Collaborating for Advocacy Success
By Jody Scardillo DNP RN ANP-BC CWOCN
Albany Medical Center- Albany, NY
It’s amazing what can happen when a little effort is made. In April of 2018, the insurer NY Medicaid decreased the allowable quantity for certain ostomy barriers from ten to eight per month. This included extended wear barriers with and without built- in convexity. This affected many of our patients with ileostomies and urostomies, who required extended wear barriers and /or convexity due to the nature of the stoma or the output.
Most of these patients in my practice require appliance changes every three days even after optimizing the products and accessories they use. The other issue that came up with this is that the ostomy supplier would not break open a box and provide a partial amount, so any patient that used a product that was packaged in multiples of five only received 5 per month instead of the eight that they were approved for. The vendors in my practice were also not able to send alternating amounts. Dispensing one box on one given month alternating with two boxes the next month was not an option. This would leave an ostomate with only five barriers per month. In reality, the ostomate had enough barriers for half of the month. The coverage for the pouches was twenty per month, which led to a mismatch of products with no solution.
The Success Story
We contacted NY Medicaid by phone and email and collaborated with them so they understood the issues, and the meaning of this for the ostomate. As clinicians, we all knew this was going to severely impact skin condition and quality of life. After reviewing the information provided, New York Medicaid restored the monthly allowable back to ten barriers.
There were several important lessons I learned as a clinician as a result of this situation:
- Be sure to provide the proper information with a question or request. For example, as a clinician I might describe a product “1-¾ inch cut to fit extended wear convex barrier”. However, the language used by insurers and supply vendors to describe a product is called the HCPCS code (Healthcare Common Procedure Coding System). A4409 is the HCPCS code for a commonly used extended wear convex barrier.
- This particular insurer was very open to suggestion and willing to listen. They reversed an important decision when they realized it was not in the best interest of the person with an ostomy. It can never hurt to advocate for yourself or your patient. The worst thing that can happen is that a situation may not be changed.
- Under NY Medicaid regulations for beneficiaries who are in need of quantities above the maximum allowable limits they can submit a “prior approval request”. Include a letter of medical necessity from ostomy care provider for the need over the limit.
So, what to do if you have problems with your ostomy supplies? Reach out to your insurer, your ostomy care provider and your supplier to see what can be done to find a solution together. You never know unless you try!
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I have tried to advocate for myself regarding this issue. I have had my prescribing physician write 2 different letters explaining my high output as my insurer and supplier would not accept the verbiage used as reason, as well as several phone calls as well as additional letters from primary doctor. Still no help and still no increase to bags for my high output. So frustrated and mad I stopped trying. So your theory does not always work.
We appreciate your tenacity and taking the steps to try to improve your situation. We are very aware that unfortunately not every advocacy effort is a success no matter the valiant effort. Every insurer is different. UOAA is collecting stories such as this to approach CMS with their cumbersome approval process. If you are a Medicare beneficiary, please contact me at firstname.lastname@example.org.