Franz Kafka was a Czech-born writer whose fictional stories depict nightmarish settings in which characters are crushed by nonsensical, blind authority. “Kafkaesque” is a term often applied to bizarre administrative situations that can’t be resolved with logical action. That situation has become the norm for most clinicians when dealing with Medicare Advantage prior authorization (PA).
This message from a Medicare Advantage plan was left on the voice mail of our Wound Clinic Program Director. I’ve cut out any patient identifiers and the name of the payer. This woman who does prior authorization is listing the documentation needed for prior authorization of hyperbaric oxygen therapy for chronic refractory osteomyelitis, although she can’t even pronounce all of the medical terms.
Many of the things below are open to clinical interpretation (words like “meticulous wound care” and “correction of vascular problems”). But note that she is indicating the patient has to be a diabetic with a Wagner 3 or worse ulcer that has failed 4 weeks of wound care in order to get HBOT for chronic refractory osteomyelitis. That is NOT a Medicare requirement for the treatment of chronic osteomyelitis – which means that the private payer isn’t even following the Medicare coverage policy for that condition. In other words, she’s demanding documentation of problems that are not required for the patient to obtain HBOT. If we don’t provide it, then the patient can’t be treated – even though those requirements should not be included.
Perhaps the only good thing about prior authorization (assuming it was fair) is that there’s a chance you will get to keep your payments if you make it through the PA process. Trying to provide all these things after the fact during a Medicare audit can be a lot harder – particularly when the auditors are asking for things that should not be required in the first place. Stay tuned for posts detailing the reasons that clinicians have failed various Medicare Administrative Contractor (MAC) audits which I took right off the MAC websites. [regarding patient redacted…
“I need to have clinical records documenting chronic refractory osteomyelitis that is unresponsive to conventional medial and surgical management –
- Including a 6-week course of parenteral antibiotics and at least one surgical debridement, unless it is contraindicated…
- With photographs with a ruler, PLUS…
- X-ray bone cultures documenting diagnosis, AND ALSO…
- Documentation of non-healing, infected deep ulceration that is a Wagner Grade 3 or more of the lower extremity WITH the photographs with the ruler documentation…
- In diabetic adults unresponsive to one month of meticulous wound care, [AND]…
- Assessment of the vascular status, AND…
- Correction of any vascular problems in the affected limb.
If you could please fax that to…”
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
