Advocating for change in healthcare is a two-sided coin. On one side, you advocate for your client’s well being. On the other side, you advocate for the regulators and policymakers well being. When done properly, both the provider and the policymaker enjoy improved efficiencies and outcomes, and at the end of the day both parties enjoy cost savings. Isn’t that the goal for healthcare? Improved healthcare quality with responsible and reasonable costs? The fewer claims rejections and the fewer auditor visits, the fewer unhappy healthcare providers and regulators you will have.

Here is but one issue that we are still advocating for in the orthopedic device market. When a Medicare Contractor for Pricing, Data Analysis and Coding (DMEPDAC) of HCPCS Level II DMEPOS Codes approves a device for inclusion in their reimbursement system, certain requirements need to be met. The manufacturer or provider of a given device is required to meet the biomechanical specifications for that device, assign a product identification number to the device (i.e., model number or similar) and get it approved by the DMEPDAC authority. After approval by DMEPDAC, a procedure code for the device is listed on their website and the device can then be dispensed by a provider as an approved Medicare device. But here is where the roof caves in at times. Since a photo image of the approved device is not attached to the device on the DMEPDAC website, the only way to ensure that a provider is dispensing an approved device, they must rely on the posted DMEPDAC model number or another defining description. However, it is not uncommon for a device that is approved and a model number assigned not to be found on the manufacturer’s website. Therefore, in those situations, how can a provider or Medicare auditor ensure that the patient received what was approved on the DMEPDAC website? If the device model numbers don’t match the approved product, they can’t. Here is a suggested solution. In this day and age of electronic wizardly, DMEPDAC should require more than they do now. Following is what should happen, in our opinion.

1. Manufacturer submits device to DMEPDAC for approval, along with a model number and three or four view photograph of the device. Enough photos to prove that the device complies with the associated requirements; front, back, side, and perhaps oblique views.
2. Model numbers cannot be changed by the manufacturer without resubmitting the device to the DMEPAC for new approval with a new model number. In other words, this is a wysiwyg approach. What you see is what you get, period.
3. Either the DMEPDAC or the manufacturer should be required to post and maintain appropriate line item photos of the device on their respective websites.
4. A simple barcode should be required to be attached to each device that is approved by the DMEPDAC. The barcode should include the approved HCPCS code (A-code, E-code, L-code, etc.), the item model number, and the date of expiration for that device.

In our opinion, this would go a long way toward making the orthopedic healthcare system more fair for everyone. First, it provides an apple to apple comparison that is useful for both the provider and the regulatory agency. Both providers and regulators, including auditors, would no longer have to guess whether the device is actually the one listed on the DMEPDAC site. Eliminating such uncertainties as product identification helps reduce errors, intentional or unintentional, and improves efficiency for everyone. It also helps to deter fraud and abuse, which unfortunately does exist.

At the end of the day, our mission is quite simple. Help our clients meet the moving target policies and regulations set forth by insurance companies and government agencies so that they can remain profitable and in business. Unfortunately, there is nothing simple about this. Insurance companies exist to make a profit and often their rules and regulations set forth are not helpful for the healthcare system. For example, the Medicare claim processing period is one year. But some insurance companies require claims to be settle within 90 days, or sorry about your luck. Since these insurance companies sometimes process Medicare claims and the rule for Medicare is one year, why are they allowed to process federal government claims and require a 90 day time frame for claim settlement? Just one more unfair discrepancy in rules and regulations that affect our citizens.

So while we work each day for our clients with their best interest in mind, we also work to advocate for logical improvements in the healthcare claims processing system. After all, if we can advocate for more fair and simple rules and regulations, not only do our clients benefit in a big way, the insurance companies and government agencies benefit as well. Healthcare audits are a VERY expensive ordeal and guess who ends up paying the bill? One guess only.