Tips for Pre-Registration through Pre-Determination

  The complexity of wound care products and procedures today, in combination with the numerous Medicare, Medicaid, and commercial payer’s coverage policies, makes the registration process for hospital-based outpatient wound care departments (HOPDs) very challenging. This article provides some tips that may make the process from pre-registration through pre-determination easy and more beneficial for the patient, the physician and the HOPD.

  It is extremely important for the processes discussed in this article to be performed for every patient and for every visit on a consistent basis. Equally important is the notion that pre-authorization and/or pre-determination should be obtained for any planned treatment for patients covered by Medicaid or private payers.

Pre-Registration/Registration Activities

  Many data elements need to be documented and verified before the patient’s first HOPD visit and for each visit thereafter. These items include, but are not limited, to:

    • Collection and/or verification of demographic information such as name, address, phone number, marital status, emergency contact information, and any additional information required by the HOPD’s registration system.

    • Patient Identification and insurance information should be reviewed for each visit. The identification should be a photo ID, such as a driver’s license or passport. This author is sure that most readers are aware of matters involving identity theft. Therefore, it is extremely import that HOPDs match other data elements to ensure that you are registering the correct patient, especially if many patients have the same last name or have common last names, like Smith. If the patient’s address that is provided is different than the information on the patient’s insurance card(s) or driver’s license, addresses should be verified by requesting the patient to bring in a copy of their bank statement or utility bill. Checking the date of birth is also advisable.

    • Collect or obtain medical information that has been provided by the referring physician, such as any labs, x-rays, and medical history information. (For coverage of some products and procedures, documentation of previous care is a requirement.) These documents may have been mailed, faxed, or presented by the patient at the time of the visit.

    • General consent to treat and consent to release information for purposes of reimbursement to the patient’s insurance.

    • Signed HIPAA privacy form.

    • Co-payments as indicated on the patient’s insurance card and/or identified during insurance verification process.

    • Financial screening according to facility policy if the patient does not have insurance or is unable to pay for non-covered products or procedures.

Insurance Verification

  Insurance cards should be copied at the time of registration. The registrar should obtain any group insurance identification number(s), as well as the patient’s insurance identification number(s). In order to properly provide coordination of benefits, this information should be verified for each of the patient’s health insurance policy(ies). The address (mail or electronic) for claims processing and the phone number for provider inquiries should also be verified.

  Insurance verification is performed by one of the following methods:

  1. For Medicare beneficiaries, instructions for verification are contained in the Medicare Claims Processing Manual. The following is a subset from the claims manual, section 10:

  Chapter 2 - Admission and Registration Requirements 10 - General Admission and Registration Rules (Rev. 1, 10-01-03) HO-300, HO-312

   “Upon admission of a Medicare beneficiary to an institution that bills Medicare, or as soon thereafter as practical, the provider must verify a patient’s eligibility in order to process the bill. The provider may obtain this eligibility information directly from the patient or through the provider’s Fiscal Intermediary’s (FI) limited Medicare eligibility data. See §30.6. The provider contacts its FI to obtain technical instructions regarding how this access may be implemented along with hardware/software compatibility details. This information does not represent a definitive eligibility status. If the individual is not on file, the provider uses the usual admission and billing procedure in effect, independent of this data access.

  The CMS maintains the electronic records for individuals enrolled in the health insurance program. Most Health Insurance Claim Numbers are 9-digit numbers with letter suffixes, e.g., 000-00-0000-A. However, an HICN might also be a 6- or 9-digit number with letter prefixes, e.g., A-000000, A-000-00-0000; or WD-000000, WD-000-00-0000. When the status of a beneficiary changes, it is possible for the prefix or suffix of his/her claim number to change.

  It is important that the patient’s HICN be obtained and accurately recorded because the claim cannot be processed if the HICN is missing or incorrect. A social security number is not sufficient.

  The CMS requires this data to record necessary benefit information on CMS records. Where the patient refuses to request payment and refuses to furnish information about his/her HICN, the provider documents the records accordingly and attempts to get the HICN from the SSO.”

Common Working File
  The Common Working File (CWF) is an "on line" Medicare benefit entitlement and utilization data base file. It allows CMS to screen every Part A and Part B claim for eligibility prior to payment. The Common Working File (CWF) is a single data source for Fiscal Intermediaries and Carriers to verify beneficiary eligibility and conduct prepayment review and approval of claims from a national perspective. It is the only place in the fee for service (FFS) claims processing system where full individual beneficiary information is housed. CWF meets CMS' core requirements for claims processing: 1) beneficiary entitlement to Part A/B, 2) accurate deductible & coinsurance, 3) appropriate services, 4) benefits on the claim are available, and 5) Medicare Secondary Payer information is correct. CWF also performs limited part A/B crossover editing to insure services are not paid twice on different types of claims. CWF has four quarterly releases that control, implement, and update software changes due to legislative mandates.

  2. For private payers there usually is a phone number on the patient’s insurance card. You may use this number to contact the payer to verify the insurance. In most instances, each private payer has a website that will contain all policies, procedures (such as pre-authorization and appeals process), forms, and other requirements for providers. In addition, if your facility has a managed care contract with a private payer, many of the forms, policies and procedures will be contained in the contract.

Insurance Coverage

  One of the most challenging aspects of wound care today are the ever-changing coverage policies. Some of them change multiple times a year! Therefore, HOPDs should create a process to obtain and understand the coverage policies affiliated with the products used and procedures performed by their wound care professionals.

  1. The first step that the HOPD program director, coding staff, or other qualified individual should perform is to conduct a complete search for all coverage policies that pertain to their business. The search for each payer’s (ie, Medicare contractor, Medicaid, private payers) coverage policies, should include policies that mention the following terms: wound care, debridement, skin substitutes, bioengineered or tissue engineered skin, human skin equivalents (research each type used in the HOPD), surgical dressings (research each type used in the HOPD), negative pressure wound therapy, hyperbaric oxygen therapy, non-covered services, modifiers, enzymatic debriders, global periods, evaluation and management, foot care and any other types of specialized products, procedures, or services provided by the HOPD.

  For Medicare, this link will take you to the recently revised Medicare Coverage Database: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search. NOTE: Some Medicare contractors have separate policies for Medicare Part A and Medicare Part B. Other Medicare contractors have one policy that is pertinent to both Medicare Part A and Medicare Part B. Wound care professionals sometimes mistakenly presume that the Medicare coverage policies only pertain to outpatient care. They think that they can do whatever they want if they admit the patient to the hospital or use the ambulatory surgery center (ASC). In fact, many of the Medicare coverage policies pertain to the HOPD, the ASC, and the inpatient hospital. Remember, if a patient is admitted to the hospital for the sole purpose of performing a non-covered procedure or receiving a non-covered product, the entire hospitalization and the physician’s work can be denied according to Medicare rules.

  Many private payers’ coverage policies may only be viewed by providers via their provider identification number. Be sure you enter the private payer’s web site via your provider identification number. This will ensure access to the private payer’s coverage policies. It is advisable to get pre-authorization by following the procedure listed on each payer’s web site, or in your provider manual. Pre-authorizations usually will require the patient’s medical/surgical history and/or any other information such as photos of the wound, peer-reviewed journal articles, and other documentation to show that the treatment is indeed, medically necessary for this patient. Prior authorization forms will be located on the payer’s website. Another term that is sometimes used interchangeably with prior authorization is pre-determination. Most plans will offer pre-determination of benefits. The proposed treatment can be submitted to an insurance carrier in order to pre-determine the costs and reimbursement for services before they are rendered. This process can estimate how the patient’s insurance will process the proposed claim for services including deductibles, co-pays, what private payer will cover, and potential patient financial responsibility. Pre-determination explains to the patient and provider what to expect once the service is rendered and billed. Please keep in mind that a positive prior authorization or pre-determination does not necessarily mean that the procedure or product will definitively be covered. The facts of the case may change from what was previously related to the payer and the payer can deny the claim even though prior authorization was received.

  Wound care providers should print all the Medicare, Medicaid, and private payer coverage policies that are pertinent to the products, procedures, and services (especially your top ten procedures and separately billable products) performed in your HOPD, and assemble a binder that contains all of the pertinent coverage policies for each payer.

  2. The second step is to create a summary sheet of coverage issues/requirements identified for each payer. (See Exhibit A for an example of a coverage policy summary sheet). This summary sheet should include information regarding: covered and non-covered indications, utilization guidelines, documentation requirements, coding guidelines, billing requirements, frequency of treatment parameters, pre-authorization requirements, any limitations of coverage, as well as, any products or procedures that are listed specifically as non-covered items or services. In addition, any products or procedures that are known to be non-covered should be listed on a separate sheet with the charge associated with that specific product or procedure. The charges associated with a non-covered products/procedures may be required to fill out an Advanced Beneficiary Notice of Noncoverage for Medicare patients.

  3. As stated before, the coverage policy summary sheet should be created by a qualified individual, on staff, that can read and summarize the policy into an abbreviated format. Don’t forget that the purpose of the summary sheet is to provide the HOPD and the physicians with a summary of potential issues with that particular payer. If a payer has 15 policies relative to wound care, the summary should include the highlights of each in an abbreviated format. Therefore, the summary sheet should be a word document, which is expandable to include all the pertinent coverage information on one document. Caution: The coverage policy summary sheet should not take the place of each wound care professional reading the entire coverage policy and deciding how he/she will personally comply with the requirements of the coverage policy. Wound care professionals should be cautious if they are given coverage policy summary sheets by outside vendors: they may only contain a portion of the information needed to comply with the coverage policy. Copies of the coverage policies for each payer should be available in a central location in the HOPD to enable all wound care professionals to read the specific details of the coverage requirements.

  4. The last step, once the coverage policy summary sheets have been created for all payers, is to provide copies of the summaries to the registrar. The HOPD can decide where these forms should be placed in the medical record. Once the patient’s insurance information is verified, the registrar can place a copy of the appropriate coverage policy summary sheet(s) inside the patient’s medical record. For example, if a patient has Medicare as his/her primary payer and Aetna as a secondary insurance, both the Medicare and Aetna summary sheets should be placed, as reference material, in the patient’s medical record. This way, the HOPD and physicians will have abbreviated insurance coverage information readily available when speaking to the patient about treatment options. The coverage policies, summary sheets, and associated charge sheets for non-covered products and procedures should be periodically reviewed and updated for any changes in the coverage policies (monthly for Medicare and annually for private payers). Many payers post new/updated coverage policies after the new Medicare Outpatient Prospective Payment System (OPPS) and the new Medicare Physician Fee Schedule regulations have been finalized at the end of each calendar year. These new or updated coverage policies can occur at any time, but are often posted in the first quarter of each calendar year. It is important to check your Medicare Administrative Contractor’s website (as well as the CMS website) for any important coverage policy updates.

Opportunities for Improved Communications and Coordination of Care for Providers

  Now, let’s tie together what we have learned thus far to create a better system in the HOPD for improved communications and coordination of care amongst the wound care professionals, billers, and coders. The coverage policy summary sheets, suggested previously, can become a vital component to the HOPD’s day-to-day operation. In most instances, the plan of care for the patient is not determined until the physician sees the patient and performs a comprehensive wound assessment. It is at this time that physicians and other wound care professionals need to understand the coverage policies that are associated with the patient’s third-party payer. Why? To make an informed decision about their plan of care, physicians should discuss treatment options with the patient. If the physician has medical policies and limitations of coverage information about the patient’s insurance coverage (via the coverage policy summary sheet) he or she can discuss all treatment options with the patient.

  For products and/or procedures recommended by physicians but not covered by Medicare, this is the most appropriate time to discuss and obtain a signed Advanced Beneficiary Notice of Non-Coverage (ABN) from the patient. The following is a link for the approved ABN form and for instructions to complete the Medicare ABN form: https://www.cms.gov/BNI/Downloads/ABNFormInstructions.zip. This is also the most appropriate time for the physician to explain what Medicaid or a private payer will/will not cover. This is the moment when the itemized charge sheet (including the charges associated with a particular product and/or procedure) will assist the physician to advise the patient exactly what he/she may be responsible for paying out of pocket. This charge information is required on Medicare’s ABN.

Summary

  Performing the activities described in this article will assist the HOPD operationally by improving communication between the entire wound care team, the patient, and the third-party payer. The tips provided will lead to everyone’s better understanding of coverage for the products and procedures performed in the HOPD. By waiting to assess coverage until after the patient has received the product and/or procedure, HOPD’s and physicians run the risk of claim denials and/or requests for refunds by the payer. By establishing an efficient process for pre-registration, registration, insurance verification, coverage policy review, prior authorization process, and pre-determination process, the HOPD and the physicians who work there should experience less denied claims and requests for repayment.

Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, is the Senior Director, Strategic Reimbursement at Integra LifeSciences Corporation. She can be reached at donna.cartwright@integalife.com