Prior Authorization
James Fenton
Description
Collection
Title:
Prior Authorization
Creator:
James Fenton
Date:
7/19/2014
Text:
For those who believe that prior authorization is the ticket; I would seriously advise that you find the proposal and read it. This proposal is a direct result of the CMS idea that there is a tremendous amount of over utilization. This proposal is not an attempt to curb fraud.
Allow me to give you an example of the methods currently being used by private insurers to provide prior authorizations (or not). The following is copied and pasted from a letter which we received from one of the largest insurers in this country. This was for custom molded foot orthotics (which are covered by the patient's plan) for a nine year old child with bilateral pronation of a significant degree.
We reviewed a request to cover custom foot orthotics for (patient's name). Based on the information submitted, we determined that the service(s) is/are not authorized.
The specific reason for our decision: The member has foot pain. He asked for custom foot inserts. To get these, he must first try store bought inserts. He must first try medicine and stretching. He may talk with his doctor about this. Custom foot inserts cannot be approved at this time. MCG Care Guidelines 18th Edition, foot Orthotics, Custom referenced. (The red lettering was added by me.) I am of the opinion that MCG will be the contractor for prior authorizations. If you feel that this will be a good thing for our field, do nothing. If on the other hand you believe like I do, read the proposal, find out what it says and way you are bothered about its possible/probable effect on you, your business and your family. Write and tell CMS abut it before July 28. In lieu of either of these, go directly to step 14 of the instructions for what to do in case of nuclear attack. Jim Fenton, LPO
Allow me to give you an example of the methods currently being used by private insurers to provide prior authorizations (or not). The following is copied and pasted from a letter which we received from one of the largest insurers in this country. This was for custom molded foot orthotics (which are covered by the patient's plan) for a nine year old child with bilateral pronation of a significant degree.
We reviewed a request to cover custom foot orthotics for (patient's name). Based on the information submitted, we determined that the service(s) is/are not authorized.
The specific reason for our decision: The member has foot pain. He asked for custom foot inserts. To get these, he must first try store bought inserts. He must first try medicine and stretching. He may talk with his doctor about this. Custom foot inserts cannot be approved at this time. MCG Care Guidelines 18th Edition, foot Orthotics, Custom referenced. (The red lettering was added by me.) I am of the opinion that MCG will be the contractor for prior authorizations. If you feel that this will be a good thing for our field, do nothing. If on the other hand you believe like I do, read the proposal, find out what it says and way you are bothered about its possible/probable effect on you, your business and your family. Write and tell CMS abut it before July 28. In lieu of either of these, go directly to step 14 of the instructions for what to do in case of nuclear attack. Jim Fenton, LPO
Citation
James Fenton, “Prior Authorization,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/236564.
