side, we would know before we ever started on a limb that it was approved (but as the disclamer always states, this is not a guarantee of payment, and they are subject to medical necessity before payments are sent), and we will have to fight to get that guarantee disclamer removed. IF they approve this device, then they must guarantee it is payed as long as the patient signs for the device, and accepts the device.
This would prevent a patient from working 2 facilities at the same time, or from going to one place, and then months after receiving a limb, starts at another facility, and WE have no way of knowing this at all!! We must rely on the patient to be honest with us, and tell us what is going on. OR if we are lucky, when asking the physician for the chart notes for the evaluation, they might let us know that they already sent an Rx to another place a few weeks ago, with could raise a red flag.
If Medicare had already given a pre-auth to a facility, then hopefully they would have that marked, and not give another pre-auth for a 2nd office to also provide the same services.
This could be a very good suggestion that is brought to the attention of interested politicians who are looking at how to crack down on the fraud that is in the news.
Let me know what your thoughts are, please.
One last note....I sent my email last night about CMS Emails too soon....I got 2 more after 4:30 pm here. That makes SEVEN emails from CMS in ONE day. Nice!!
Thanks
Jim DeWees
Citation
Jim DeWees, “CMS Pre-Authorization...thoughts, suggestion??,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 26, 2024, https://library.drfop.org/items/show/234220.
