Contradicting the Reimbursement Myth for Non-Transfused Blood Components

Many clinicians believe that the procedure and supplies for producing and applying non-transfused blood components, including platelet gel, is not reimbursable.

That’s not true, according to the experts at Health Benefits Advocates, Inc. (HBA), a reimbursement consulting company. HBA staff has 27 years experience as reimbursement advisors with 21 years specialization in blood component procedures.

They explain that although the reimbursement landscape is often complicated and that there is no “cut and dried” method for obtaining coverage, most platelet gel procedures can be reimbursed, subject to a number of variables:

Documented medical necessity of the procedure.

“The north star of reimbursement is medical necessity,” opines HBA.

The payer’s policy

Some payers do have coverage exclusions — others do not. For instance, Medicare excludes coverage for use of platelet rich plasma (PRP) or platelet poor plasma (PPP) on chronic subcutaneous wounds. However, all other platelet gel procedures are eligible for coverage. HBA requires compliance with payer policy as mandatory in all communications. Of course, there are no payment guarantees and payers always reserve their right to review claims for payment upon receipt.

The location of the procedure

Whether a procedure is covered may depend on where it is performed: as an in-patient service, an out-patient service, in a physician’s office, or elsewhere.

Documentation of procedure and supply descriptors used by the provider

The physician and facility need to choose and document the appropriate descriptors (codes) for all their procedures and items.

Charge set up for the procedure

For instance, for procedures performed on an in-patient basis, it is important to identify the correct facility cost center for the charge.  When all these variables favorably align, one can have a reasonable expectation of successful reimbursement. HBA believes a reimbursement advisor’s role is to act as a chosen resource by the provider “as they navigate through the complexities of the landscape” and that working with an advisor may reduce by months or years successful cost recapture of non-transfused blood component items and procedures.

Useful Reimbursement Resources: