Saturday, May 25, 2024

Reimbursement vs cost

Rick Stapleton

Good afternoon List-serve,

I wonder how Medicare can set a price on a specific L-code and reimburse us less than the cost of the component? The question at hand is how can we as a profession bring to light this conundrum and not allow the government or any Insurance company to expect us to take a loss on any product we provide. As you all know, there are certain components that we have to have for manufacturer’s “specific systems” and can’t use anyone elses product. When I replace “those components” I am reimbursed (in this case Medicare) less than what it cost me, how is this fair or appropriate? If it truly costs the manufacturers (with a small? profit) that much to produce, then how did Medicare come up with that fee schedule? Is there another, cheaper source that I can buy batteries that are specifically designed for one manufacturer’s prosthesis that I don’t know about? Is that how Medicare based their fees on a cheaper product by a supplier that I know nothing about? I do know that I can become a non-participating facility, accept assignment on all or any claim I choose and charge the patient (informing the patient ahead of time about not accepting assignment) what I feel is an appropriate fee (although Medicare caps my non-participating charges at 115% over Medicare’s fee (of course Medicare knocks off 5% for being non-participating right off the top.)

I am going to lose $##.## on each myoelectric Lithium-ion battery I replace on a patient’s prosthesis. His prosthesis is almost three years old, is used every day and fitting very well, no problems, just needs batteries because they no longer hold a charge. Not only are they (Medicare) not reimbursing me the cost, but the fact that I have to see the patient, document the need, have the patient get a prescription, get physician notes, and then make sure the product works as designed, and I can’t even get covered for the cost of the component let alone my PROFESSIONAL time and experience! That doesn’t even include the rest of my staff: Scheduler, receptionist, biller, and the cost of having a clean, comfortable office/exam rooms. Since Medicare sets the pricing standard that all insurance companies use, that sets us up to lose even more if those companies demand discounts to Medicare’s price.

Somewhere there needs to be dialogue between the manufacturers, the professionals using the products, and Medicare to allow for a reasonable pricing structure to reimburse us (Medical Professionals) at a reasonable level. Their needs to be a formula we can all agree on to allow for REASONABLE pricing/profit to keep businesses going in a very challenging environment and a mechanism for us to be able to address this issue (not just non-participating not accepting assignment option.)

Thanks for reading my rant.

Best regards,

Rick Stapleton, CPO

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