List serve,
Thanks to all who responded, I appreciate the time and all of the recommendations. In the future I am going to follow the path that we have already initiated when we adjust anyone’s prosthesis or orthosis and use the labor and small parts code and include secretary, billing, and any other office functions for labor. I suspect the insurance company will still want to challenge that, but we will see. I still think the manufacturers owe it to us to have a suggested retail price for their products and send us copy along with our actual invoice. As many pointed out our invoices are our proprietary information and they (the insurance industry) really don’t have any rights to that information. The problem is, when talking to several people from the insurance company they are not going to pay the bill without that invoice, period. So if I want any money, I am going to have to provide something to them that they will accept. It seems to me that this should be changed through our government and force the insurance companies to abide my normal business practices but then I am not going to hold my breath on that one. The insurance companies are really modern day Bullies and thieves, they are stealing our money right in front of everyone’s eyes. Below are all the responses:
Get a copy of quick books and create a new company that sells l5999 products to prosthetic company’s.
that may work, but who knows.
I have made an educated change in my policy. If it isn’t M. Care, it’s a non covered item, period!
The one’s that can pay do and the one’s who cannot won’t.
At the end your probably breaking even but feeling a lot better with less stress. Especially with all the other Barbara Streisand we put up with.
How about photoshop? Or a program on Macs called Grab where you can copy anything from a page or document and then paste into place?
That is a good point, I would think our suppliers would help us out on this one, they should have an MSRP price on their products and include that when we request it.
If the foot shell for a dynamic foot is an Ottobock foot, we can provide you with a manufacturer’s retail price. Unfortunately, we can’t currently put it on a packing slip. Again, if it’s our foot we are willing to work to find a solution for you. Please call the reimbursement department to find a solution (800.328.4058). I know some payers are being particular in what they will and won’t accept.
I dont know if this helps but I do the cost of the item on the 99 code and then I also bill for my time. In your case with the foot shell I will bill the 99 code for cost of shell so I have an invoice to support the cost then I bill for my time to remove the footshell and reapply the new one, check fit and alignment and so forth . It definitely does not get excellent reimbursement but helps a little!
You should be using code L8499 which is described as UNLISTED PROCEDURE
FOR MISCELLANEOUS PROSTHETIC SERVICES. L5999 is described as LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED. I recently billed Medicare for a foot shell that cost me net $** and I billed 1.5 times that= $***. Medicare approved $**.**. I asked them to explain their methodology but haven’t heard from them yet.
Three ideas
Send a forceful letter explaining you provide professional care and services which often includes replacing parts. Point out that if the insurance prefers you can simply replace the entire foot for (use appropriate L-code) the much greater cost. Emphasise that while we (P&O) are lumped in with DME professional care is totally different then simply handing the beneficiary a box of items.
Have you tried using the codes for labor and repair parts instead of the 5999? Then if they ask for parts invoice you can provide an invoice while making your profit on the labor side. Make sure to include an invoice for your secretarial time in ordering, receiving, and notifying patient.
The third idea is a bit more complex. If you have sufficient numbers to warrant it can be the easier fix. Start a separate company using a UPS box store for address. Establish dual accounts with your vendors (like having two offices with different names) and when you need repair parts order using the UPS company. Then generate an invoice from the UPS company to your company for the parts, here I would use a ***% markup (if the part and shipping cost $* you invoice $*), this will protect your labor and profit.
I refuse to use the L5999 (or similar) codes because of this same issue. I have had much better luck using (lets use your example) L5972RP, flexible keel foot REPAIR and then I bill it out at slightly less than L5972 knowing that the insurance will usually cut the fee themselves and I end up with a fair and reasonable fee, hopefully.
In the past DME world we would get an invoice from a manufacturer showing retail cost. The insurance co. Knocks off no more then 30% off retail. However the discounts in O&P are much less. The manufacturer has to change and elevate retail cost so you profit.
All insurance plans have payment policy for uncoded product (i.e. they pay 20% lower than retail invoice or 20% higher than manufacturer invoice etc). In these instances you will be lucky to break even and should always bill L4205 or L7520 for labor too. Don’t let them tell you you can’t bill for labor. (I just had a part replaced on office water heater under warranty, they didn’t charge for the part but they charged us labor to replace the part.)
Whenever possible I try to bill a similar code with similar price to avoid the whole Lx999 issue.
I see their point of view would you pay for something that you did not know what it was. Back in the day as a prosthetist approving payments I wanted to know what the L-5999 was.
As you know, the preamble to the HCPCS level II “L-Code” system indicates that you are providing services and device. Get paid for your services and the care you provide. It’s not about the device. Support your invoice with an approach that speaks to their bottom line through improving the patient’s quality of life, improved functional mobility and decreased costs through quality prosthetic care….. unless you simply provide devices in which case ignore what I said. Good luck.
If you study the way that large corporations handle their purchases, you might find a solution that is perfectly legal to do. Large oil companies don’t purchase their oil directly. They typically purchase it from a shell corporation at an inflated price so that their income looks less than it actually is. The shell corporation buys it from a broker who buys it from a refinery overseas. Which invoice do you pass on to the company that is demanding it from you? If you had your own fabrication department that orders things, then sells them to your patient care company, you could utilize the invoice from the fabrication department because that’s who you are paying for it.
We’ve had several insurance companies contact my company demanding that I show proof of how much we are selling our resin and skin sleeves to the professionals. We have flatly refused to do so. They also asked for prices on what we charge to shape a foam cover and apply skins.
I am not condoning lying to anyone, but being honest about what you pay to who can take many forms. Large corporations know how to play the game well so we should observe and learn from them
I can understand the insurance company’s argument for not wanting to “over pay” for a specific item. I just wish they could better understand the true nature and particle realities of O&P physical restoration and rehabilitation.
I read your post on the list serve and thought that I would pass along my experience on the subject. I have been asked, by customers, to provide the exact invoicing in question. Two simple ways that you could provide this invoice; first, call the manufacturer and have them provide a retail “quote on company letterhead” for the specific product or purchase the product at retail cost with an understanding of a credit back on your discounted pricing. These seem to be the only way around the ridiculous reimbursement that you are talking about. It seems the VA is asking for the same invoice as you are probably aware. I hope this helps, please call me if you would like to speak in more detail.
Rick, you are the manufacturer/fabricator. Insurance companies don’t get it. Fight and Resist. When a physician submits a misc code they are not required or even asked to submit the costs of performing the service/product. Boeing isn’t asked by the gov’t the cost of titanium in the engines they buy form military. We all need to push back, unfortunately it effects cash flow which is understandable why there is less fighting back.
You do not have to submit your actual MFGR invoice with YOUR Negotiated costs.. The internal invoice should suffice. That’s what I do.. BCBS T accepts as well as MCR. They have no business with your invoices and your Negotiated pricing. Joe Schmo down the way may have better negotiation skills than Jane Doe up the way. Let the ins determine the pricing. With our invoices 95% of the time I get our listed rate. I sometimes add the MFGR product info from the web with my claims and invoice. Let them go to the website and determine costs… as long as your within reason there shouldn’t be a problem.
We bill foot shells at L7510 and L7520
Code for the foot and adjust the fee down to cover your fee for the shell.
Thanks again to all,
Rick Stapleton, CPO
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