Due to recent changes Medicare might not pay for your surgery. Other insurance companies have a service called Pre-Certification or Prior Authorization that your doctor can use to verify whether surgery will be paid; however, currently there is no way for your doctor to know beforehand if Medicare will decide to pay. Medicare might pay your doctor and hospital then request the payment back at a later date because they determined the procedure was not “Medically Necessary.”
Our main priority is patient care. Our goal is to provide you with excellent, customized patient care that will ultimately improve your quality of life. You are the reason we are here. In order to provide you with that care we need your help.
Medicare published an “outline” showing what they use to determine medical necessity for your surgery. Below is a list of the information they are requesting. If you have received treatment for your condition by another doctor please provide our office with the medical records that show:
- A minimum of 3 months of “unsuccessful” conservative management, including:
- 12 weeks of physical therapy
- Medications used to treat arthritis, including the dates the medication (prescribed or over the counter) was started and your response to the treatment (did it help?).
- Steroid injections, including the date they were given and your response.
- Viscosupplementation injections (Synvisc, Orthovisc, Euflexxa, etc.), including the dates they were given and your response. (Knee patients only)
- Pain medication, including dates and your response
- The use of assistive devices (canes, crutches, and/or walker), including the date you started using the device.
- Braces (hinged braces, even over the counter braces), including the date you started wearing the brace.
If any of these treatments were not provided, they are requesting “clear evidence” documenting why you could not participate in the conservative management. This evidence must be in the form of office notes/dictation from your treating doctors.
Without your help in gathering these records we might not be able to justify the need for surgery to Medicare. This would place the financial burden of the procedure on you. We appreciate your help as we try to navigate through this rapidly changing healthcare environment. If you feel these new requirements cause a delay in your care or prolong your pain and suffering, we urge you to contact your local, state and federal elected representatives to describe your personal experience.
Thank you for allowing us to be a part of your care.
Notice to Medicare Patients Needing Hip and/or Knee Surgery
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