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David McGill Blogger

Medical Policy Defined

Posted by David McGill | December 22, 2015

What is a medical policy and why is it important? Read this post to find out.​

We were speaking with a customer recently and asked her to forward a copy of the medical policy that applied to the insurance issue confronting her patient. She sent us what she thought of as a medical policy: a summary of benefits brochure.

When we talk about a medical policy, we're discussing a very specific type of document. In this post, we clarify both what medical policies are and why they're important.

Medical Policies: What They Are

Medical policies (also called clinical policies by some insurers) are documents that explain a payer's coverage criteria and exclusions for particular kinds of devices. They typically include a discussion of available clinical research and define whether certain types of treatments are classified as covered, not medically necessary, or experimental and investigational.

For an example of a medical policy applying to prosthetics, go​ogle "Aetna" and "bulletin 0578." The first result you'll see is "CPB 0578," Aetna's medical policy for lower limb prostheses.

Importantly, medical policies are quite different from summary of benefits brochures, which generally spell out coinsurance, deductibles, and major areas of coverage. While some mention prosthetics specifically, many don't. In addition, summary of benefits forms do not typically include detailed discussions of coverage criteria, so they're much less helpful to you as you try to evaluate the potential for claim approval than a medical policy is.

Even Medicare has a medical policy for lower limb prosthetics - it's called a Local Coverage Determination, and the LCD sets forth all of Medicare's coverage requirements. As you read more and more private insurance company medical policies, you'll see that the majority are based in significant part on Medicare's LCD for lower limb prostheses.

Medical Policies: What Do They Mean for You?

I frequently speak with prosthetists who are fighting claim denials. When I ask them what the medical policy for the specific payer says about the item they're delivering, far more often than I'd care to admit the only response I get is silence.

We can't state this strongly enough: medical policies are the blueprint for how to win a claim. They tell you what the insurer does and does not cover and why. Even when medical policies say that specific items are not covered, you often find that the rationale supporting that coverage position isn't supported by the evidence, or that the payer has selectively quoted only those parts of research that support denial, while leaving positive findings from the same studies out of the medical policy altogether.

It is critical that you have copies of the medical policies from all of your major payers before you file your claim. After all, if you knew that United Health Care required A, B, and C in order to deliver a PROPRIO FOOT®, wouldn't you make sure your medical record addressed all 3?

Look at who your biggest payers are. For most of them, you can go online to their websites to the "Provider" section and locate their medical policy library or index. From there, narrow your search to "prosthetics" or "limbs" or "Microprocessor" and you'll generally identify the applicable medical policy. Then, after you locate it, create a library of those medical policies that you can refer to for every claim from that payer moving forward. You still need to separately confirm your patient's benefits to make sure that the medical policy applies to your specific claim, but this will give you a huge jumpstart on what your claim needs to include in order to be successful, as well as a pretty good gauge of whether or not the claim will be authorized or approved.

Now you know what medical policies are and why they're important. Take the time to create your medical policy library today and you'll eliminate a lot of anxiety tomorrow. ​

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