Medical Professionals: Don’t Miss an Opportunity to Educate Payers

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Physicians, podiatrists, nurse practitioners, physical therapists, and certified wound/ulcer management nurses frequently contact this author with complaints about the Medicare Administrator Contractor (MAC) that processes their claims and releases coverage policies that pertain to their work.

In some instances, the professionals do not understand the coding, payment, or coverage regulations. This author does her best to educate those professionals to prevent them from making the same mistakes in the future. In other instances, the professionals’ complaints appear to be legitimate. Depending on the situation, this author often recommends that the professionals either request a peer-to-peer conference call with the medical director of the MAC or request a revision to the Local Coverage Determination (LCD) via the LCD Reconsideration Process.

Unfortunately, most of those professionals choose not to take the opportunity to educate their MAC’s medical director. In fact, most of them say that educating the MACs is the job of manufacturers. What they do not understand is that the MAC medical directors prefer to learn from medical professionals, rather than from manufacturers. When medical professionals do accept the responsibility of educating their MAC medical directors, this author personally witnesses many successful interactions which result in positive coverage changes. Those medical professionals quickly learn that most MAC medical directors are not wound/ulcer management specialists and they deeply appreciate learning from specialists who take the time to educate them, rather than to argue with them.

Following are a few representative scenarios that should inspire you to proactively educate your MAC’s medical director(s).

Scenario 1

For many years, a physician had great success using a certain product (that was listed as “covered” in his MAC’s LCD) on chronic wounds/ulcers that failed to progress when he followed all standards of care. Then the physician moved his practice to a different state and his claims were processed by a different MAC. It never occurred to the physician that he should check his new MAC’s LCD. He simply followed his normal clinical guidelines and protocols, which included using the product that was successful in his last workplace.

Approximately 2 months after the physician started his new job, the billers informed him that every claim for this successful product was denied. The physician immediately contacted this author, who first recommended that the physician read the new MAC’s LCD to learn what it said about coverage for the product. The physician was surprised to learn that the new MAC’s LCD did not cover the product in question, even though the product had a code and multiple published clinical trials.

Then this author recommended that the physician should request a peer-to-peer conference call with the MAC medical director. The physician’s immediate response was “that is the job of the manufacturer to obtain coverage for the product.”

This author reminded the physician that 1) the manufacturer did its job of conducting and publishing clinical trials and of obtaining a code for the product, and 2) now the physician should do his part to educate the MAC medical director “why” the product is clinically important for certain Medicare beneficiaries and that the lack of coverage denies access to care that the beneficiaries could receive if they lived in other states.  

Outcome to Scenario 1

The physician did request the peer-to-peer teleconference and was surprised that the call was scheduled quickly—just 7 days later. In preparation for the call, the physician prepared a concise PowerPoint presentation to help him make his case in a methodical, yet concise manner.

When the call began, the MAC medical director was congenial and listened carefully when the physician delivered his 2-minute “elevator speech.” The physician said he prepared a short PowerPoint presentation if the medical director would like to learn more about “when” and “why” physicians use the product that the MAC currently did not cover. To the physician’s surprise, the medical director said he definitely wanted to hear the presentation but wanted to schedule another call so that all the medical directors who worked for this MAC could learn from the presentation.

The presentation was scheduled for the following week. The physician sent the slides to the medical directors the day before his teleconference and then professionally delivered his educational presentation. The medical directors were attentive and asked particularly good questions, which showed that a lot of learning was happening. At the end of the call, the medical directors thanked the physician for taking the time to educate them and told him they would get back to him in a few weeks. Two weeks later, to the physician’s amazement, the MAC medical directors sent the physician a copy of the LCD that was revised and provided positive coverage for the product in question. To share the “good news,” the physician immediately sent a copy of the revised LCD to this author.

While reviewing the revised LCD, this author found another amazing surprise: The revised LCD’s effective date was retroactive to the exact date that the physician shared his educational presentation with the MAC’s medical directors! That physician was glad that he took responsibility for educating the medical directors.

Scenario 2

A MAC medical director released a draft LCD about a procedure that appeared to be abused. When the draft LCD was released, it shocked the wound/ulcer management physicians and other qualified healthcare professionals (QHPs) because it included clinically inappropriate guidelines. This author learned that many physicians and QHPs intended to submit comments and to criticize the MAC medical director who wrote the draft LCD. This author was genuinely concerned that the negative comments were not going to educate the MAC medical director how to write an LCD that would correctly limit utilization of the procedure while covering it in clinically appropriate situations.

Therefore, this author contacted a well-known wound/ulcer management physician who worked in that MAC’s jurisdiction and recommended that the physician request an in-person meeting with the MAC medical director while the comment period was still open for the draft LCD.

Outcome to Scenario 2

The physician thought that was a great suggestion and said he would make the appointment if this author would go with him to the in-person meeting. The physician was given a meeting date and time for the next week. Therefore, the physician and this author quickly made airline reservations and drafted the agenda we hoped to cover.

When we arrived, the MAC medical director warmly welcomed us and spoke to the physician by calling him “Doctor.” The physician explained that the two reasons for our visit were 1) to assist the medical director with controlling abuse of the procedure in the draft LCD, and 2) to provide LCD language that would allow clinically appropriate use of the procedure.

At that moment, something very surprising happened. The MAC medical director stood up, closed the office door, and spoke to the physician by using his first name. The medical director said “[Physician’s first name], I am so glad you came to assist me. I know this LCD is necessary, but I was not sure how to write it. I figured if I released a very restrictive draft LCD, that a wound/ulcer management professional would step forth to educate me how to write it correctly.”

The remainder of the meeting was an educational dialogue between the physician and the medical director that addressed every item of our preplanned agenda. At the end of the meeting, the medical director thanked us for requesting the meeting and taking the time to fly across the country and asked the physician to put all the recommendations that they discussed into formal written draft LCD comments.

When the medical director released the Final LCD, we received another surprise: the LCD included nearly every word of the physician’s recommendations, which reduced abuse and provided positive coverage language that guided medically necessary use of the procedure. That physician, and many other wound/ulcer management professionals, benefited greatly due to the physician’s willingness to address the coverage problem by educating the MAC medical director.

Summary

This author could share many additional scenarios to explain how medical professionals have successfully educated MAC medical directors, despite the medical professionals’ belief that manufacturers should do this work. The best outcomes have been achieved when manufacturers published their clinical evidence and provided it to the medical professionals who needed the evidence to gain coverage for a particular service, procedure, or product.

In fact, this author has participated in many open coverage meetings where both manufacturers and medical professionals made presentations. In nearly every situation, the MAC medical directors subtly made it clear that they appreciated medical professionals who were not sponsored by manufacturers, who spent their own money to travel to the meeting, and who took the time to educate the MAC medical director(s) and staff about real-life clinical examples pertaining to the coverage issue(s) under consideration.

Therefore, when draft LCDs are released in your Medicare jurisdiction, this author highly encourages all wound/ulcer management professionals to educate the MAC medical directors about draft language that is correct and about draft language that should be refined to align with published evidence, clinical practice guidelines, coding guidelines, etc. This should be done in writing and should be enhanced by presentations at announced open LCD meetings. After the MAC medical directors review and consider all comments to draft LCDs, they publish their responses to the comments at the same time they publish the Final LCDs.

Some Final LCDs are not 100% clinically correct and/or do not contain coding information that aligns with published coding guidelines. For example, this author continues to be amazed that wound/ulcer management professionals have not challenged several LCDs that do not correctly follow the surgical, selective, and non-selective debridement code descriptions and guidelines published by the American Medical Association in the CPT^®1 codebook. The CMS expects everyone to follow the CPT^® code book unless the CMS creates different codes and instructs the physicians/QHPs to use CMS’ codes. Therefore, wound/ulcer management professionals should bring these incongruities to the attention of their MAC medical director(s).

If a MAC releases final LCDs that contain inaccurate clinical or coding guidance, anyone can request a revision to the LCD by following the LCD Reconsideration Process. The Centers for Medicare & Medicaid Services (CMS) requires all MACs to publish their LCD Reconsideration Process guidelines on the MAC’s website. In fact, several wound/ulcer management LCDs were recently revised due to medical professionals’ using the LCD Reconsideration Process.

Now that you have learned that the MAC medical directors appreciate and value your sharing wound/ulcer management expertise with them, this author hopes that wound/ulcer management professionals will assume the responsibility of educating the medical directors when a coverage situation does not align with published evidence, clinical practice guidelines, and/or coding guidelines. Do not miss opportunities to educate the payers!

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

1. CPT Professional 2021 Codebook. The American Medical Association, 2021.