Resources – New Patient Care
Reimbursement Q & A
IGL readers are encouraged to submit their questions about reimbursement.
Below you will find a sampling of previous questions and answers.
Question: What is the most common reimbursement error?
Answer: Incorrect, incomplete or improperly matched coding are the most common reasons for denials or delays in payments. Many pharmaceutical companies recognize this and often have a team of experts willing to help. Depending on the product, much of that information is readily available online. Keep in mind that all coding must match the therapy. For instance, intravenous immunoglobulin (IVIG) generally requires infusion services to administer the treatment. If the claim fails to have a corresponding procedure code or claim for infusion services, all claims related to the IG may be automatically kicked out of the computer system, thus generating a denial or delay in payment until supporting documentation is filed.
Question: Is it advisable to change a diagnosis so Medicare will cover the treatment?
Answer: It is fraudulent to inappropriately use a diagnostic code to attain reimbursement. In the case of primary immune diseases, Medicare currently reimburses for five disease states, with common variable immunodeficiency (CVID) (code 279.06) being the most commonly used. Medicare Local Coverage Determinations (LCDs) establish how broadly a diagnostic code can be used to attain reimbursement. Therefore, one must pay close attention to the LCDs in their regions for clarification.
For instance, the following is wording from a LCD covering Florida. “An adequate response of the stereotypes tested should include a two- to three-fold increase in titers to at least 50 percent of the stereotypes. In rare instances when there is recurrent bacterial infection and normal IgG levels, this criterion will be considered adequate to confirm the diagnosis of CVID.”
Code 279.06 (CVID) includes these diagnoses:
- Dysgammaglobulinemia: acquired, congenital, primary
- Hypogammaglobulinemia: acquired primary
- Hypogammaglobulinemia: congenital non-sex-linked
- Hypogammaglobulinemia: sporadic Caution should be exercised, as misinterpretation of the wording could still result in claims not being paid
Question:: What are the qualifiers insurers consider medically necessary to treat alpha-1 antitrypsin deficiency (AAT) with an alpha 1-proteinase inhibitor?
Answer: Alpha-1 antitrypsin deficiency (AAT) is an inherited disorder that can cause lung disease in adults and liver disease in adults and children. Symptoms of AAT include wheezing, difficulty breathing, shortness of breath, unintentional weight loss, fatigue, recurrent respiratory infections, a barrel shaped chest and a chronic cough. Delayed or poor treatment can lead to permanent disability and premature death. Patients with this type of deficiency are often misdiagnosed as having chronic obstructive pulmonary disease (COPD) or asthma. The World Health Organization recommends all patients diagnosed with COPD or asthma be tested for AAT.
The following is an excerpt from one major insurer’s policy detailing what documentation warrants treatment of AAT with an alpha-1 proteinase inhibitor.
- the patient’s alpha1-antitrypsin (AAT) concentration must be less than 80 milligrams per deciliter (mg/dl) [or greater than 11 micromolar (μM)]
- the patient’s obstructive lung disease, as defined by a forced expiratory volume in one second (FEV1) of 30 percent to 65 percent of predicted or a rapid decline in lung function, must be defined as a change in FEV1 of greater than 120 mL/year
- the patient must be a non-smoker
Question:: My patient is about to become too old to be covered by his parents’ health insurance. How long can he be covered under COBRA?
Answer: He can be covered under COBRA up to 36 months or until he qualifies for insurance on his own, whichever comes first. For more questions about COBRA, go to
www.dol.gov/dol/topic/health-plans/cobra.htm.
Question:: My patient is about to become too old to be covered by his parents’ health insurance. How long can he be covered under COBRA?
Answer: Medigap plans, also known as supplemental plans, for individuals under age 65 are governed by state laws. Currently, about one half of the states require Medigap plans be made available for the disabled under age 65. To see if your state is one of them, go to www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap. Alternatively, disabled patients under 65 may want to explore Advantage plans, also known as Medicare Part C. You can learn more about these Medicare Advantage Plans at www.medicare.gov/plan-compare/.
Question:: Do insurance companies restrict brands of immune globulin and coagulation factor products?
Answer:Coagulation factor and immune globulin (IG) products are medically necessary, but expensive, treatments. Most insurance companies require preauthorization for factor and IG. However, coagulation factor and IG products do not come in a generic form. Therefore, in general, insurance companies do not specify certain brands via a formulary. NuFACTOR believes patients and providers should have a choice of products. That is why we carry all brands of IG and coagulation factor products.
