Medicare Mistakes to avoid when submitting a PA

Years of working with my team submitting the Prior Authorizations needed for IVIG or SqIG treatment for patients has lent me a lot of experience. The problems and pitfalls are everywhere. Something that we cannot avoid is Medicare guidelines. We must follow them exactly or risk a denial and delay in treatment for our patients. So as quickly as I can here are three things to remember when submitting a PA.

  1. Match the Diagnosis Codes - So Important but often missed. If the MD is documenting one dx code in the notes and another on the Rx or the labs. This is a sure way to get a Medicare denial. The Dx Code need to be very clearly matching on all documentation. If there is even the slightest difference or indication in the notes of a differing Dx code then a denial could be near.

    Solution: Double check the clinical notes, Labs and Rx to ensure they all say the same ICD-10 Code.

  2. Primary Diagnosis Code is #1 - When submitting a PA make sure the Primary Dx code you want to get approved for Immunoglobin is listed as the “Primary”. If it is listed as secondary then you run the risk of Medicare denying the PA.

    Solution: Think of Medicare as a “Checklist not up for interpretation”. Medicare guidelines are very strict and if there’s a small mistake they will deny the PA. The Primary Dx code line seems like an easy mistake but can cause major issues!

  3. The Dreaded B VS D Denial - Here we go, the worst of the worst! The Dreaded B Vs D Denial! If you get this back after submitting a PA, you are in for the long haul. Your first step is to call me :) But if you can’t then you need to find where the issue is and backtrack. This denial is triggered because somewhere along the line a Dx code approved under Medicare Part B was used AND a Dx code approved under Part D was also used. Either they were included in the Notes and then a different Dx code was used in the Rx. The problem with this is inconsistency. Find it and change it!
    Solution: Below is a list of Diagnosis codes Covered by Medicare Part B. If you are using a Dx code NOT on the list, that means the code would be used under Part D.


    IVIG/SCIG

    ICD-10 codes that are Medicare covered diagnoses for Part B in the home

    G11.3- Cerebellar ataxia with defective DNA repair

    D80.0- Hereditary hypogammaglobulinemia

    D80.2- Selective deficiency of immunoglobulin A [IgA]

    D80.3- Selective deficiency of immunoglobulin G [IgG] subclasses

    D80.4- Selective deficiency of immunoglobulin M [IgM]

    D80.5- Immunodeficiency with increased immunoglobulin M [IgM]

    D80.6- Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia

    D80.7- Transient hypogammaglobulinemia of infancy

    D81.0- Severe combined immunodeficiency [SCID] with reticular dysgenesis

    D81.1- Severe combined immunodeficiency [SCID] with low T- and B-cell numbers

    D81.2- Severe combined immunodeficiency [SCID] with low or normal B-cell numbers

    D81.5- Purine nucleoside phosphorylase [PNP] deficiency

    D81.6- Major histocompatibility complex class I deficiency

    D81.7- Major histocompatibility complex class II deficiency

    D81.82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS] *New Oct 22

    D81.89- Other combined immunodeficiencies

    D81.9- Combined immunodeficiency, unspecified

    D82.0- Wiskott-Aldrich syndrome

    D82.1- Di George syndrome

    D82.4- Hyperimmunoglobulin E [IgE] syndrome

    D83.0- Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function

    D83.1- Common variable immunodeficiency with predominant immunoregulatory T-cell disorders

    D83.2- Common variable immunodeficiency with autoantibodies to B- or T-cells

    D83.8-Other common variable immunodeficiencies

    D83.9- Common variable immunodeficiency, unspecified

PA APPROVALS: 3 QUICK TIPS

Dealing with insurance companies can often feel like navigating a labyrinth, especially when it comes to obtaining prior authorization for medical treatments or procedures. Prior authorization is a process in which healthcare providers must obtain approval from an insurance company before delivering certain treatments or services. While the process can be daunting, understanding how to navigate it effectively can save time, reduce frustration, and ensure timely access to necessary care. In this blog, we'll explore three essential tips for increasing your chances of getting a prior authorization approved with your insurance company.

  1. Understand the Requirements: The first step in obtaining prior authorization is to thoroughly understand the requirements set forth by your insurance company. Each insurance plan may have its own specific guidelines, criteria, and documentation requirements for prior authorization requests. These requirements may include clinical documentation, medical records, diagnostic test results, treatment plans, and more. It's essential to carefully review your insurance policy or contact your insurance provider to familiarize yourself with the necessary steps and documentation needed for the prior authorization process. By ensuring that your request meets all requirements from the outset, you can increase the likelihood of approval and minimize delays.

  2. Advocate for Medical Necessity: One of the key factors that insurance companies consider when evaluating prior authorization requests is the medical necessity of the proposed treatment or procedure. It's crucial to provide compelling evidence and justification demonstrating why the requested treatment is medically necessary for your condition. This may include clinical guidelines, peer-reviewed studies, specialist recommendations, and documented evidence of previous treatments or interventions. Additionally, including a detailed explanation of the expected benefits of the treatment, potential risks of not receiving the treatment, and any alternative options that have been explored can strengthen your case. By effectively advocating for the medical necessity of the requested treatment, you can demonstrate its importance in addressing your healthcare needs and improve the chances of approval.

  3. Communicate Effectively: Effective communication with both your healthcare provider and your insurance company is essential throughout the prior authorization process. Keep lines of communication open with your healthcare provider, providing them with any necessary information or documentation they may need to support your prior authorization request. Make sure to ask questions, clarify any uncertainties, and stay informed about the status of your request. Additionally, when communicating with your insurance company, be polite, professional, and persistent. Keep detailed records of all communication, including dates, names of representatives spoken to, and summaries of discussions. If your request is denied, don't hesitate to appeal the decision, providing additional information or addressing any concerns raised by the insurance company. By maintaining effective communication and advocating for your needs, you can work towards achieving a favorable outcome in the prior authorization process.

Navigating the prior authorization process with insurance companies can be complex and challenging, but it's not impossible. By understanding the requirements, advocating for medical necessity, and communicating effectively, you can increase your chances of getting your prior authorization approved and accessing the care you need in a timely manner. Remember to stay informed, be proactive, and persist in your efforts to ensure that your healthcare needs are met effectively and efficiently.