Prior Authorization is the first step you need to take to verify if a piece of durable medical equipment you are looking to have approved by your health insurance carrier is covered under your plans policy.

It is a decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or piece of durable medical equipment is “medically necessary.” In most cases, your health insurance provider requires that you submit prior-authorization paperwork for certain services before you receive them; except in an emergency.

Prior-authorization is not a promise your health insurance provider will cover the cost of the equipment you are looking to have approved.  It is just the first step in the approval process you need to go through.

1. How Does the Prior-Authorization Process Work?

Each step of the approval process requires its own strategy, which we will dive into “step-by-step”, in order to empower you to be your own advocate in getting the proper durable medical equipment approved that you need for “in the home” use only.

Below is an infographic of the whole process to get an idea on the overall process.

Parties involved for Prior-Authorization:

  1. Durable Medical Equipment (DME) Provider
  2. Physical Therapist
  3. General Practitioner and/or other Medical Professional
  4. Patient

Your insurance company will be looking to see if the DME you are looking to have approved is medically necessary for your medical condition.

Prior-Authorization Flow:

  • You first need to decide on what piece of medical equipment you are looking for and why it is “medically necessary” to your daily life in your home.
  • Schedule an appointment with your general practitioner or other medical professional to get them on board with why you need a specific piece of equipment. Your physician will write a Letter of Medical Necessity (LOMN) on behalf of you, the patient.
  • Schedule an appointment with your physical therapist for an evaluation to justify why this piece of DME is “medically necessary” for your medical condition. Your physical therapist can also write a LOMN/Evaluation on behalf of you, the patient.
  • Work with your “in-network” DME provider to make sure they are a dealer of that piece of DME equipment. If not, ask them if they can work with the company who manufactures that piece of DME equipment. Your DME provider will collect all of the necessary documents, signatures, and LOMN’s from your physical therapist & physicians. Your DME provider will then send in all paperwork to the Prior-Authorization department for your health insurance provider.

Tips & Tricks: Prior-Authorization Flow

Before you embark on the Prior-Authorization path with insurance it is important to understand what you’re trying to accomplish.

  1. For any piece of medical equipment you are looking to have approved by insurance you first need to speak with your doctor, physical therapist, or other medical professional to make sure they are on board with your plan to agree a piece of equipment is “medically necessary” for your condition.
  2. Do your homework. Make sure the piece of equipment you are after is appropriate for your disability. If it is not, chances are you will be denied.

Timeline Expectations

Each of the three steps mentioned above take time. You are going to need to have a little patience with respect to getting scheduled for your appointments, following up with your medical professionals about writing the evaluations and LOMN’s, etc.

This is why we suggest you give yourself about two months of prep time to get everything organized.

2. Getting Prepared: Tools & Mindset

Be Organized

  • It can be a trying process and a confusing one to try and mediate between a physical therapist, primary care physician, and a durable medical supplier. Don’t lose heart though because it can be done.
  • It just requires a little bit of organization on your part by simply keeping a word document, Google doc, Excel sheet, or a pad of paper to write down who did what, when, and where you are in the process.

Letters of Medical Necessity (LOMN)

  • While your medical professionals will understand the best medical terminology of how to justify a specific piece of DME you are looking to have approved, you’re going to have to explain to them why this piece of DME is “medically necessary” in your home.
  • They don’t live with you, so you have to elaborate in your own words and then they will, in turn, translate this into the appropriate “medical terminology” for your insurance company.
  • There are numerous examples of different strategies for helping your medical professionals make sure they include key pieces of information in your LOMN.

Tips & Tricks: Letters of Medical Necessity (LOMN) Advice

Your medical professionals will be responsible for justifying the equipment you are trying to have approved by your insurance company is “medically necessary” by writing an LOMN on your behalf.

While your medical professionals will understand the best technical medical wording for your insurance company, it’s helpful to work with them to make sure they understand your needs properly.

  • For Example – If you are trying to justify the need for a seat elevator on a power wheelchair you have to let your physical therapist who is doing your evaluation understand that it may be because you need to raise the chair up to the proper bed height for transfer; you can’t reach kitchen appliances in your home; you can’t open the front door without a seat elevator; you can’t pull up to your desk without raising the seat elevator for work, etc.
    • REMEMBER: You are your own best advocate and need to let your medical professionals know why said piece of equipment helps you in your home. They cannot read your mind. They can help you craft a carefully worded letter, but not without your help.

To help you better understand different expectations, requirements, and tips for assisting your medical professionals write the best LOMN’s for you – here are some examples:

  1. Palforziapro.com
  2. PatientsRising.org
  3. Genetech-access.com
  4. Medicalhomeportal.org
  5. Easy-walking.com
  6. Patient Advocate Foundation

There are dozens of other websites out there, but these should get you started and familiarized with proper templates, advice, and tips for LOMN’s.

Tip: While we should be able to trust our medical professionals, we, as patients, need to verify that they have our best interests at heart. Print out some of the above documents to review after reading your medical professionals LOMN’s to make sure they have all the necessary components for insurance justification.

NOTE: Your insurance company will likely justify these pieces of equipment as “accessories” and not “medically necessary.” Again, remember that you are trying to convince your insurance company “said” pieces of equipment are critical to your safety, quality of life, and help assist you in improving your Assisted Daily Living Activities.

3. Don’t Get Discouraged

  • Navigating the health insurance approval, denial, and appeals process is a frustrating one to say the least. When you hit a roadblock, don’t give up.
  • If you really want a specific piece of DME, you have to be “Pleasantly Persistent” by repeatedly calling your medical professionals to have them explain where they are in the process.
  • If you happen to get someone rude or someone who is unhelpful, then ask to speak to a supervisor, nurse, or manager. It is important to be polite even if you are really frustrated.
  • If you do not get approved at the Prior-Authorization phase of the process, don’t panic. You still have many internal appeals rights, which we dive into in the next section in order to plead your case.

Tips & Tricks: Patient Recommended Responsibilities

  1. It is a great idea to make sure you schedule an appointment with each medical professional who will be involved in helping you get your piece of equipment approved. For Example – If you are looking to have a seat elevator approved for a power wheelchair you will want to schedule an appointment with your durable medical supplier, general practitioner, and physical therapist for a seating evaluation.
  2. It’s also important to help assist your medical professionals in justifying why you need said piece of equipment in your home. Pay attention to the language they use and make sure that each of your medical professionals use similar language for each of your LOMN’s
  3. Finally, make sure to review all of the paperwork prior to your medical professional submitting Prior-Authorization to your insurance company. Sometimes a doctor will forget a signature or forget to justify something specific – this will undoubtedly result in denial from your insurance company right off the bat.

They will “Respect what you Inspect” as they say!

3. Schedule an Appointment with Your Physical Therapist

When it comes to the justification of Durable Medical Equipment (DME) such as seat elevators, specialized wheelchairs, exercise equipment, specialized shower chairs, specialized mattresses & frames, etc. –  your physical therapist (PT) is going to be your biggest advocate, and hold the most weight with your insurance company with respect to having this piece of DME approved.

It is important to note that if you are after a piece of DME such as a cardiovascular device, for example, then your physician or cardiologist will be your biggest advocate. You need to determine who your best advocate will be for any piece of DME you are trying to have approved.

When you decide on a piece of equipment you think is “medically necessary” for in-home use, the first step is to make an appointment with your PT for an evaluation of said piece of DME equipment.

Your PT will evaluate your physical needs and determine, with you, if said piece of DME is a good fit for you. Sometimes you will have to convince your PT why you need this piece of equipment.

TIPS

  • Your PT will generally be knowledgeable about your disability, but they cannot read your mind. With that said, you need to work carefully with your PT on explaining why you need a certain piece of DME.
  • For example, if you are a quadriplegic and you need a specialized shower chair that tilts, reclines, has a headrest, foot plates, etc. it is important to justify why each function of the shower chair is medically necessary for you. Here are a few common justifications:
    1. Low Blood Pressure – If you don’t tilt back in your shower chair and only have a simple shower bench it may cause you to lose consciousness. It goes without saying this is a life-threatening situation, especially if you are alone without a caregiver to assist you.
    2. Pressure Sores and Skin integrity – If you are unable to tilt your back chair the weight on your tailbone will cause skin breakdown leading to pressure sores. You may need the head rest because you do not have the upper body strength to hold your head up unassisted. In addition, you may be prone to pressure sores on your heels, which is why shower chair foot plates may be necessary for you.
    3. Safety – If you are paralyzed from the chest down and do not have the functional mobility to hold yourself up on a simple shower bench it can lead to falls, fractures, and safety issues.

The more information you are armed with the better chance you have with success in having your insurance company approve your request.

4. Schedule an Appointment with Your General Practitioner/Medical Professional

Your Primary Care Physician (PCP) or other medical professional is another key relationship you are going to need to develop because they are going to write you a Letter of Medical Necessity (LOMN) in addition to your PT Evaluation.

More often than not you will be working with a PCP unless your DME is highly specialized for specific medical conditions relating to things such as kidney disease, cardiology issues, etc., in which case you will likely be working with a specialist.

Oftentimes, patients ask their PT to work directly with their PCPs because many PCPs are not only lacking in the understanding of specialized DME for specific disabilities, but may not fully understand the intricacies of your disability on the whole.

Your PCP should follow your PT’s lead with respect to justifying the “medical necessity” of a piece of DME.

It is IMPORTANT that LOMN letters and PT Evaluations line-up in the assessment of your condition, why you need this piece of DME, and how it will improve your quality of life for Assisted Daily Living Activities — Hence having both PT’s and PCP’s working together is advised.

 

TIPS

  • Depending on your health insurance provider it’s a great idea to try and find a physician’s office that does not consist of an overwhelming number of physicians.
  • While there may be longer wait times to see your physician, a smaller practice of physicians usually means that they know your particular medical history and conditions in great detail, and will be willing to work with you on making sure the best LOMN is written.
  • When you work with a physician’s office with over 10 physicians, for example, and you don’t see your physician regularly they have a tendency to forget about you. It’s unfortunate, but they just see so many patients on a regular basis.
  • Also trying to navigate the staff within a larger physician’s office to make sure all the documents you need to submit for Prior-Authorization are where they need to go can be very challenging because you spend days waiting for someone to call you back.

Process

  • After your PT submits an LOMN/Evaluation for you justifying why this piece of DME is “medically necessary” for your specific condition, they then fax it over to your PCP’s office.
  • This is where your PCP will need to be organized in order to get the documents sent back over to your DME supplier in a timely fashion, and with all the proper notations & signatures.
  • This is why we suggest finding a smaller practice because you can build a relationship with the office manager, nurse, or front desk gatekeeper who can push the doctor along to get organized.

5. Work with your “In-Network” DME provider to make sure they are a dealer of this piece of DME equipment.

Your “in-network” DME Supplier relationship is an important one. Your DME supplier will generally be the one who submits the initial paperwork to your insurance company for Prior-Authorization. In some cases, your physician will submit all the paperwork, but not usually for DME.

Once you have your Letters of Medical Necessity (LOMN) and/or Evaluation from your PT and your PCP or other medical professional; your DME supplier will gather all the necessary paperwork to submit to your insurance company.

It’s important to note that not all DME suppliers are created equal. There are smaller local DME companies and large national DME companies such as Numotion. This is where paperwork, organization, signatures, etc. can get lost throughout the winding process of submitting Prior- Authorization paperwork to your insurance company.

Tips & Tricks: DME Provider – “In-Network”

It’s really important that you first contact your health insurance provider or go to your online portal to make sure your durable medical provider is “in-network.”

If they are not and they are “out-of-network,” then you are going to be left with a pretty hefty financial responsibility because any company not contracted with your insurance company will make you responsible for payment.

Smaller DME Companies

Smaller and locally run DME companies are easier to work with because you are able to build a relationship with them and they know you. This is great because it ensures they will fight for you and notify you if they need any further information from you or your medical professionals.

The challenge with smaller DME companies is that they don’t always have a large selection of the DME you may require.

It’s a pretty simple solution to figure out by having a conversation with them and ensuring that they are willing to work with you on whatever piece of DME you would like. Oftentimes, if you have a great relationship with them, they will even go above and beyond to become distributors of certain pieces of equipment for you too.

National DME Companies

Larger national DME companies definitely have more clout with respect understanding how to navigate within the insurance approval, denial, and appeals realm. They also have a larger selection of DME for you to choose from because they are simply a larger dealer.

The challenge you run into with these larger companies, as with any large company, is that you can become just a number and oftentimes get lost in the mix of other patients. It is a great idea to try and build a personal relationship with one or two people within the company in your area. If you are unable to do this then you NEED to be your own self advocate.

What does this mean?

Follow up in a word. It’s important to make sure you understand who all the players are in the game such as your PT, PCP’s, and DME suppliers, so you can help coordinate all the paperwork simultaneously to make sure the right documentation is getting submitted to insurance.

If you are not sure what all the right paperwork is to be submitted, just ask. Ask an employee in the insurance department of your DME company to walk you through the process step-by-step, take notes, and ask to see the documentation prior to submitting everything to insurance.

It’s all too common for Prior-Authorizations to get denied simply because a signature was left off, a medical code was not inserted properly, etc.

TIPS

  • Be aggressive, but polite. Remember that these companies work for you. They want to get paid and hopefully help you along the way. With that said, it is in your best interest to make sure your DME supplier or PT or physician walks you through the exact steps for each level of insurance approval.
  • There is an age-old saying – “They will Respect What You Inspect”. This is particularly key in the world of navigating your insurance company.
  • Try to make sure you get all conversations in writing by email in case something goes wrong down the line, so you can refer back to what a specific person told you.

6. Document Submission

Documents to be submitted:

  • PT Evaluation and/or Letter of Medical Necessity (LOMN) written by your PT
  • LOMN written by your Physician
  • Physician will also sign off on your PT’s evaluation
  • DME Suppliers quote for requested DME
  • Insurance Prior-Authorization Form

All these documents will be faxed in by either your DME supplier or your physician. Typically with DME, it is your DME supplier who will organize and fax in all the documents.

7. Next Steps…

  • In-Network Approval: Yay!
  • Out of-Network Approval: If you received an out-of-network approval, you’ll end up paying more than the in-network approval. To find out how to deal with that check out  – Out-of-Network Approval Guide.
  • Denial? Don’t panic, this is the time for the next step.  Check out Step 2: Internal First-Level Appeal to find out Why Your Prior-Authorization Got Denied and How to Prepare for the Next Steps.

Tips & Tricks: Expectations

If you are trying to get approved for a piece of medical equipment that is deemed an “accessory” as defined by your health insurance company, but you are trying to convince them that said piece of equipment is “medically necessary,” then don’t be surprised if you get denied during Prior-Authorization.

Don’t get discouraged!

“NO” during the Prior-Authorization stage of the approval process is really just a starting negotiation point. It’s pretty standard for health insurance companies to deny you right off the bat, but this is what the appeals process is for, which we dive deep into in the next section.

Make sure to keep all of your paperwork organized because when you do move on to the appeals process it is a little bit more involved, and requires some serious organization on your part.

  • It is only natural to think your medical professionals have it together and work with one another with respect to organization of your files. Unfortunately, this is far from the reality of the situation. You are your own best advocate, so you need to make sure you stay on top of them during every phase of the process

Terminology

1. Durable Medical Equipment (DME)

DME is any equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illnesses.

DME equipment under Medicare guidelines must meet these criteria

  • Durable (can withstand repeated use)
  • Used for a medical reason
  •  Are not will to a person in the absence of illness or injury
  •  Used in your home
  •  Generally has an expected lifetime of at least 3 years
  •  Must be ordered or prescribed by a physician
  •  Most private insurance companies follow Medicare guidelines.

DME includes, but is not limited to:

  •  Wheelchairs (manual and electric), hospital beds, traction equipment, canes, crutches, walkers, kidney machines, catheter care products, colostomy products, ventilators, oxygen, monitors, pressure mattresses, lifts, and nebulizers.

2. Letter of Medical Necessity (LOMN)

A LOMN is a carefully written letter by your physician and/or physical therapist stating why the patient needs a specific piece of equipment, test, treatment, or medication. Your medical professional will diagnose your medical condition, include pertinent medical history, outline why said piece of DME equipment is medically necessary for your condition even if your insurance provider deems certain DME equipment as an accessory and not “medically necessary” under your insurance plan’s policy.

Please refer to Tips & Tricks for LOMN patient strategies to write the most effective lette

3. In-Network Providers

In-network providers are healthcare providers who are contracted by an insurance company, and provide medical care to those enrolled in plans offered by that insurance company.

The providers in the health insurance plans network are called in-network providers. Every insurance plan provides a list of in-network providers on their patient portals.

4. Out-of-Network Providers

A provider who is not contracted with your insurance company for reimbursement at a negotiated rate.

5. Durable Medical Supplier

A durable medical supplier is any company selling medical equipment used in the home to aid in a better quality of living.

Durable medical suppliers offer DME equipment such as wheelchairs, shower chairs, canes, incontinence products, colostomy products, etc.

6. Prior Authorization / Prior Approval

Under your medical and prescription drug plans, certain medications, services, and equipment may need approval from your health insurance carrier before they are covered.

Prior to receiving any service, product, or medication from an insurance company your physician and other medical professionals will write a letter of medical necessity for the patient justifying why a product or service is medically necessary for the patient’s medical condition.

7. Explanation of Benefits (EOB)

An explanation of benefits is a statement from your health insurance plan describing what costs it will cover for medical care or products the patient is eligible to receive.

The EOB is generated when your provider submits a claim for the services you have received.

You can find your explanation of benefits on your Health Providers Patient Portal and/or they send you a booklet each year when enrolling in a health plan.

8. What is a Department of Insurance (DOI)

Insurance is regulated at the state level, so each state has its own insurance department to help you. Each department is tasked with one overarching duty of regulating insurance for the protection of consumers.

The DOI serves several roles including licensing insurance companies and agents, regulating insurance policies and rates, reviewing insurance company practices, and serving consumers through education and complaint resolution

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SPINALpedia
Spinal Cord Injury
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