Insurance coverage for our devices
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Daril Atkins
Jul 27, 2010, 12:23:38 PM7/27/10
to Anaplastology
Since the last one year some significant changes have taken place in
the health care system here in the United Arab Emirates. The most
significant being the medical insurance linked health card. However
the insurance does not cover the devices made by us.
What is the situation in this regard in the USA, Canada, UK, Europe,
Australia and elsewhere?
the health care system here in the United Arab Emirates. The most
significant being the medical insurance linked health card. However
the insurance does not cover the devices made by us.
What is the situation in this regard in the USA, Canada, UK, Europe,
Australia and elsewhere?
michael williams
Jul 28, 2010, 5:27:42 AM7/28/10
to anapla...@googlegroups.com
| Hello Daril, regarding NZ, we operate like the UK. Free universal healthcare which also includes the provision of facial,somato and ocular prosthetics. In the public system removable denture prosthetics which includes obturators and also fixed appliances (crowns and bridges) are paid for by the patient though their dental treatment is free if they are oncology patients undergoing treatment and for up to 6 weeks post completion of radiation therapy. Medical insurers in NZ generally do not cover external prosthetics, only prostheses used in surgery, eg hip replacement, or HA implant for enucleation of a globe. Craniofacial implants for prosthetic retention or BAHA I'm sure would NOT be covered. Whereas for example, an engineered assisted surgical implant for facial reconstruction from CT data probably would be. NZ is also unique in that we have ACC, The Accident Compensation Corporation which is a government body whichcovers the medical/surgical and living costs of a patient who has had an accidental injury requiring medical intervention. Prosthetics and also craniofacial implant surgery can be charged back to ACC if a patient is covered. To ease the load on the public system, ACC patients are often referred to the private sector so that they can be treated /rehabillitated quickly which saves health dollars and helps to get people back to work faster. The healthcare system here though seems happier to pay for surgical costs which often is a single or staged treatment eg partial nasal construction with rotation flaps whereas prosthetics isn't really budgeted for and to many managers is an incidental continual cost to be borne that doesn't seem to fit in with the contracting volumes/ budgeting system that is used. I'm sure that practitioners in other countries must face similar problems too. I know that in Australia they have a medicare insurance card and free healthcare too with free prosthetics provided at major hospitals in each state but it is different to NZ. Hopefully you will get a response from a colleague in Australia to clarify what the situation is there too with insurance co's. Hope that helps with the discussion from downunder, regards Mike Mike Williams, RCDT,MIMPT(UK), Maxillofacial Prosthetist & Technologist Maxillofacial,Oral Surgery and Dental Department, Waikato Hospital, Pembroke Street, Private Bag 3200, Hamilton, New Zealand. Tel ++64 7 839 8805 Fax ++64 7 839 8996 --- On Wed, 28/7/10, Daril Atkins <darila...@gmail.com> wrote: |
|
Muhanad Hatamleh
Jul 29, 2010, 8:25:32 AM7/29/10
to anapla...@googlegroups.com, Haylock Colin
Hello Daril,
For the UK, and considering NHS (National Health Services) All facial, eye, limbs, maxillofacial devices are free to the patient. However, Where things get a little complicated are where a hospital does not have a prosthetic service it has to buy in those services from and other NHS provider
( cross charging) from one nhs hospital to another. It is like taking the money from one pocket and putting it into another pocket as the finances always stay within the NHS.
For the private medical insurance; it depends on the individual insurance company as they take every case on its own standing and at what level of insurance the patients pay for etc..Most seem to pay for the first prosthesis.
( cross charging) from one nhs hospital to another. It is like taking the money from one pocket and putting it into another pocket as the finances always stay within the NHS.
For the private medical insurance; it depends on the individual insurance company as they take every case on its own standing and at what level of insurance the patients pay for etc..Most seem to pay for the first prosthesis.
Best regards,
Muhanad
PS: Thanks to Mr Colin Haylock (who wroked within the NHS as MPT for more than 15 years) who shared his views above.
---------------------------
Dr Muhanad Hatamleh, BSc, MPhil, PhD
School of Dentistry
University of Manchester
Higher Cambridge street
Manchester, M15 6FH
School of Dentistry
University of Manchester
Higher Cambridge street
Manchester, M15 6FH
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Juan Garcia
Jul 29, 2010, 4:17:19 PM7/29/10
to anapla...@googlegroups.com
In the USA, typically a letter from a physician, also known as a Certificate of Medical Necessity documents the medical necessity of the prosthesis (usually due to factors such as protecting fragile tissues, maintaining proper airflow, supporting eyeglasses, etc). The Centers for Medicare and Medicaid Services (CMS) requires such a certificate as part of the requirements for payment. To the anaplastologist, prostheses are considered Durable Medical Equipment (DME) and are paid for according to the member's DME benefits level. Prostheses can also be billed for by dentists and physicians as part of clinical services, using what are called CPT codes, and as such are covered according to the member's dental or medical benefits.
Covered facial prostheses include the following adhesive retained prostheses: Auricular, Hemi-facial (nose, orbit and cheek), Midfacial (nose and cheek), Nasal, Orbital, Upper Facial (not involving eye, nose or cheek). Ocular codes include the following categories: Prosthetic Eye (custom- indwelling or for orbitals), and Prosthetic Eye (stock), Enlargement of ocular prosthesis, Reduction of ocular prosthesis, Scleral Cover Shell, Fabrication and Fitting of Ocular Conformer. Each of these devices has its own unique billing code, as well as modifiers that are used to identify remakes with a new moulage or remakes using the previous mold. So far, osseointegrated prostheses do not have their own unique code and are billed for using a code designated as Unspecified Maxillofacial. Most private health insurance plans follow the CMS standards, so the same codes are used to bill these entities. However, depending on the participating or non-participating status of the clinician, pre-authorization for services may be required.
Once the argument regarding the medical necessity for prosthetic rehabilitation is won with the government run health care system, establishing such a billing structure may prove beneficial. I believe Julie Brown and Gillian Duncan were instrumental in obtaining the codes anaplastologists use to bill for the prostheses we make. You may want to speak further with them.
Hope this helps.
Juan
Juan R. Garcia, Jr., MA
Certified Clinical Anaplastologist and Medical Illustrator
Assistant Professor
Department of Art as Applied to Medicine
Johns Hopkins University
1830 E. Monument Street, Suite 7000
Baltimore, MD 21205
Phone 410 955-8215; Fax 410 955-1085
Internet: http://www.hopkinsmedicine.org/medart/
E-mail: jgar...@jhmi.edu
CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, (or authorized to receive for the recipient) you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please destroy all copies of this communication and any attachments and contact the sender by reply e-mail or telephone (410-955-3213).
-----Original Message-----
From: anapla...@googlegroups.com [mailto:anapla...@googlegroups.com] On Behalf Of Daril Atkins
Sent: Tuesday, July 27, 2010 12:24 PM
To: Anaplastology
Subject: [Anaplastology] Insurance coverage for our devices
--
Daril Atkins
Jul 30, 2010, 3:38:00 AM7/30/10
to Anaplastology
Thank you Mike, Muhanad, Colin, and Juan for the valuable information
on what precedents I can refer to, regarding medical insurance
coverage for the devices we make. Since over here we are just entering
these phases, while you all have been with a system since longer, it
may be the right time for me to make a case for coverage of prosthetic
devices. The unique part of this geographical area in particular, also
called the GCC countries, is their large expatriate populations. While
the local Government takes resposibility for the citizens, the
expatriate population is multicultural, employed in casual or skilled
labor, or as professionals or management. The new insurance coverage
varies in its package accordingly. In any case, prosthetic devices are
not covered. Thus expatriates who have a need may go to their
country of origin if such a facilty exists there, while the government
picks up the tab for their own citizens. So I guess it makes it fuzzy
for the insurance companies and they are happy with the status quo.
Perhaps the best justification, as pointed out by Juan, is the factor
of Medical Necessity. If there is any indication that the device is
for cosmesis or camouflage, the insurance companies would probably not
consider. Can anyone else from Canada, Australia, Europe, and
particularly Asian countries shed more light on this subject?
Daril Atkins
On Jul 30, 12:17 am, Juan Garcia <jgarc...@jhmi.edu> wrote:
> In the USA, typically a letter from a physician, also known as a Certificate of Medical Necessity documents the medical necessity of the prosthesis (usually due to factors such as protecting fragile tissues, maintaining proper airflow, supporting eyeglasses, etc). The Centers for Medicare and Medicaid Services (CMS) requires such a certificate as part of the requirements for payment. To the anaplastologist, prostheses are considered Durable Medical Equipment (DME) and are paid for according to the member's DME benefits level. Prostheses can also be billed for by dentists and physicians as part of clinical services, using what are called CPT codes, and as such are covered according to the member's dental or medical benefits.
>
> Covered facial prostheses include the following adhesive retained prostheses: Auricular, Hemi-facial (nose, orbit and cheek), Midfacial (nose and cheek), Nasal, Orbital, Upper Facial (not involving eye, nose or cheek). Ocular codes include the following categories: Prosthetic Eye (custom- indwelling or for orbitals), and Prosthetic Eye (stock), Enlargement of ocular prosthesis, Reduction of ocular prosthesis, Scleral Cover Shell, Fabrication and Fitting of Ocular Conformer. Each of these devices has its own unique billing code, as well as modifiers that are used to identify remakes with a new moulage or remakes using the previous mold. So far, osseointegrated prostheses do not have their own unique code and are billed for using a code designated as Unspecified Maxillofacial. Most private health insurance plans follow the CMS standards, so the same codes are used to bill these entities. However, depending on the participating or non-participating status of the clinician, pre-authorization for services may be required.
>
> Once the argument regarding the medical necessity for prosthetic rehabilitation is won with the government run health care system, establishing such a billing structure may prove beneficial. I believe Julie Brown and Gillian Duncan were instrumental in obtaining the codes anaplastologists use to bill for the prostheses we make. You may want to speak further with them.
>
> Hope this helps.
>
> Juan
> Juan R. Garcia, Jr., MA
> Certified Clinical Anaplastologist and Medical Illustrator
> Assistant Professor
> Department of Art as Applied to Medicine
> Johns Hopkins University
> 1830 E. Monument Street, Suite 7000
> Baltimore, MD 21205
> Phone 410 955-8215; Fax 410 955-1085
> Internet:http://www.hopkinsmedicine.org/medart/
> E-mail: jgarc...@jhmi.edu
>
> - Show quoted text -
on what precedents I can refer to, regarding medical insurance
coverage for the devices we make. Since over here we are just entering
these phases, while you all have been with a system since longer, it
may be the right time for me to make a case for coverage of prosthetic
devices. The unique part of this geographical area in particular, also
called the GCC countries, is their large expatriate populations. While
the local Government takes resposibility for the citizens, the
expatriate population is multicultural, employed in casual or skilled
labor, or as professionals or management. The new insurance coverage
varies in its package accordingly. In any case, prosthetic devices are
not covered. Thus expatriates who have a need may go to their
country of origin if such a facilty exists there, while the government
picks up the tab for their own citizens. So I guess it makes it fuzzy
for the insurance companies and they are happy with the status quo.
Perhaps the best justification, as pointed out by Juan, is the factor
of Medical Necessity. If there is any indication that the device is
for cosmesis or camouflage, the insurance companies would probably not
consider. Can anyone else from Canada, Australia, Europe, and
particularly Asian countries shed more light on this subject?
Daril Atkins
On Jul 30, 12:17 am, Juan Garcia <jgarc...@jhmi.edu> wrote:
> In the USA, typically a letter from a physician, also known as a Certificate of Medical Necessity documents the medical necessity of the prosthesis (usually due to factors such as protecting fragile tissues, maintaining proper airflow, supporting eyeglasses, etc). The Centers for Medicare and Medicaid Services (CMS) requires such a certificate as part of the requirements for payment. To the anaplastologist, prostheses are considered Durable Medical Equipment (DME) and are paid for according to the member's DME benefits level. Prostheses can also be billed for by dentists and physicians as part of clinical services, using what are called CPT codes, and as such are covered according to the member's dental or medical benefits.
>
> Covered facial prostheses include the following adhesive retained prostheses: Auricular, Hemi-facial (nose, orbit and cheek), Midfacial (nose and cheek), Nasal, Orbital, Upper Facial (not involving eye, nose or cheek). Ocular codes include the following categories: Prosthetic Eye (custom- indwelling or for orbitals), and Prosthetic Eye (stock), Enlargement of ocular prosthesis, Reduction of ocular prosthesis, Scleral Cover Shell, Fabrication and Fitting of Ocular Conformer. Each of these devices has its own unique billing code, as well as modifiers that are used to identify remakes with a new moulage or remakes using the previous mold. So far, osseointegrated prostheses do not have their own unique code and are billed for using a code designated as Unspecified Maxillofacial. Most private health insurance plans follow the CMS standards, so the same codes are used to bill these entities. However, depending on the participating or non-participating status of the clinician, pre-authorization for services may be required.
>
> Once the argument regarding the medical necessity for prosthetic rehabilitation is won with the government run health care system, establishing such a billing structure may prove beneficial. I believe Julie Brown and Gillian Duncan were instrumental in obtaining the codes anaplastologists use to bill for the prostheses we make. You may want to speak further with them.
>
> Hope this helps.
>
> Juan
> Juan R. Garcia, Jr., MA
> Certified Clinical Anaplastologist and Medical Illustrator
> Assistant Professor
> Department of Art as Applied to Medicine
> Johns Hopkins University
> 1830 E. Monument Street, Suite 7000
> Baltimore, MD 21205
> Phone 410 955-8215; Fax 410 955-1085
> Internet:http://www.hopkinsmedicine.org/medart/
>
> CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, (or authorized to receive for the recipient) you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please destroy all copies of this communication and any attachments and contact the sender by reply e-mail or telephone (410-955-3213).
>
>
>
> -----Original Message-----
> From: anapla...@googlegroups.com [mailto:anapla...@googlegroups.com] On Behalf Of Daril Atkins
> Sent: Tuesday, July 27, 2010 12:24 PM
> To: Anaplastology
> Subject: [Anaplastology] Insurance coverage for our devices
>
> Since the last one year some significant changes have taken place in
> the health care system here in the United Arab Emirates. The most
> significant being the medical insurance linked health card. However
> the insurance does not cover the devices made by us.
>
> What is the situation in this regard in the USA, Canada, UK, Europe,
> Australia and elsewhere?
>
> --
> You received this message because you are subscribed to the Google Groups "Anaplastology" group.
> To post to this group, send email to anapla...@googlegroups.com.
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> For more options, visit this group athttp://groups.google.com/group/anaplastology?hl=en.- Hide quoted text -
> CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, (or authorized to receive for the recipient) you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please destroy all copies of this communication and any attachments and contact the sender by reply e-mail or telephone (410-955-3213).
>
>
>
> -----Original Message-----
> From: anapla...@googlegroups.com [mailto:anapla...@googlegroups.com] On Behalf Of Daril Atkins
> Sent: Tuesday, July 27, 2010 12:24 PM
> To: Anaplastology
> Subject: [Anaplastology] Insurance coverage for our devices
>
> Since the last one year some significant changes have taken place in
> the health care system here in the United Arab Emirates. The most
> significant being the medical insurance linked health card. However
> the insurance does not cover the devices made by us.
>
> What is the situation in this regard in the USA, Canada, UK, Europe,
> Australia and elsewhere?
>
> --
> You received this message because you are subscribed to the Google Groups "Anaplastology" group.
> To post to this group, send email to anapla...@googlegroups.com.
> To unsubscribe from this group, send email to anaplastolog...@googlegroups.com.
>
> - Show quoted text -
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