Optimizing Insurance Outcomes 3 rd Annual California Laryngectomee

Optimizing Insurance Outcomes 3 rd Annual California Laryngectomee Conference September 22, 2017 Brenda Capobres Villegas, M. S. , CCC Assistant Professor of Clinical Otolaryngology USC Caruso Department of Otolaryngology-Head and Neck Surgery

2

3

Disclosures No financial disclosures Non-financial disclosures Medical Advisor for Nu. Voices Los Angeles Laryngectomee Support Group and HNC Support International 4

5

6

7

Learning Objectives By the end of this presentation, you will be able to: Ø Demonstrate a basic understanding of your insurance Ø Familiarize yourself with the common codes for doctor’s visits, common procedures, and DME Ø Understand your role as a patient, caregiver, or medical professional regarding DME 8

Questions to ask • What insurance plan do you have? • Do you have a deductible? Have you met your • • deductible? What CPT codes do you need for your doctor’s visit? What are the following: CPT, HCPC, DME What do you do if a service is denied? What does it mean if they modify an authorization? 9

10

11

Cost Allowed Amount-maximum amount that your insurer will pay for covered services Balance Billing-difference between the allowed amount and what your provider charges (what you need to pay) Deductible-how much you have to pay before your health plan starts to its portion of the bill Out-of-pocket limit-maximum amount that you will have to pay out-of-pocket for covered services in a plan year Premium-how much you pay for insurance usually seen as monthly amount 12

Coverage • Benefit/Plan-services covered by your healthplan, • • type of coverage you choose Benefit year-how long your benefits are good for, usually one calendar year Excluded services-what is not covered under your health plan Network-list of providers that you plan contracts with, “in-network” (covered) and out-of network (sometimes not covered) Pre-authorization/pre-approval-determination that a service is medically necessary 13

Administration • Carrier-entity defined by state law that is • • authorized to see health insurance plans Claim-demand for payment of services from a medical provider Enrollment period-when you can sign-up for health insurance Explanation of benefits (EOB)-statement that breaks down a claim, including what insurer paid and how you much you owe PCP-Primary Care Physician/Primary Care Provider 14

Administration continued • Plan type-HMOs, PPOs, it refers to your plan’s approach to coverage • Provider-medical entity providing your care, preferred (contracted), non-preferred (no contract) 15

16

CPT v Current Procedural Terminology v Medical code set maintained by the AMA v Level of visit or procedure “The CPT coding system offers doctors across the country a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency. “ American Medical Association http: //www. ama-assn. org/ama/pub/physician-resources/solutions-managingyour-practice/coding-billing-insurance/cpt-process-faq/code-becomescpt. page 17

Doctor’s Visits New Patient Visit 99201, 99202, 99203, 99204, 99205 Established Patient Visit 99211, 99212, 99231, 99214, 99215 18

CPT codes 92597 -Evaluation for use and/or fitting of voice prosthetic device 92610 -Evaluation of oral and pharyngeal swallowing function 92611 and [74230]-Motion fluoroscopic evaluation of swallowing 92612 -Flexible fiberoptic endoscopic evaluation of swallowing 92526 -Treatment of swallowing dysfunction and/or oral function 92524 -Behavorial and qualitative analysis of voice 92507 -Treatment of speech, language, voice, communication 2017 for Medicare Fee Schedulefor Speech-Language Pathologists, 92607 -Evaluation prescription speech-generating American Speech-Language-Hearing Association (ASHA) device

Physical Therapy Services 20

21

22

23

24

25

26

HCPCS v Healthcare Common Procedure Coding System v “hickpicks” v Standardized coding system that is used primarily to identify products, supplies, and services v Ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. HCPCS Coding Questions - Centers for Medicare & Medicaid. . . www. cms. gov/Medicare/Coding/Med. HCPCSGen. Info/HCPCS_Coding_Ques tions. html 27

L 8509 • Describes a tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type. • Inserted in a physician’s office or other outpatient setting. • Claims for code L 8509 should not be submitted to the DME, but instead should be submitted to the A/B MAC or Part B carrier. Effective Date: October 1, 2010 Implementation Date: October 4, 2010 https: //www. cms. gov/Regulations-and. Guidance/Transmittals/downloads/R 686 OTN. pdf 28

L 8507* • Tracheo-esophageal voice prostheses that are changed by the patient/caregiver in the home setting • Billed using HCPCS code L 8507 (trachea-esophageal voice prostheses, patient inserted, any type, each) • Eligible for coverage under the prosthetic device benefit. The filing jurisdiction for these claims remains with the DME. *Considered to be DME https: //www. cms. gov/Regulations-and. Guidance/Transmittals/downloads/R 686 OTN. pdf 29

HCPC codes A 7501 Free Hands Starter Kit A 7502 Free Hands Membranes A 7503 Titanium Cap A 7507 HME Cassettes A 7508 Baseplates/Adhesives A 7520 Larytube A 7523 Shower Aid A 7524 Lary. Button/Barton Mayo Button A 4456 Remove A 4364 Silicone Glue A 7526 Laryclip/tube holder HCPC codes that must be billed by a licensed DME provider 30

HCPC codes continued A 4456 Provox cleaning towel A 9270 Free Hands cleaning and storage box E 1700 Therabite System (now only rental) E 1701 Therabite Bite pads E 1702 Therabite ROM scales L 8500 Electrolarynx L 8505 Trutone Hands Free A 5120 (AU) Skin Tac L 8507 Non Indwelling Style Prosthesis L 8510 Personal Amplifier (e. g. , Boom. Vox, Chatter. Vox, Soni. Vox etc) 31

HCPC codes continued L 8511 Plug L 8512 Gel caps (quantities of 10) L 8513 Brush L 8514 Dilator L 8515 Gel Cap Insertion System L 8499 Kapigel Spacer 32

Durable Medical Equipment (DME) What kind of supplies do I need? Where can I get more supplies? Will insurance cover my supplies? Do I need a prescription for supplies? 33

BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS • (1) Health benefits within the ten categories of essential health benefits enumerated in subdivision (a)(1) of section 10112. 27. • (2) Medically necessary basic health care services, as defined in subdivision (b) of section 1345 of the Health and Safety Code and section 1300. 67 of Title 28 of the California Code of Regulations. • (3) The health benefits mandated to be covered by the basebenchmark plan pursuant to all of the following: • (4) Durable medical equipment for home use and prosthetic and orthotic devices covered by the base-benchmark plan, including, but not limited to, all of the following: • (D) Tracheostomy Equipment: artificial larynx; replacement battery for artificial larynx; tracheo-esophageal voice prosthesis; tracheostomy supplies, including: adhesive disc, filter, inner cannula, tube plug/stop, tube collar/holder, cleaning brush, mask, speaking valve, gauze, sterile water, waterproof tape, and tracheostomy care kits. • • (A) The sections of the Health and Safety Code enumerated in subdivisions (a)(2)(A)(ii) and (a)(2)(A)(iv) of section 10112. 27 of the Insurance Code. (B) Subdivision (a) of section 1300. 67. 24 of Title 28 of the California Code of Regulations. (C) Section 1300. 68. 2 of Title 28 of the California Code of Regulations. 34

Insurance and DME • Most but not all Group Health plans provide some coverage for durable medical equipment (DME). • Plans may have variable levels of coverage, deductibles, copayments, or coinsurance. • Contract with multiple vendors for members' DME needs. • Coverage varies greatly for DME. 35

DME face-to-face requirement Effective July 1, 2013, Section 6407 of the Affordable Care Act (ACA) established a face-to-face encounter requirement for certain items of DME. ü Physician must document a face-to-face encounter with the patient ü Encounter must occur within the 6 months before the order is written for the DME ü Date of the written order must not be prior to the date of the face-to-face ü Document that the beneficiary was evaluated and/or treated for a condition that supports the item(s) of DME MLN Matters® Number: MM 8304 Detailed Written Orders and Face 36 to-Face Encounters at http: //www. cms. gov/Outreach-and. Education/Medicare-Learning

Prescription for DME* Written order must include: ü Beneficiary's name ü Item of DME ordered, quantity ü Prescribing practitioner's National Provider Identifier (NPI) ü Signature of the ordering practitioner ü Diagnosis ü Date of the order *Failure to meet any of the above requirements will result in denial of the claim. *In. Health Technologies and Atos Medical have prescription forms. “Program Integrity Manual, ” Chapter 5, Section 5. 2. 3 (available at http: //www. cms. gov/Regulations-and. Guidance/Manuals/Internt. Only-Manuals-IOMs. Items/CMS 019033. html) 37

Medicare • Covers medically necessary DME that your doctor prescribes for use in your home. • Only your doctor can prescribe medical equipment DME meets these criteria: • Durable (long-lasting) • Used for a medical reason • Not usually useful to someone who isn't sick or injured • Used in your home • Has an expected lifetime of at least 3 years https: //www. medicare. gov/what-medicare-covers/partb/durable-medical-equipment. html 38

Physician Enrollment in Medicare • Medicare will only pay claims for DME if the ordering physician and DME supplier are actively enrolled in Medicare on the date of service. • If you are not enrolled on the date the prescription is filled or re-filled, Medicare will not pay the submitted claims. • https: //www. cms. gov/Outreachand-Education/Medicare. Learning. Network. MLN/MLNProducts/downloads/Med. Enroll_ Phys. Other_Fact. Sheet_ICN 903768. pdf on the CMS website. 39

COMPANIES Apria Healthcare Atos Medical, Inc. Boston Medical Products Bruce Medical Supply-Medicare Edgepark Medical Supplies In. Health Technologies Lauder The Electrolarynx Company-Medicare Life. Care Solutions (no longer in CA, Oct 1, 2017) Lincare Luminaud Mc. Kesson Patient Solutions Remedy Patient Super. Care Western Drug Medical Supply 40

HCPC, Reference #, Item # REMEMBER! These are not all the same numbers. 41

• Find out who your insurance is contracted with for DME! 42

Denials and Filing a grievance • Obtain your insurance policies on the appeal process • Send a letter • Request a face-to-face meeting • Re-submit request 43

• Each insurance plan is different in coverage • Contact your provider to ask about specific coveage • Ask for a case manager to help you • Remember that not all treatment costs are covered • Be your own advocate! 44

Acknowledgments UC San Diego Foundation for Voice Restoration John Ready USC Caruso Department of Otolaryngology-Head and Neck Surgery Dr. Uttam Sinha, Dr. Niels Kokot, Dr. Dennis Maceri, Joy Lin, PA-C USC Keck Medical Center, Department of Speech Pathology Melody Ouyoung, M. S. , CCC-SLP HNC Support International Nu Voice Los Angeles

Brenda Capobres Villegas Assistant Professor of Clinical Otolaryngology USC Caruso Department of Otolaryngology. Head and Neck Surgery Keck School of Medicine of USC Office: 323 -442 -7432 Email: Brenda. Villegas@med. usc. edu