Tag Archive for: Medicare

Access to Supplies with Medicare – The Never-Ending Story

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Words of Advice from UOAA’s Advocacy Committee Co-Chair Sue Mueller and Advocacy Manager Jeanine Gleba

UOAA often hears from the ostomy community about their struggles with getting quantities of ostomy supplies that are over the Medicare allowable limits. UOAA recognizes that the process to obtain supplies beyond the maximum amount is difficult to navigate and is not well understood.  

Medicare’s coverage of ostomy supplies is explained in their Local Coverage Determination (LCD) policy (A52487) and the allowable quantity limits are in LCD policy L33828.  According to their policy:

“The quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual beneficiary need and their needs may vary over time. The actual quantity needed for a particular beneficiary may be more or less than the amount listed depending on the factors that affect the frequency of barrier and pouch change. 

The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary’s medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary.”

According to our conversations with the Center for Medicare and Medicaid Services’ (CMS) billing contractors the quantities listed are reasonable and necessary for 80% of the patient population. The key for the small population who require quantities of supplies that exceed the usual maximum amount, is the information documented in the medical record that explains the need for the increased amount.  What are the factors that affect the greater frequency of changes for you? You must determine what documentation is missing from your medical record that medically necessitates having the greater quantity and then work with your medical professional to get the missing information included in your records and have your supplier submit them to Medicare. Please note that a letter from a nurse or doctor is not sufficient nor is just having it listed on your prescription. The justification of your need for additional supplies must be in your medical record. To learn more read UOAA’s blog “Know What’s In Your Medical Record”.

Any claim that goes over the allowable quantity is automatically denied in the Medicare billing system. It must then be appealed and the supplier has to show the documentation that proves medical necessity etc.  Appeal denial is so frequent that most suppliers no longer advance the increased amounts while waiting for an appeal decision and do not automatically file appeals. They only submit claims for the allowable limits and then the consumer has to pay out of pocket for any overages. 

Given the cumbersome frustrating process, before you deal with the hassle, UOAA suggests that you consider being re-evaluated by an ostomy nurse. Together you can evaluate why you need more supplies and determine if you need a different pouching system or can find another work around.  For example someone who uses 3-5 pouches per day may benefit from changing to a drainable pouch. If there isn’t an ostomy nurse in your local area, some facilities have telemedicine options or UOAA has a self-pay virtual ostomy clinic. There are many different types of supplies available to meet varied needs of ostomates and remedy the challenges that occur over the lifetime of an ostomy. A certified Wound Ostomy Continence (WOC) nurse is the ideal person to assess your situation and make recommendations. 

Increasing the number of pouches is not the solution for every problem. For example someone with a high-output stoma producing greater than 2L of liquid stool daily will want to first consider looking at their diet by working with a dietician and reading UOAA’s Eating with an Ostomy information. In some situations the solution may be adding medications or the timing of medication and eating.  This is why it is important to consult with your medical team or obtain a medical team that is responsive to your needs.

After you have consulted with your medical team and determined that you have a justifiable need that can be documented for more pouches, then pursue the Medicare appeal process with your supplier. Be prepared to purchase your additional supplies while you wait for the Medicare decision. Try to get your needed supplies at the lowest cost through discounts and free supplies. UOAA lists lower cost supply resources here.

If your appeal is denied, another resource is your local State Health Insurance Assistance Program (SHIP). They can assist you with correcting billing issues, and filing complaints and appeals. With your permission, SHIP will work with Medicare directly to help solve problems on your behalf. Find your local SHIP here.

The information we just discussed applies to people with traditional Medicare, if you have a Medicare Advantage plan you should follow the appeal procedure of your plan. You may also request a case manager who is an employee of the plan for assistance with the process. The decision-making process is different with Medicare Advantage plans. 

UOAA has been advocating on this issue for many years and we will continue to beat this drum with the Centers for Medicare and Medicaid Services (CMS) and their coverage jurisdiction Medical Directors until improvements are made.

 

OPEN ENROLLMENT – YOUR CHOICES ARE IMPORTANT!

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Jeanine Gleba, UOAA Advocacy Manager
Sue Mueller, RN, BSN and UOAA Advocacy Committee Co-Chair

The Medicare Open Enrollment Period occurs each year from Oct. 15 to Dec. 7, and this gives consumers the chance to review and make changes to their current Medicare coverage. Many employers also have open enrollment for health insurance during this time period. Health care insurance plans are not equal and the plan you choose can make a difference in the amount and type of ostomy supplies you receive and the companies that provide your supplies. It’s crucial that people living with an ostomy understand their health insurance plan and shop around for the best plan to meet all of their medical needs. 

Although UOAA is not in the insurance business and does not give insurance advice, it does listen to our members and respond by taking action. We are committed to preserving your access to the supplies that you choose. UOAA’s Advocacy Committee has submitted federal comments and recommendations to the Centers for Medicare and Medicaid Services (CMS) as well as partnering with coalitions and endorsing policy papers that are used when advocating with healthcare insurance companies and key decision-makers. An example of this is the White Paper that UOAA co-authored and endorsed entitled “The Critical Need to Provide Ostomy Supplies Specific to Patient Need to Improve Health Outcomes”

As you do your research during your open enrollment period or become eligible for Medicare for the first time, be cautious with Medicare Advantage Plans (MC Advantage). These are also known as “Part C” and are a type of Medicare health plan offered by a private company that contracts with Medicare. Learn more about understanding Medicare Advantage plans.  According to data (from CMS) over half of eligible Medicare beneficiaries are now enrolled in private Medicare Advantage Plans (1). There are many known problems with these plans such as narrow provider networks, prior authorization requirements and high out-of-pocket costs. 

For the ostomy community, although MC Advantage Plans must cover the same medical services and treatments as original Medicare, how much they cover is up to them.  Some MC Advantage plans have less ostomy supply coverage than Medicare specifically by restricting where beneficiaries can shop for supplies and what kind they approve. UOAA has found that some ostomy patients with these plans must use products from multiple manufacturers. Some MC Advantage plan benefits exclude Medicare HCPCS (Healthcare Common Procedure Coding System) product codes for ostomy supplies such as filters, tape, adhesives, deodorants and other medically necessary items. What this means is that these supplies are not even available for you to choose.

There are many Medicare Advantage Plans in the United States. Each state’s insurance department approves the MC Advantage plans that can be sold in each state and each county within the state. So the plans vary from county to county. The MC Advantage plans usually have approved national provider networks for supplies however UOAA has found that in some counties the MC Advantage plans limit the suppliers you can use to local providers and do not let their beneficiaries choose from the national network providers. This may result in a limitation of your supply choices. One example UOAA has discovered is the difference in suppliers available in a rural county as compared to the national network provider offered to the residents in a large city.

Some MC Advantage Plans also have much lower reimbursement rates than traditional Medicare. These reduced fee schedules have resulted in suppliers to either stop taking individuals with an ostomy, offer lower quality products or offer a limited product line. (see the policy paper link above).  

This practice of restricting beneficiaries to particular brands, specific suppliers or less product coverage, limits patient access to the products they need. The consequence of this practice is that many ostomates are unable to obtain their prescribed ostomy supplies and are no longer able to effectively manage their ostomy.  

If you chose a high deductible plan, remember that although you have a lower monthly premium you will be paying out of pocket for all of your ostomy supplies which are expensive until you meet the deductible requirements. 

If you aren’t on Medicare but are selecting a new health plan, carefully review “basic” plans on the marketplace.  Some of these bare bones plans do not cover ostomy supplies.  

For more tips and information refer to the article released by UOAA’s Advocacy Committee entitled “Are You Covered? Know Your Healthcare Insurance and What You Need”. As you compare plan options and shop around, ask questions such as “Can I use my current supplier with this insurance?”. Here are more: 10 Questions to Ask Before You Choose a Health Plan.

 

 

1. Freed, Meredith, et al. “Half of All Eligible Medicare Beneficiaries Are Now Enrolled in Private Medicare Advantage Plans.” KFF, 1 May 2023, https://www.kff.org/policy-watch/half-of-all-eligible-medicare-beneficiaries-are-now-enrolled-in-private-medicare-advantage-plans/. Accessed 17 October 2023.

Positive Change is Happening!

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2019 Advocacy Accomplishments We Can All be Proud of

By UOAA Advocacy Manager Jeanine Gleba

I pride myself on being an “action person” and nothing gives me greater satisfaction than checking those boxes and crossing off items on my lists to-do (daily, short-term, long-term etc) both in my personal life and professionally. So I get super excited at year-end when I can reflect and look back at all that UOAA has accomplished in our advocacy efforts!  I’m happy to report 2019 was not an exception. Although many priorities are ongoing and I can’t actually cross them off my list, I remind myself that Rome was not built in a day and realize to make a major impact in the health care world it could take many years. The important thing for all of us to remember is that we are making progress and positive change is happening.

UOAA Ostomy Advocates at the DDNC

Ostomy advocates at the DDNC Public Policy Forum in March.

Each year UOAA’s Advocacy Committee establishes annual goals based on the strategies outlined in UOAA’s Advocacy Agenda. We have learned that the needs of the ostomy community are fluid and more often than not, I find each year that new priorities must get added to the list. These goals and priorities keep us organized and ensure we stay focused on where we can have the most effect given our organization’s limited resources.

In no particular order and not an all-inclusive list below will give you an idea of what we worked on and accomplished in 2019. This does not include Ostomy Awareness Day efforts as they were previously shared: 

Completed the “Expect More: Take Control of Your Healthcare” self-advocacy toolkit with checklists – All of the parts and resources are online here. In 2019 there were 579 downloads of the resources and the ostomy supply checklist had the most downloads at 247.

Best in Practice Research Project Launched – The purpose of this research project is to examine components of UOAA’s Ostomy and Continent Diversion Patient Bill of Rights (PBOR) and demonstrate best in practice standard guidelines for ostomy care. In 2019 we collected the data, in 2020 we will conduct the data analysis phase, publish results and ideally find ways to use the results to improve patient outcomes.

Centers for Medicare and Medicaid Services (CMS) Ostomy Supply Policy 

  • Conducted an online survey earlier and analyzed results to better understand the issue of obtaining greater than allowable quantities for those that have a medical necessity such as a high output stoma
  • Submitted comments and recommendations from UOAA to CMS for the Simplifying Documentation Initiative (SDI) and the Patients Over Paperwork Initiative to reduce burden as it relates to the ostomy supply process. 
  • We have a subcommittee comprised of medical professionals, manufacturer representatives, and patient advocates who will continue this effort in 2020.

Legislative Priorities 

  • Advocated on the Disability Integration Act (DIA), Removing Colorectal Screening Barriers, Ostomy Awareness Day, Step Therapy, and Competitive Bidding Program
  • Released two new position statements for DIA and Opioids
  • Supported the DDNC Step Therapy National Day of Advocacy

Additional Efforts to Expand Patient Bill of Rights

  • Safe n Simple is now including the PBOR Wallet Card in new ostomy patient starter kits and Byram Healthcare now includes it in their ostomy educational booklet

Further Advocacy Outreach and Collaborations 

  • Upfront with Ostomies Column: As a result of contacting the editor of the Wound Management Prevention journal UOAA now has its own column in this clinician journal.  5 articles were published in 2019
  • UOAA was invited by the CMS Quality organization to submit a new idea for the 2021 Improvement Activities used in the Merit-based Incentive Payment System. Ex-committee Member Barbara Dale and I submitted for consideration two modifications to existing improvement activities that focuses on re-evaluation of ostomy care and supplies
  • Access and Care Coalition: Successfully continued to ensure Congress refrains from expanding the Medicare Competitive Bidding program to include ostomy and urological supplies 
  • 3172 people downloaded the TSA Travel Communication Card
  • Started efforts with OEM of LAX airport in CA to make restroom improvements for ostomy accessibility; created UOAA guidelines for United States ostomy restroom accommodations 
  • Between myself and members of the Advocacy Committee we authored or contributed to 18 magazine and UOAA e-newsletter articles on advocacy-related topics

Looking forward to greater achievements in 2020!

Do You Know Where We Stand?

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By UOAA Advocacy Manager Jeanine Gleba

Under UOAA’s national advocacy program we develop position papers on topics concerning people living with an ostomy or continent diversion. This official “position” is formally approved by the Board of Directors. These important documents might give background information, description of the impact on our community, and in some cases, advocate for change. 

These papers also provide a perspective into UOAA’s views, and can be used by you, to strengthen your own self-advocacy efforts. Individuals and UOAA Affiliated Support Groups can use them when talking to key decision-makers such as your elected officials, the media, or anyone who wants to know more about where UOAA stands on the topic/issue. 

UOAA currently has position statements available on the following advocacy efforts:

 

Disability Integration Act (DIA) (S117/HR555) – This civil rights bipartisan legislation would require insurance providers to cover community-based health care services for people with disabilities as an alternative to institutionalization. The DIA would ensure that people could not be prematurely forced into nursing facilities because they couldn’t get assistance with health-related tasks such as maintenance and use of a stable ostomy. This is a good thing and we support it! UOAA’s position is here. 

Medicare’s Competitive Bidding Program – UOAA is actively working to maintain the current Medicare reimbursement system for ostomy and urological products. Currently ostomy and urological supplies are not included in the Competitive Bidding Program and we want to keep it that way. UOAA’s full opposition is here. 

Opioid Crisis – UOAA wants to ensure that any plan, especially legislatively or regulatorily, to address the opioid crisis considers the needs of those who require the use of opioids for non-pain treatments of medical conditions such as high output stomas for some people living with an ostomy or fecal continent diversion. UOAA’s position is here. 

Removing Barriers to Colorectal Cancer Screening Act (S668/HR1570) – This act would eliminate cost-sharing for initial and follow-up colorectal cancer screening tests such as removal of polyps for Medicare beneficiaries. Cost-savings for senior citizens and move lives saved is a no-brainer. UOAA’s position is here.

All of our position statements are available for download and printing on our advocacy webpage.  We encourage our community to frequently check this page as efforts get updated or closed, and new issues may arise.

Are You Covered? Know Your Health Care Insurance and What You Need

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Expect More – Take Control of Your Health Care

Part 5 in Series

By Jeanine Gleba, UOAA Advocacy Manager and Sue Mueller, CWOCN

In Part 5 of the Expect More – Take Control of your Health Care series, we tackle the sticky subject of health insurance and the importance of knowing what you’re getting in your policy. How many people plan on getting an ostomy? It’s one of those things that happens in life. So you learn to live with it and then adding insult to injury you discover that the health care insurance you had proves to be inadequate to cover the costs of your ostomy supplies.  You are stunned to discover that ostomy supplies cost $300-$600 a month. Suddenly you’re expected to adjust to your new circumstance and also cope with a significant cost as you scramble to find solutions.

Every year individuals have an opportunity to re-evaluate their health care needs and insurance coverage, and if need be, during that window of opportunity, change health care plans or increase coverage.  

How do YOU get your health care insurance?

First step is to know exactly where your coverage is coming from so you know where to get information from and ask questions.

You get health care insurance:

  1. Through your employer (usually you and your employer share costs)
  2. When you buy your own healthcare insurance from your state Health Insurance Marketplace
  3. You qualify for Medicare by age and work history
  4. You qualify for Medicare by disability and work history.
  5. You qualify for Medicaid because you are a dependent child,are a parent of a dependent child, or by low income.
  6. You qualify for military health benefits because you or your family are active US military, or have retiree benefits.
  7. You qualify for veterans benefits because of your military service and honorable discharge.
  8. You qualify for American Indian/Alaska Native healthcare coverage.

What are your medical needs?

You can begin to determine your needs by calculating your medical risks. What is your medical history and your family’s medical history?  What are your lifestyle health behaviors (i.e., diet, exercise, smoker etc.)? As you age, your medical risks increase, so take this into consideration when planning health insurance coverage. If you have several medical diagnoses/pre-existing conditions (e.g.., colostomy, urostomy or ileostomy), take prescription medications, and require visits with specialist physicians you have different needs and risks than someone with no diagnoses and no prescriptions.

So what is the best employment and financial strategy for you? If you can’t afford marketplace healthcare insurance can you or your spouse become employed by a large company with comprehensive benefits? What is your age? You might make one choice at your present age and another choice at a later date. Ask around, educate yourself, every state has a number to call to get healthcare insurance information (ask for SHIP- state health insurance assistance plan).  For example, some people don’t understand that they need to sign up for Medicare Part B insurance (where ostomy supplies are covered) when they are first eligible or simply don’t because of the additional premium due. Others have been misinformed and thought the VA would cover all their healthcare needs; however, they actually need to sign up for Medicare A and B AND use the VA. Also many people don’t realize that there is a penalty for not signing up for Medicare B and D when you are first eligible.

Once you calculate your medical risks, examine your finances and are choosing a healthcare policy, you need to know:

Your health insurance policy is an agreement between you and your insurance company, a contract. The policy lists a package of medical benefits such as tests, drugs, and treatment services. The insurance company agrees to cover the cost of certain benefits which are listed in your policy. These are called “covered services.” Your policy also lists the kinds of services that are not covered by your insurance company, and circumstances that are not covered (exclusions). You have to pay for any uncovered medical care that you receive. Don’t confuse what your policy covers with what is “right”, what your neighbor’s policy covers or what you think you are “entitled to”. What is covered is what is stated in your policy. If you understand this key concept it will save you a lot of stress down the road. This concept is true for Medicare, for Medicaid and all other health insurances who set the terms (rules) of the insurance policy agreement that you have made with them.

Insurance Basics

Some other items you need to know about your health insurance are these basic terms:

Plan Types- HMO (Health Maintenance Organization, managed care), PPO (Preferred Provider Organization ), POS (Point of Service). They all have different rules.

Premium- If you have employer sponsored insurance this is the amount you or your employer pays for your insurance coverage. Frequently you pay part and your employer pays part. If you are buying the insurance independently this is what you pay for your insurance. This is paid even if you don’t need to go to the doctor or use your insurance. Insurance costs vary by state.

Deductible- What you need to pay before your insurance kicks in. (Original Medicare and many companies have an annual deductible which must be met. Some people save money on the cost of insurance premiums by buying high deductible policies). You may get denied for supplies or a service because you have not met your deductible for the year. For example, someone with an annual deductible of $4,000 will have to pay for all of their supplies or health services until they reach that $4,000.

Coinsurance- The percent of the cost that you are responsible to pay for covered services after you meet your deductible. (ex. Original Medicare pays 80% of the Medicare approved amount of a covered service you pay 20% unless you have a supplemental policy which picks up the remaining 20%). Medicare Advantage Plans/Type C insurances set the costs of the copays which are covered in their benefit booklets. Some people have purchased insurance through the Affordable Care Act (Obamacare) Marketplace and tried to save money on premiums but found that they are responsible for 30% of the costs with insurance paying 70%.

Copay- This is the fixed amount of money you pay for certain services such as prescriptions or MD visits. Usually, visits at urgent care or the emergency department have higher copays. These rules are all listed in your insurance policy and/or benefits book. For example, a plan might indicate that you pay $20 for each doctor visit.   

In-Network versus Out-of-Network Benefits- An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. Typically, when you see an in-network provider you receive 100% coverage.  An out-of-network provider is one not contracted with the health insurance plan and you will need to pay a percentage of the cost of the services (usually insurance covers 80% and you pay 20%).

Accepts Medicare assignment- Means your doctor, provider or supplier agrees to accept the Medicare-approved amount as full payment for covered services.

Non participating providers have NOT signed an agreement to accept an assignment. They can charge you more than the Medicare approved amount up to the “limiting charge”.

Maximum Out of Pocket Expense- This is the maximum amount that you pay for in-network services and prescriptions in a calendar year. This includes the deductible, coinsurance and copays. It is wise to keep track of what you have paid for and be aware of the amount of the maximum because after this amount is reached the services are covered 100%.

For a more complete list of insurance term definitions visit this website.

All of the above can change, so it’s important to annually review your plan and see if it still meets your needs. This can greatly affect the cost to you for your health care, so it’s always a good idea to compare plan options, estimate the costs of your care and consider all of the insurance costs (premium, deductible etc.). How well does your insurance cover your needs?  For example how much do your supplies cost each month and how much will you pay out of pocket until your plan coverage starts paying the bill? UOAA gets many calls from people who are looking for help with paying for their ostomy supplies because they can’t afford their high deductibles or copays.

Are your ostomy medical necessities a covered benefit?  

Is a medical necessity the same as a covered benefit? A medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy. Insurance companies determine what tests, drugs and services they will cover. These choices are based on their understanding of the kinds of medical care that most patients need. Your insurance company’s choices may mean that the test, drug, or service you need isn’t covered by your policy and then you will need to pay for that service or item. It’s important to know what is covered by your insurance policy such as your ostomy supplies, so you will need to consult the summary plan description and evidence of coverage, (ex. benefits booklet, Medicare and You publication). The customer service agent may be able to tell you how to document your need or what they require if you have a medical reason to need more or different supplies.

Knowing what you need and being able to explain it is vitally important. Don’t expect people who don’t have an ostomy or experience with an ostomy to understand what you need. An example of this is the gentleman who had a new ostomy and went to an insurance broker to choose a Medicare C /Medicare Advantage Plan. He was assured that the plan he chose was an excellent plan and certainly covered all the bases. What resulted was that he had very high copays for his supplies and it was not a good plan for him at all. He also was not aware that if you join a Medicare Advantage Plan for the first time and you aren’t happy with the plan, you have special rights under federal law to buy a Medigap policy if you return to Original Medicare within 12 months of joining (Medicare and You- section 5).

Today the vast majority of health insurance plans do cover ostomy supplies, but how they are covered varies.  Make sure you ask if the plan will cover what you need and how they will cover it. As you compare plan options and shop around ask yourself these 10 Questions to Ask Before You Choose a Health Plan.

Final thoughts

It is critical that as an ostomate you be your own patient advocate and ensure your health plan covers your medically necessary ostomy supplies. Insurers should not determine your medical treatment plan.  That should be between you and your medical professional.

Really, there is a logical structure, rhyme and reason to all this health insurance business and if you approach it with that in mind you will be more successful. For more information on insurance reimbursement check out this webinar.

Take the time and effort to do some necessary research on insurance plans to find the best quality, and most cost-effective to meet your ostomy needs and financial situation. In the long run you’ll be thankful you did.

Take control of your healthcare and don’t let your health plan let you down!

Disclaimer: UOAA does not provide insurance advice or financial assistance for supplies. We do recognize there may be times for emergency supplies. Please use this list of resources which may provide assistance on a temporary basis.

Know What’s In Your Medical Record

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Expect More – Take Control of Your Health Care 

Part 4 in Series

By Susan Mueller, BSN, RN, CWOCN and UOAA Advocacy Committee

“Details matter. It’s worth getting it right.” ~ Steve Jobs

The Buck Stops Here

Since UOAA started the advocacy campaign we have been stressing that YOU are your own best advocate.  This may be hard to believe since the whole business of insurance is so overwhelming that it feels like a David and Goliath story.  Like anything else, once you understand the rules of the game it makes it a lot easier. You actually have a bigger part in the game then you may know.  Often consumers of medical care, patients, people like you, think that everyone knows their story. You are asked a million questions every time you pass through the doorway of any hospital or doctor’s office and everyone is writing things down.  How many times do you have to tell your story? Answer: as many times as it takes to get the results you want. Unfortunately, the goal of great communication among the players in the healthcare game has not been reached, and all these computers do not talk to each other as much as you think. So what this means is that you have to make sure that everyone knows the important parts of your story and that they understand what you need.

So it goes like this, the people who pay the bills want to make sure that the money that is paid is according to their rules; that is, for a medical reason.  So the people who are asking to be paid have to explain that the service or supply is medically necessary. For example, the company that sends out your supplies (ostomy supply distributor) has to be able to say that you need the supplies because you have an ostomy, what kind of ostomy you have, why you have an ostomy, and when you had your surgery.  Then if you have Medicare they have to ask you questions to make sure someone else is not giving you supplies (like a home care agency or nursing home or hospital) because Medicare doesn’t want to pay double. The doctor or physician’s assistant or nurse practitioner has to report some of the same things plus show in their notes (your medical record) they have spoken to you about your ostomy and what you need for your care.  This is where you come in; you have to make sure your doctor knows what you need and why, even though your doctor may know very little about ostomies.

Get More Involved with your Doctor in Your Healthcare

A good suggestion is to visit your healthcare provider (doctor, nurse practitioner, physician assistant) at least once a year and provide a supply checklist which includes all the supplies you need (with the product numbers), and what type of ostomy you have. At this visit discuss what has happened in the last year; for example, you had a yeast infection around your stoma, you went to the emergency room for an obstruction or dehydration, you developed a hernia around your stoma, you gained or lost weight and had to change your type of ostomy product… This is the kind of information that needs to be in your medical record.  Your medical care provider may then give you a referral to an ostomy nurse at a wound or ostomy clinic, or a dermatologist or may just write it down in your record so when the insurance company wants to know why you now need a belt or a different kind of pouch or a greater quantity of pouches, they will know why.

Medicare has done research to figure out how many supplies an “average” person with an ostomy usually needs. If what you need is different, then your doctor must include information on your medical condition to support the need for the type and quantity of items ordered.  If you are working with a nurse who is specially educated about ostomies, the nurse may also be able to help you by writing down why you need different supplies than the average ostomate and give that information to your doctor to put in your medical record. This information in your medical record can then be given to your ostomy supply company and or your insurance. It is then the responsibility, under Medicare guidelines, of your supply company to get this information from your medical provider.  

An example of a special situation that would require additional supplies might be that your skin is irritated from frequent leakage of your pouching system due to your stoma being flush to the skin or below the skin. You require frequent pouch changes until your skin can heal. Any request for supplies more than the average amount is marked for review.  Just because a person “wants” more is not a good enough reason and those requests for supplies (claims) will be denied. You might have to have detailed notes in your medical record about why you need to use a convex wafer or pouch (such as because you have a stoma which is below skin level, or the stoma opening is at skin level).

Medicare has specific guidelines for the coverage of ostomy supplies, including that they be used exclusively for colostomy, ileostomy or urostomy management.  Ostomy pouches being used to manage fistula or wounds are not covered under Medicare guidelines.

Be aware that suppliers will not receive payment from Medicare for the items that are ordered if your physician did not provide the proper detailed information from your medical records when it is requested or if your detailed written order (prescription) is missing information like a signature. Furthermore, not providing this information may result in you, the patient, having to pay for the item yourself.  Note that your doctor’s cooperation is a legal requirement as outlined in the Social Security Act, the law governing Medicare.

To help you better prepare for your next office visit, please use this new checklist resource.

Pay Attention to the Details

The details are important, sometimes a date is wrong, the type of ostomy is wrong, the code for your diagnosis has a number missing…your insurance was not recorded or was recorded incorrectly, the doctor didn’t sign the note. Those things are minor and require a little detective work.  So if you have a request (claim) denied you may have to be a detective. You can speak with someone at the company who provides your supplies (ostomy supply distributor) and ask them to help you understand why your request (claim) was denied. Maybe together you can discover that a number was off or incomplete information was submitted.  Another example of an ostomate taking control of their healthcare is to not assume that your supplier has the proper documentation, but to ensure that your file at your supplier does include all of the necessary information. Ask your supplier for a copy of this documentation including prescriptions.

The same thing may be true with your doctor’s office, a request for supplies may have been denied because the information needed was not given to the insurance company or supply company. So then you need to speak with someone to discover what was missing. Sometimes the problem can be found, corrected and then the supply company can resubmit with positive results.

If you receive a denial, you have the right to appeal. The appeal usually has a time limit attached so follow the instructions for an appeal and respond that you want to appeal the denial.  If you have non-Medicare insurance you may be able to speak with someone at the insurance company about your denial to figure out why your request was denied as part of the appeal process. You may also contact your insurance customer service and request a case manager to assist with your supply denial.

If you have Medicare, for assistance you can contact your local representative from the  Beneficiary of Family Centered Care – Quality Improvement Organization (BFCC-QIO) or call 1-800-MEDICARE to help you understand the appeal process and determine what is still missing from your record. Your supply company may also be able to help you.

Do You Know What’s in Your Medical Records?

You have a right to request a copy. In 1996 the Health Information Portability and Accountability Act (HIPPA) was passed. It is the law that protects patients’ health information from being shared with only those who have a need to know. It also states that patients are allowed access to their health records.  Your medical record is not just your doctor’s office records, it includes hospital, nursing home, or home health agency (HHA) records, and records from other healthcare professionals including, but not limited to, nurses, therapists, and social workers. Here is a great video example of advocating for yourself and knowing what’s in your record.

Each state has its own laws about what is required to get copies of your medical records. Check with your medical provider/facility for their policy on obtaining your medical records.

Conclusion

To avoid claim denials, long appeal processes, costs to you, or the possibility of not receiving your ostomy supplies, you need to make sure that:

  1. Your supplier is submitting correct information and up to date medical records to your insurance company (or Medicare); and
  2. Your physician keeps up-to-date medical records about your health, your ostomy and your supplies in your medical record.

Just recently ostomy advocate Megan, The Front Butt YouTuber, tweeted, “Currently going through some of my medical records. Found several pieces of misinformation, which I cleared up in visits and it was marked incorrectly. Yet, they are still present on my record. Again, patients are NOT being listened to.” (9/4/18 Twitter) Kudos to her for taking an active role in her healthcare, and going through her medical records. Self-advocacy is ongoing and no doubt she will be bringing this up again until it is CORRECT!

Remember that you have the right to change physicians and the right to change your ostomy supply company if they are not working with you.

It’s time to take control of your health. You deserve high-quality care.

Quality of Care Resource at the Centers for Medicare and Medicaid Services (CMS)

By Jeanine Gleba, UOAA Advocacy Manager

The overall goal of the UOAA Patient Bill of Rights (PBOR) initiative is to ensure high quality of care for people who had or will have ostomy or continent diversion surgery. To accomplish this it’s important that patients and families actively participate in patient health care.

According to CMS an integral part of the U.S. Department of Health and Human Services’ (HHS) National Quality Strategy is the CMS Quality Improvement Organization (QIO) Program. It is one of the largest federal programs dedicated to improving health quality at the community level.

Under the QIO program there are two Beneficiary and Family Centered Care-QIOs (BFCC-QIOs) who help Medicare beneficiaries and their families exercise their right to high-quality healthcare. The two BFCC-QIOs are KEPRO and Livanta and they serve all fifty states. BFCC-QIO services are free-of-charge to Medicare beneficiaries.

Depending on where you live (Locate your BFCC-QIO) they are available to help Medicare beneficiaries and their families or caregivers with questions or concerns such as:

• Am I ready to be discharged from the hospital?
• Should I be receiving needed skilled services such as physical therapy, occupational therapy, from a home health agency, skilled nursing facility, or comprehensive outpatient rehabilitation facility? (Care from a certified ostomy nurse is a skilled service.)
• I’m concerned about the quality of care I received from my hospital, doctor, nurse or others.
Examples of quality of care concerns that pertain to our PBOR include but are not limited to:
• Experiencing a change in condition that was not treated (such as skin infection around stoma)
• Receiving inadequate discharge instructions (such as inadequate individual instruction in ostomy care, including the demonstration of emptying and changing pouch or no instruction on how to order ostomy supplies when you leave the hospital)

*Why should Medicare Beneficiaries contact their BFCC-QIO with concerns?

First, BFCC-QIOs can help when you have a concern about the quality of the medical care you are receiving from a healthcare facility (e.g. hospital, nursing home, or home health agency) or professional. You can also file a formal Medicare complaint through your BFCC-QIO.

Furthermore, according to CMS, when Medicare beneficiaries share their concerns with their BFCC-QIO, they help identify how the health care system can better meet the needs of other patients. Beneficiary experiences, both good and bad, give the QIO Program the perspective to identify opportunities for improvement, develop solutions that address the real needs of patients, and inspire action by health professionals. This is what we are working towards achieving with our PBOR initiative. This is a resource to help the UOAA community make this happen.

Last, Medicare beneficiaries have the right to file an appeal through their BFCC-QIO, if they disagree with a health care provider’s decision to discharge them from the hospital or discontinue services, or when they have a concern about the quality of the medical care they received from a health care professional or facility.

*When and who should Medicare Beneficiaries contact?

A Medicare beneficiary can call 1-800-MEDICARE or your Local State Health Insurance Assistance Program (SHIP) if he or she:

• Has general questions about Medicare coverage;
• Needs clarification on how to enroll in Medicare;
• Wishes to discuss billing issues.

A beneficiary can contact their BFCC-QIO if he or she:

• Needs to discuss the quality of care received;
• Wants to file a formal quality of care complaint; or
• Needs help to understand his or her Medicare rights.

While BFCC-QIOs are the primary point of contact for Medicare beneficiaries and their families, when necessary, quality of care complaints can also still be made by calling 1-800-MEDICARE.

For those interested in learning more about what to do if you have a concern about the care you received while on Medicare, please refer to this FAQs page produced by CMS.

Be involved in your healthcare and if you are a Medicare beneficiary, take advantage of this resource to self-advocate and ensure a better outcome for yourself.

*Source qioprogram.org