Navigating Catheter Selection, Insurance Coverage, and Reimbursement - Diane Newman & Don Darais
May 18, 2023
In this discussion, Diane Newman, a Urologic Nurse Practitioner and Don Darais, the Associate Director of US Marketing for ConvaTec, explore the complexities of catheter selection, reimbursement, and insurance coverages. Newman emphasizes the importance of individualized patient care in choosing the right catheter, highlighting the need for medical necessity letters for specific products. Darais delves into the intricacies of insurance coverage, explaining how different catheters fall under specific billing codes regardless of their brand or type. Newman stresses the significance of patient involvement in decision-making, advocating for informed choices based on a partnership between patient and provider.
Biographies:
Don Darais, Associate Director of U.S Marketing, Continence Care, ConvaTec, Oklahoma City, OK
Diane K Newman, DNP, ANP-BC, BCB-PMD, FAAN, Urologic Nurse Practitioner, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA
Biographies:
Don Darais, Associate Director of U.S Marketing, Continence Care, ConvaTec, Oklahoma City, OK
Diane K Newman, DNP, ANP-BC, BCB-PMD, FAAN, Urologic Nurse Practitioner, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA
Read the Full Video Transcript
Diane Newman: These products have to be prescribed by a healthcare provider, what we call a prescribing provider, which would be a physician, a doctor, or an advanced practice provider, nurse practitioner or physician assistant. I'm a nurse practitioner at the University of Pennsylvania and I specialize in neurology and most insurers will cover the cost of these products with medical necessity. What that means with the diagnosis, that means that you have to perform catheterization.
There are several different codes for reimbursement, and I have to tell you that depending on your insurance, they may cover as many catheters as I want you to use. But sometimes we need to write why specifically you need a certain product such as if you have repeated urinary tract infections, I usually write what we call medical necessity letter stating why I feel that you need a certain product to maybe prevent recurrent or repeated urinary tract infections. Say you're a guy who has an enlarged prostate or has what we call urethral stricture disease. I may need to support why I am prescribing a curve tip catheter for you because it will lessen problems with trauma or injury to your urethra. So what I have here is some different examples of products that are reimbursed by most major insurers. So I'm going to have Don here who's with me today, explain some of the ins and outs of getting reimbursed or getting your insurer to cover these products.
Don Darais: Yeah, well I appreciate it. So all of these intermittent catheters, they fall within three billing codes. So there's one A4351, A4352, and A4353. So those three billing codes, just as Diane was talking about, some insurances require certain types of documentation depending on which billing code the patients going to be receiving. So what's really unique though is that insurance looks at these three billing codes, although there's so many different catheters that fall within each of those billing codes. So I've got one here. This is actually a pediatric straight tip catheter, and the fact that this is a straight tip catheter makes this one an A4351. So insurance doesn't really care about the brand, they don't care about the size. The fact that this is a straight tip catheter is what ultimately dictates that this is A4351 product. What makes this very unique as well though, is that, so I've got a glide catheter.
This is a male link, but this is a hydrophilic catheter, so it's much more technologically advanced. However, it is also a straight tip catheter. So in insurance's eyes, what's fascinating is that they look at this as an A4351 as well. So they reimburse at the same amounts, even though these are actually two very different products. And just as Diane was talking about with a coude tip product, that is what dictates. So we've got a Cure Ultra® coude tip here. That's what dictates the A4352 category. So it could be coded, could be uncoded, hydrophilics could be integrated hydrophilic technology. If it is a coude tip catheter, chances are it's going to be in that A4352 category.
Lastly, we have this catheter within a closed system. So this is our catheter, Cure Dextra®. This rounds us out with the A4353 category. So insurance really ultimately cares about the fact that this is a touchless system inside of a bag, and that's what dictates and makes this product fall under that A4353 category. And then additionally, sometimes catheters come with like insertion supplies, like sterile gloves and a kit, and then wipes that also can make a product A4353 product as well.
Diane Newman: Not every catheter is for everyone. I really advocate that clinicians, whoever's going to teach you to perform catheterization, individualizes, which catheter for you. We have a lot of different catheters out there. Clinicians need to understand that the choice of the catheter is between you and the clinician that is what we call informed decision making. I try to look at where you're going to catheterize. Maybe there's a certain catheter that will work for you when you catheterize at home, but when you're at work, you need something different. And that's really important to understand. So I've created a lot of these different types of series on catheterization to educate you so that you become informed and can make decisions on what's the best catheter for you. So it's really kind of a partnership. You need to talk to your provider about it. If you feel that, hey, you found a different catheter that works for you, how can I get maybe this covered by insurers?
There's things that we can put into what we call a medical necessity letter to support why that catheter's best for you and maybe because of your hand use and maybe because you have an enlarged prostate and maybe because of your history and the fact that you have a spinal cord injury and need a certain product specifically for you. So really we need to individualize the care. We need to individualize which catheter is the best for you.
I always get the question was, "How many catheters do you try, Diane, when you teach someone to catheterize themselves?" And I always say, I usually try maybe two to three and I'll say, I'll demonstrate the catheter. I have them do something called a teach back, which means they show me how they're going to catheterize, so they show me that, which I demonstrate how to do the catheterization, and then they demonstrate how they're going to do it themselves. And they may go home and try several different catheters and then we talk about which is the best for them. But it's really important that you're involved in the decision making of what's the best catheter for you.
Diane Newman: These products have to be prescribed by a healthcare provider, what we call a prescribing provider, which would be a physician, a doctor, or an advanced practice provider, nurse practitioner or physician assistant. I'm a nurse practitioner at the University of Pennsylvania and I specialize in neurology and most insurers will cover the cost of these products with medical necessity. What that means with the diagnosis, that means that you have to perform catheterization.
There are several different codes for reimbursement, and I have to tell you that depending on your insurance, they may cover as many catheters as I want you to use. But sometimes we need to write why specifically you need a certain product such as if you have repeated urinary tract infections, I usually write what we call medical necessity letter stating why I feel that you need a certain product to maybe prevent recurrent or repeated urinary tract infections. Say you're a guy who has an enlarged prostate or has what we call urethral stricture disease. I may need to support why I am prescribing a curve tip catheter for you because it will lessen problems with trauma or injury to your urethra. So what I have here is some different examples of products that are reimbursed by most major insurers. So I'm going to have Don here who's with me today, explain some of the ins and outs of getting reimbursed or getting your insurer to cover these products.
Don Darais: Yeah, well I appreciate it. So all of these intermittent catheters, they fall within three billing codes. So there's one A4351, A4352, and A4353. So those three billing codes, just as Diane was talking about, some insurances require certain types of documentation depending on which billing code the patients going to be receiving. So what's really unique though is that insurance looks at these three billing codes, although there's so many different catheters that fall within each of those billing codes. So I've got one here. This is actually a pediatric straight tip catheter, and the fact that this is a straight tip catheter makes this one an A4351. So insurance doesn't really care about the brand, they don't care about the size. The fact that this is a straight tip catheter is what ultimately dictates that this is A4351 product. What makes this very unique as well though, is that, so I've got a glide catheter.
This is a male link, but this is a hydrophilic catheter, so it's much more technologically advanced. However, it is also a straight tip catheter. So in insurance's eyes, what's fascinating is that they look at this as an A4351 as well. So they reimburse at the same amounts, even though these are actually two very different products. And just as Diane was talking about with a coude tip product, that is what dictates. So we've got a Cure Ultra® coude tip here. That's what dictates the A4352 category. So it could be coded, could be uncoded, hydrophilics could be integrated hydrophilic technology. If it is a coude tip catheter, chances are it's going to be in that A4352 category.
Lastly, we have this catheter within a closed system. So this is our catheter, Cure Dextra®. This rounds us out with the A4353 category. So insurance really ultimately cares about the fact that this is a touchless system inside of a bag, and that's what dictates and makes this product fall under that A4353 category. And then additionally, sometimes catheters come with like insertion supplies, like sterile gloves and a kit, and then wipes that also can make a product A4353 product as well.
Diane Newman: Not every catheter is for everyone. I really advocate that clinicians, whoever's going to teach you to perform catheterization, individualizes, which catheter for you. We have a lot of different catheters out there. Clinicians need to understand that the choice of the catheter is between you and the clinician that is what we call informed decision making. I try to look at where you're going to catheterize. Maybe there's a certain catheter that will work for you when you catheterize at home, but when you're at work, you need something different. And that's really important to understand. So I've created a lot of these different types of series on catheterization to educate you so that you become informed and can make decisions on what's the best catheter for you. So it's really kind of a partnership. You need to talk to your provider about it. If you feel that, hey, you found a different catheter that works for you, how can I get maybe this covered by insurers?
There's things that we can put into what we call a medical necessity letter to support why that catheter's best for you and maybe because of your hand use and maybe because you have an enlarged prostate and maybe because of your history and the fact that you have a spinal cord injury and need a certain product specifically for you. So really we need to individualize the care. We need to individualize which catheter is the best for you.
I always get the question was, "How many catheters do you try, Diane, when you teach someone to catheterize themselves?" And I always say, I usually try maybe two to three and I'll say, I'll demonstrate the catheter. I have them do something called a teach back, which means they show me how they're going to catheterize, so they show me that, which I demonstrate how to do the catheterization, and then they demonstrate how they're going to do it themselves. And they may go home and try several different catheters and then we talk about which is the best for them. But it's really important that you're involved in the decision making of what's the best catheter for you.
