Got FAQs?

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By Lisa Lake

Billing for O&P devices and care is complicated. When you have questions, count on Got FAQs? to help keep your claims on track. This month's column answers your questions about joining insurance provider networks and coding for scoliosis orthoses.

Q: I am an O&P provider in Arkansas. I recently opened my own facility and, with the exception of Medicare, all the insurance companies I have approached have told me that their panel is closed. How can I survive as a business if I am unable to treat any patient who does not have Medicare? Do you have information that can help?

A: Congratulations on opening your new practice. Fortunately, Arkansas is one of 27 states that has an any willing provider (AWP) statute. AWP statutes are state laws that require health insurance carriers to allow specifically designated healthcare providers (physicians, pharmacies, suppliers of durable medical equipment and orthotics and prosthetics) to become members of the carriers' networks of providers if certain conditions are met. Such statutes prohibit insurance carriers from limiting membership within their provider networks based on geography or other characteristics, so long as a designated provider is willing and able to meet the conditions of network membership set by the carrier. Laws can be broad in scope, applying to a few, some, most, or all licensed providers in the state.

Broad laws typically either spell out a list of providers covered by the provisions (e.g., physicians, pharmacists, chiropractors, speech therapists, podiatrists, optometrists, facilities), or assert that the provisions apply to all providers licensed in the state without specifically listing any. The 27 states with AWP statutes are Alabama, Arkansas, Connecticut, Delaware, Georgia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Massachusetts, Minnesota, Mississippi, Missouri, New Hampshire, New Jersey, North Carolina, North Dakota, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.

The applicable law for Arkansas is Ark. Code Sections 23-201, 23-202, 23-203, 23-204, 23-205, 23-206, 23-207, 23-208, and 23-209: Benefit differentials are prohibited. Insurers must give qualified healthcare providers the opportunity to participate if providers are willing to accept the plan's terms and conditions. For a list of states with statutes similar to any willing provider, go to  pbmwatch.com/state-awp-statutes.html.

Q: My husband recently lost his billing clerk and I have been asked to step in. I have been going through our Medicare claims denials, and I am a bit confused. On some of our braces we get paid in full while others are rejected as not payable separately. The codes billed were L-1005, L-1300, and L-1200. Can you explain which codes are payable and which are not?

A: Medicare issued a publication dated July 23 regarding correct coding for scoliosis bracing. L-1005 (tension based scoliosis orthosis and accessory pads, includes fitting and adjustment) and L-1300 (other scoliosis procedure, body jacket molded to patient model) are inclusive codes and have no addition codes that are payable separately. L-1200 (thoracic-lumbar-sacral-orthosis inclusive of furnishing initial orthosis only) can include addition codes for billing (L-1210, L-1220, L-1230, L-1240, L-1250, L-1260, L-1270, L-1280, and L-1290). To view the publication with a complete listing of all codes and description on separately payable codes, visit cgsmedicare.com/jc/pubs/news/2020/07/cope18172.html.

Lisa Lake is an independent medical consultant with over 25 years of experience in the O&P industry, increasing providers' revenue by product recommendation, product and billing knowledge, and contract access assistance. She is a nationally recognized speaker on billing reimbursement and government compliancy. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. Lake can be contacted at llakeusa@gmail.com.