Reimbursement Q & A: Submit Your Questions

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New Patient Care</h1> <h1 class="page-head">Reimbursement Q & A<a href="" class="fb-share-btn" target="_blank"></a><div class="fb-share-text">share</div></h1> <h1 class="sub-head">IGL readers are encouraged to submit their questions about reimbursement.</h1> <img src="/assets/img/main-image-half-width-new-patient-care.jpg" class="main-image-half-width img-responsive" alt=""> <h4>Below you will find a sampling of previous questions and answers.</h4> <p><span class="bracketed-link"><a href="/resources/reimbursement-q-and-a-form.html">Submit your question here.</a></span></p> <p class="question"><strong class="begining-label">Question:</strong> What is the most common reimbursement error?</p> <p class="answer"><strong class="begining-label">Answer:</strong> 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. </p> <hr> <p class="question"><strong class="begining-label">Question:</strong> Is it advisable to change a diagnosis so Medicare will cover the treatment? </p> <p class="answer"><strong class="begining-label">Answer:</strong> 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. </p> <p>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.” </p> <p>Code 279.06 (CVID) includes these diagnoses:</p> <ul class="indent-left-1x"> <li>Dysgammaglobulinemia: acquired, congenital, primary</li> <li>Hypogammaglobulinemia: acquired primary</li> <li>Hypogammaglobulinemia: congenital non-sex-linked</li> <li>Hypogammaglobulinemia: sporadic Caution should be exercised, as misinterpretation of the wording could still result in claims not being paid</li> </ul> <hr> <p class="question"><strong class="begining-label">Question:</strong>: What are the qualifiers insurers consider medically necessary to treat alpha-1 antitrypsin deficiency (AAT) with an alpha 1-proteinase inhibitor?</p> <p class="answer"><strong class="begining-label">Answer:</strong> 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. </p> <p>The following is an excerpt from one major insurer’s policy detailing what documentation warrants treatment of AAT with an alpha-1 proteinase inhibitor.</p> <ul class="indent-left-1x"> <li>the patient’s alpha1-antitrypsin (AAT) concentration must be less than 80 milligrams per deciliter (mg/dl) [or greater than 11 micromolar (μM)]</li> <li>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 </li> <li>the patient must be a non-smoker</li> </ul> <hr> <p class="question"><strong class="begining-label">Question:</strong>: My patient is about to become too old to be covered by his parents’ health insurance. How long can he be covered under COBRA?</p> <p class="answer"><strong class="begining-label">Answer:</strong> 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 <br> <a href="https://www.dol.gov/dol/topic/health-plans/cobra.htm" target="_blank">www.dol.gov/dol/topic/health-plans/cobra.htm</a>.</p> <hr> <p class="question"><strong class="begining-label">Question:</strong>: My patient is about to become too old to be covered by his parents’ health insurance. How long can he be covered under COBRA?</p> <p class="answer"><strong class="begining-label">Answer:</strong> 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 <a href="https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap" target="_blank">www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap</a>. 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 <a href="https://www.medicare.gov/plan-compare/" title="Medicare Plans" target="_blank">www.medicare.gov/plan-compare/</a>. </p> <hr> <p class="question"><strong class="begining-label">Question:</strong>: Do insurance companies restrict brands of immune globulin and coagulation factor products?</p> <p class="answer"><strong class="begining-label">Answer:</strong>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.</p> </div>   <div class="col-md-3 sidebar interior" > <div class="row rt-nav hidden-xs hidden-sm"> <ul class="list-group sidebar-nav-v1" id="sidebar-nav">  <li class="list-group-item list-toggle"> <a data-toggle="collapse" data-parent="#sidebar-nav" class="accordion-toggle" href="#collapse-new-patient-care">New Patient Care</a> <ul id="collapse-new-patient-care" class="collapse"> <li><a href="/resources/new-patient-care.html">Overview</a></li> <li><a href="/resources/new-patient-care.html?scrollto=nufactor">Nufactor Patient Resources</a></li> <li><a href="/resources/reimbursement-q-and-a.html">Reimbursement Q&A</a></li> <li><a href="/resources/new-patient-care.html?scrollto=appeal">Write an Effective Appeal Letter</a></li> <li><a href="/resources/connect-patient-support.html">Connect with Patient Support</a></li> <li><a href="/resources/new-patient-care.html?scrollto=ig">IG Health Tools</a></li> </ul> </li> <li class="list-group-item"><a href="/resources/products-and-manufacturers.html">Products & Manufacturers</a></li> <li class="list-group-item list-toggle"> <a data-toggle="collapse" data-parent="#sidebar-nav" class="accordion-toggle" href="#collapse-education-studies">Education & Studies</a> <ul id="collapse-education-studies" class="collapse"> <li><a href="/resources/literature.html">Literature – Books & Articles</a></li> <li><a href="/resources/medical-research-studies.html">Medical Research Studies</a></li> <li><span class="badge badge-igl">New</span><a href="/resources/scholarships.html">Scholarships</a></li> </ul> </li> <li class="list-group-item"><a href="/resources/legislation.html">Legislation</a></li> <li class="list-group-item"><a href="/resources/disorders-treated-with-ig.html">Disorders Treated with IG</a></li> <li class="list-group-item"><a href="/resources/insurance.html">Insurance</a></li>  </ul>  <div class="col-md-12">     <div class="rt-col-divider"></div> <div class="rt-col-divider"></div> </div> </div> <div class="row"> <div class="col-md-12"> <div class="rt-col-divider hidden-md hidden-lg"></div>    <div class="sidebar-wrapper latest-issue"> <div class="gray-bg-top" ></div> <h3>Read the Latest Issue Online</h3> <div class="img-container"> <a href="/magazine/current-issue.html" title="IG Living Current Issue"><img src="/assets/img/sidebar-current-issue.jpg" class="img-responsive" alt=""/></a> </div> <h6>Making Connections: Starting a Support Group <span class="bracketed-link" style="font-weight:500;"><a style="font-size:17px;" href="/magazine/current-issue.html" title="IG Living Current Issue">more</a></span></h6> </div>  </div> </div> </div>  </div> </div>   <div class="footer-v2"> <div class="footer"></div> <div class="copyright"> <div class="container"> <div class="col-md-9" style="text-align: center;"> <p style="margin-bottom: 35px;"> <a href="/index.html">Home</a> | <a href="/magazine/learn-about-ig-living.html">About</a> | <a href="https://www.igliving.com/magazine/subscribe.aspx">Subscribe</a> | <a href="/advertise/advertise.html">Advertise</a> | <a href="/site/subscriber-services.html">Contact</a> | <a href="/site/privacy-statement.html">Privacy Statement</a> | <a href="/site/terms-of-use.html">Terms of Service</a> | <a href="/site/consumer-health-data-privacy-policy.html">Consumer Health Data Privacy Policy</a> |  <button id="ot-sdk-btn" class="ot-sdk-show-settings do-not-sell-link">Do Not Sell My Personal Information</button><img src="/assets/img/privacyoptions29x14.png" alt="California Consumer Privacy Act (CCPA) Opt-Out Icon" style="display: inline-block; margin-left: 6px; margin-top: -2px;">  <br><sup class="copyright">©</sup><script>document.write(new Date().getFullYear())</script> FFF Enterprises, Inc. <a style="margin-bottom: -15px;" href="https://www.facebook.com/IGLivingMagazine/" target="_blank" class="btn" title="IGL Facebook page" aria-label="IGL Facebook page"> <i class="fa fa-facebook" aria-hidden="true" aria-label="IGL Facebook page" title="IGL Facebook page"></i> </a> </p> </div> <div class="col-md-3"><p><a href="/"><img src="/assets/img/logo-igl-site-new.png" class="footer-logo" alt="IG Living!"/></a></p></div> </div> </div> </div>  </div>  <script type="text/javascript" src="/assets/js/jquery/jquery-3.6.0.min.js"></script> <script type="text/javascript" src="/assets/js/jquery/jquery-migrate-3.3.2.min.js"></script> <script type="text/javascript" src="/assets/js/bootstrap/bootstrap-3.3.7.min.js"></script> <script type="text/javascript" src="/assets/js/bootstrap/bootstrap-accessibility.min.js"></script> <script type="text/javascript" src="/assets/js/track-focus.min.js"></script> <script type="text/javascript" src="/assets/js/bootstrap/bootstrap-hover-dropdown.min.js"></script> <script type="text/javascript" src="/assets/js/back-to-top.js"></script>  <script type="text/javascript" src="/assets/js/app.js?v=2.0.1"></script>    <div id="myOtherAd"></div> </body> </html>

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Reimbursement Q & A: Submit Your Questions