Got FAQs

Billing for O&P devices seems to get more complicated by the day. Count on Got FAQs? to help answer your toughest questions. This month’s column addresses your questions about prior authorization for knee orthoses and any willing provider statutes. Q: I work for an orthopedic surgeon in Texas. We recently opened an orthotic facility and received our Medicare provider number so we can bill for custom orthotics. We hired a practitioner, and I want to ensure I have all the proper documentation and clear understanding about how to bill these items. I have heard that we may need to start obtaining prior authorization for certain orthotic devices. Does that apply to knee braces? Our physician has been reading your column for over 15 years and is extremely impressed with your knowledge and understanding. A: Medicare/CMS published a notice in the Federal Register on January 13 requiring a prior authorization for knee orthoses HCPCS codes L-1832, L-1833, and L-1851. Since you are in Texas you will be in Phase 2, which is effective for dates of service on or after July 12. This information can be found at bit.ly/3MkFQgo. The article from Medicare titled “Condition of Payment Authorization expands to include select orthotics,” updated on February 28, is available at bit.ly/3tyxoSc. All knee orthosis claims should have a standard written order (SWO) that includes the beneficiary’s name or Medicare beneficiary identifier (MBI) and order date. The description can be either a general description, an HCPCS code, an HCPCS code narrative, or a brand; treating practitioner name or NPI; treating practitioner’s signature; that the SWO was obtained prior to submitting the claim to Medicare; and delivery documentation. Custom-fitted and custom-fabricated items require fitting at the time of delivery. Medicare provides a documentation checklist at bit.ly/3vGDa74. In addition you can review the LCD for the complete coverage criteria, documentation, etc., at go.cms.gov/3pFpGVf. Q: My husband and his partner are O&P providers in Tennessee. We are looking to expand and open facilities in Kentucky, Virginia, or South Carolina. Every time I have tried to get contracted with an insurance company, they tell us their panel is closed. We don’t want to open a facility if we are unable to obtain contracts for that state. I recall reading something in a past column about certain states having to give you a contract by law. Is there such a law, and in which states? A: The law you are referring to is an any willing provider (AWP) requirement. 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. Virginia is an AWP state. Per Section 38.2-3407: Insurers shall establish terms and conditions in order to receive payment as a preferred provider. The terms and conditions shall not discriminate unreasonably against or among such healthcare providers and cannot exclude any provider willing to meet the terms and conditions. Kentucky is also an AWP state. Per Section 304.17A-270: A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the plan and who is willing to meet the terms and conditions for participation established by the plan, including the Kentucky State Medicaid program and Medicaid partnerships. Section 304.17A-505: ...if the provider meets the insurer’s enrollment criteria and is willing to meet the terms and conditions for participation, the provider has the right to become a provider for the insurer. South Carolina does not have an AWP statute. For a list of states that have some form of AWP statues, visit https://bit.ly/3sG2S9Y. 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.

Got FAQs

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Certified Prosthetist / Prosthetist-Orthotist (CP/CPO) Gates Prosthetics + Mobility Clinic — Mountain Home, AR

Clinic Manager – Certified Prosthetist Orthotist (CPO) – Rogers, AR

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Related posts:

Problem Solving in a Cranial Clinic: Improving Issues That Negatively Affect Referrals and Insurance Coverage

Editor’s Note–April 2022

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O&P JOBS

Certified Prosthetist / Prosthetist-Orthotist (CP/CPO) Gates Prosthetics + Mobility Clinic — Mountain Home, AR

Clinic Manager – Certified Prosthetist Orthotist (CPO) – Rogers, AR

CPO

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