Wound Care Articles and Insights

Navigating the Wound Care Reimbursement Landscape for Cellular and Tissue-Based Products

Navigating the Wound Care Reimbursement Landscape for Cellular and Tissue-Based Products

With more than 60 cellular and tissue-based products (CTP) on the market, wound care clinicians often tell us they have a difficult time finding the right product, for the right wound, at the right time, and at the right cost. To complicate things even further, navigating the reimbursement landscape is arduous. Documentation requirements are onerous. And when you get audited, supporting “medical necessity” can be a challenge. At Wound Care Advantage, we don’t push one product over another, but we do educate our clinicians so they can make the most informed decisions and give their patients, many who suffer from chronic wounds stemming from diabetes and/or vascular insufficiency, the best care possible.

There are four classifications of bioengineered skin substitutes: human skin allografts, allogeneic matrices, composite matrices, and acellular matrices. Each has their own unique advantage, and it’s up to the physician to make the determination on which one to use. That said, before a product can be used, the patient must meet “medical necessity” for the procedure.

CMS defines medical necessity for the application of a CTP for a “wound that hasn’t responded to standard wound treatment for at least 30 days during organized comprehensive conservative therapy” (Novitas LCD L35041). The “conservative therapy” must be thoroughly documented in the patient’s chart.

Charting is critical. In fact, I believe that in the future, CTPs will become a focus of audits much like hyperbaric oxygen therapy (HBOT) has been. If proper documentation isn’t present at the time of service, you risk significant recoupment of payments in future years. The best way to avoid this is to have a reliable partner pre-verify documentation prior to the initial application. We provide this service for many of our partners. It never hurts to have a second set of eyes and an aggressive, results-oriented denials team helping you out.

Another aspect to keep in mind is that just because a product is on the medical policy of an insurance company, it doesn’t mean that your specific facility is going to get fully reimbursed for it. The contract of the specific payer needs to be consulted prior to the application of the CTP. The authorization services that product companies provide are good for determining if their products are on the payer medical policy, but they don’t have access to your specific payer contracts with your specific rates.

Unfortunately, it isn’t uncommon for a facility to use an expensive CTP on a patient only to find that their wound care reimbursement is only at a “per visit” or “per diem” rate. If the products are not “carved out” or a “percentage of charge” in your contracts, be cautious about using them – or use a more cost-effective product. Your patients could be at risk of a high share of the cost, depending on your agreements with the payers. Saddling them with high medical debt is counterproductive to their healing process.

When it comes to using CTPs in a wound care clinic, we recommend the following:

Step 1: Make sure your documentation meets the requirements for medical necessity.

Step 2: Check contracted rates with your business office.

Step 3: Obtain proper authorization.

If you have any questions or doubts about whether your clinic is properly following those two steps, give us a call. A revenue cycle audit may be in order.  One of our six rules is “always make it better.” Helping hospitals manage their resources effectively is one way we do that.