Insurers using DRAFT LCD criteria to deny codes

Insurers using DRAFT LCD criteria to deny codes

William Lifford

5/6/2020

Hello Colleagues,


I don't know how many of you are faced with this particular issue, but we
have been having, for the past few years, seeing a tremendous amount of
L-codes denied from prosthetic pre-authorization requests where the denied
code is not listed as non-covered in either the current, in-force LCD or
the insurer's Clinical Policy Bulletin, Coverage Determination Guidelines,
Utilization Management Guidelines, or Clinical Medical Policy.


Instead, the origin of the denial seems to be that the insurer is using the
DRAFT LCD (yes, that's right, the never-in-force, permanently retired Draft
LCD) coverage criteria, which is much more restrictive than the current,
in-force LCD. Additionally, the insurer denies using the draft LCD and
insists (falsely) that the denial is based on real medicare coverage
criteria.


When I appeal the denials, and I point out the real reason for the denial
and show them the proof, I always win the case. BUT, it is incredibly
time consuming and it's wasteful. And it makes me furious that I have to
fight dishonesty.


My understanding is -- and if you have knowledge that proves me wrong (or
right), please let me know -- is that there is one individual (a
not-practicing CPO) who either currently works or has worked in the past as
a prosthetics consultant who advises the insurers on ways to reduce costs
by knocking out several L-codes from prosthetic pre-authorization requests,
either by working with insurers directly or by working for a firm that
advises many insurers. I believe this individual is one of the primary
architects of the Draft LCD and had a huge part in writing the actual
document. I understand also that this individual feels that there is a
tremendous amount of fraud/waste/abuse going on in O&P and he considers
himself a crusader for good. I also understand that this individual has
an impact on these pre-auths -- even after he no longer works specifically
for the insurer. My guess is probably by creating some sort of algorithm
or procedure template that guides auth reviewpersons on the best ways to
chip a few codes off of each preauthorization request.


However, I don't have any written or documentary proof -- this is all just
stuff that has been told to me by people in the field (granted, influential
people in O&P who are substantially in the know about such things).



To that end, I have a few questions:


1. How many of you are having difficulty with insurance companies (Medicare
Advantage) denying particular codes from prosthetic preauthorizations using
coverage criteria that only exist in the never-in-force, retired DRAFT LCD
and not the current, in-force LCD? * One recent example: denying L5968,
saying that this code is cover-able only for K3 and K4, when it only says
that in the Draft LCD -- the current LCD says nothing about L5968 only
being covered for K3/K4.*


2. Do any of you have any knowledge about the various insurance companies
for whom Performant Recovery advises/does preauth review for prosthetic
cases?


3. If there is an individual (a CPO) who keeps advising insurance companies
to deny codes for Medicare Advantage beneficiaries using DRAFT LCD criteria
(especially since this individual had a major hand in writing the Draft
LCD), is this something that I could file an ethical complaint with ABC
about?


4. Is it some sort of crime to use false information to deny
products/services/benefits to Medicare beneficiaries?


5. How would I go about getting a list of the authors of the DRAFT LCD?


Thank you so much for your advice and counsel with these issues. I care a
lot about O&P and more so, I care a lot about our patients. It incenses me
that insurers are flat-out lying when they deny certain codes and I want to
put a stop to this dishonest nonsense.


I wish you all safety and health in these weird, scary coronavirus times.


Bill Lifford, CPO




--
*William Lifford, CP*
*American Board Certified Prosthetist*
*Progressive O&P, Inc.*
1111 Willis Avenue
Albertson, NY 11784
516-338-8585