How Does Clawback Insurance Work?
Medicare Audits
Medicare reserves the right to go back up to 6 years to perform audits on reimbursements to Clinicians. It is very important that Clinicians exercise best judgement when determining "medical necessity" when prescribing allografts for advanced wound care.
As such, it is mission-critical for Clinicians to properly document the healing journey of each patient from week to week. They will be required to medically justify why they made the decision(s) to use allografts to heal the advanced wounds on each of their patients.
Why Should Clinicians Consider Using Clawback Insurance?
The cost of advanced wound care can be astronomical depending on the total square centimeters of the patients wounds. The cost for the allografts can range from thousands to millions of dollars. If a Clinician doesn't have the protection of Clawback Insurance they run the risk of Medicare requiring them to repay the reimbursement amount back to Medicare. If Medicare makes the decision not in favor of the Clinician then the results can be financially catastrophic to that Clinician and their practice.
What is the Cost to the Clinician?
The Clinicians pay nothing up front. There is a cost of 6% to the Clinician of what is reimbursed. The Clinician will pay Shoreline when they are reimbursed. This is 100% coverage for 6 years per patient that they opt to have covered.
Remember, this is optional for the Clinicians. Some of them love this and others are not a fan so tread lightly when discussing it and be prepared to pivot in the conversation.
Which Allografts Are Covered?
As far as coverage, here is a listing of ASP Allografts that are approved for our Clawback Insurance coverage:
- Membrane Wrap (Q4205)
- AmnioWrap2 (Q4221)
- Barrera (Q4281)
- Esano ACA (Q4275)
- Amnio-AMP (Q4250)
- Restorigin (Q4191)
- Phoenix (A2015)
- AmnioCore (Q4227)
- Amnio Tri-Core (Q4295)
- Amnio Quad-Core (Q4294)
- AmnioCore Pro (Q4298)
- AmnioCore Pro+ (Q4299)
- DermaBind TL (Q4225)
- CompleteFT (Q4271)
- Amnio-Maxx (Q4239)
- Xwrap (Q4204)
- Complete-AA (Q4303)
- Helicoll (Q4164)
- MLG-Complete (Q4256)
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