Introduction

Wound care providers often need to obtain prior authorization (PA) for specific, specialized treatments or medications in order for a patient’s insurance to cover some or all of the cost. It has been reported as a source of burnout and frustration, while payors assert that this process ensures the necessity of prescribed treatments and medications.¹ Many organizations including the American Medical Association (AMA) have acknowledged that the protocol is expensive, time-consuming, and, at times, hard to navigate.^2,3

Recently, the Centers for Medicaid and Medicare Services (CMS) have announced a new rule regarding prior authorization. Payors will be expected to shorten review processes, detail reasons for denying a PA, and provide particular PA metrics.⁴ Although this change will not come into full effect until 2027, it is vital that wound care professionals stay abreast of PA protocol and any incoming changes.⁴

What is Prior Authorization?

Prior authorization may be a long process. It begins with submitting a request for payor approval. Review can take anywhere from same day to 30 business days and may depend on the item or service being requested.^5,6 Each insurer has lists of services or items that require PAs, and these lists are updated periodically. In 2019, Medicare dropped the PA requirement for nonemergent hyperbaric oxygen therapy for diabetic foot ulcers after a 3-year program proved that PAs had no significant effect on total Medicare costs.⁷ Also in 2019, CMS mandated PAs for pressure-reducing support surface use in Medicare or Medicaid patients.⁶

Prior Authorization Versus Pre-Claim Review

A PA is similar to a pre-claim review. According to the Centers for Medicare and Medicaid Services (CMS), a pre-claim review entails that “the provider or supplier submits the pre-claim review request and receives the decision before submitting the claim.” In addition, the item can be provided before the provider submits the request.² Unlike the pre-claim review process, PAs must receive approval before an item or service can be provided to a patient and submitted for payment.^6,8

How Can Wound Care Practices Obtain PA?

Let us consider the example of when a pressure-reducing support surface or another type of durable medical equipment (DME) is ordered and the supplier or provider submits a PA request. This request should include the provider’s documentation and is sent to a Medicare Administrative Contractor (MAC). The MACs comprise a regional network of private health care insurers that process Medicare medical claims or DME claims.⁹ Medicare PAs can be mailed, faxed, or submitted electronically.⁶ Sometimes, the provider may be notified by a dispensing or providing entity (such as a pharmacy or imaging center) that PA is required.

The MAC reviews the request and sends the supplier or provider a letter approving or denying the PA.^6,8 This letter contains a Unique Tracking Number (UTN), and claims submitted must include the UTN to receive payment.⁶ In a wound care practice, designated administrative staff can request PAs or work with providers to request PAs.¹⁰ PA requirements and updates should be reviewed.¹

What Are the Components of a PA?

This section is summarized from the Wound, Ostomy and Continence Nurses Society guidelines for DME PA in Medicare patients.⁶

A PA request may include the following information, which may also be supplied by a designated representative of the prescribing provider:

• Beneficiary’s name, Medicare Beneficiary Identifier, date of birth, and address
• Supplier’s name, National Supplier Clearinghouse number, National Provider Identifier (NPI) number, address, and telephone number
• Requester’s name, telephone number, NPI (if applicable), and address
• Submission date
• Healthcare Common Procedure Coding System code
• Whether the request is an initial or resubmission review
• Whether the request is expedited and why

Information that one must include from providers in a PA request may include:

• Detailed Written Order
• Documentation from the medical record to support medical necessity
• Prior Authorization Request Coversheet (can be found on DME MAC websites)

Using the example of pressure-reducing support surfaces for pressure injury, providers must be able to show documentation that the patient meets at least 1 of the 3 criteria below. Other conditions or types of equipment or services may have their own unique requirements for PA approval.

1. Multiple stage II pressure injuries (PIs) on the trunk or pelvis with no improvement over the past month, with an appropriate treatment program, including (a) a group 1 support surface, (b) regular assessment by a licensed health care practitioner, (c) turning and positioning, (d) wound care, (e) moisture/incontinence management, and (f) relevant nutritional assessment and intervention 2. Large or multiple stage III or IV PIs on the trunk or pelvis 3. A myocutaneous flap or skin graft for a trunk or pelvis PI within the past 60 days, with a group 2 or 3 support surface immediately before discharge from a hospital or nursing facility within the past 30 days

Conclusion

Prior authorization has become a daily reality in contemporary health care. Despite the drawbacks of the PA process, health care providers must be able to navigate the system to provide needed and appropriate care for their patients. One should note that obtaining a prior authorization is not a guarantee of insurance coverage, but simply an important step in working towards that potential coverage. Using high-quality practice management workflows and good standards of practice like documentation can help wound care practitioners be best prepared in these circumstances.

References

1. Shah J. How to Deal With Prior Authorization Hassles in the Wound Clinic. Today’s Wound Clinic. Published February 2020. https://www.hmpgloballearningnetwork.com/site/twc/articles/how-deal-pri…
2. Daly R. Prior-authorization cost and time burdens increase for providers, report finds. Healthcare Financial Management Association. Published 2020. Accessed January 1, 2024. https://www.hfma.org/payment-reimbursement-and-managed-care/health-plan…
3. American Medical Association. Prior authorization. Accessed January 1, 2024. https://www.ama-assn.org/practice-management/prior-authorization/prior-…
4. CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process. Centers for Medicare & Medicaid Services. Published January 17, 2024. Accessed January 19, 2024. https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-a…
5. Bhatia S, Pizarro M. How to Get Prior Authorization for Medical Care. American Academy of Dermatology Association. Updated February 3, 2021. https://www.aad.org/public/fad/prior-authorization
6. Wound, Ostomy and Continence Nurses Society. Pressure reducing support surfaces prior authorization. Accessed January 1, 2024. https://www.wocn.org/public-policy-advocacy/hot-topics/pressure-reducin…
7. Centers for Medicare & Medicaid Services. Prior authorization of non-emergent hyperbaric oxygen (HBO) therapy. Link found in: Prior authorization and pre-claim review initiatives. Accessed January 1, 2024. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-serv…
8. Centers for Medicare & Medicaid Services. Prior authorization and pre-claim review initiatives. Accessed January 1, 2024. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-serv…
9. Centers for Medicare & Medicaid Services. What’s a MAC? Accessed January 1, 2024. https://www.cms.gov/medicare/coding-billing/medicare-administrative-con…
10. American Medical Association (AMA). AMA Steps Forward: Private Practice Staffing Guide. AMA; 2022.

Actual practice management scenarios and local and/or institutional policies may vary from the information provided in the scenarios included in this document. Readers should consult with their respective institution, practice manager, state, and/or regional agencies for specific guidance. The information within is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. HMP Global and the author do not represent, guarantee, or warranty that the coding, coverage, payment, or regulatory/policy information is error-free and/or that payment will be received. The responsibility for verifying regulatory/policy accuracy lies with the reader.