Ask the Board

  In this exclusive column, TWC offers readers the chance to ask industry-related questions to our expert editorial board members. This month’s question comes from Orlando, FL.

  Q: Do you agree or disagree with some insurance companies not covering any skin substitutes – and why?

A: By Donna J. Cartwright, MPA, RHA, CCS, RAC, FAHIMA

  The Today’s Wound Clinic board is not in a position to agree or disagree with the medical directors of insurance companies. Therefore, following is a quick review of how qualified healthcare professionals should educate payers about products with published clinical evidence:

  Medical directors of the Medicare Administrative Contractors (MACs) do provide coverage for cellular and/or tissue-based products for wounds that have published evidence such as meta-analysis, randomized clinical trials, etc. If a particular product has published evidence and is not covered by the MAC that processes your claims, you should educate the MAC medical director through the Local Coverage Determination Reconsideration Process. This process is clearly outlined on the website of each MAC. Medical directors of private payers also provide coverage for cellular and/or tissue-based products for wounds that have published evidence. Sometimes coverage criteria are more lenient, the same as, or less lenient than the MAC medical directors’ coverage criteria. If a particular product has published evidence and is not covered by the particular private payer for a specific plan, you should educate the private-payer medical director through the prior authorization or pre-determination process.

Donna J. Cartwright is senior director of strategic reimbursement services with Integra LifeSciences Corp., Plainsboro, NJ.