Thursday, May 26, 2022

Re: Medicare Law

Albert J Garney

Okay simple question if a O&P provider don’t have collaborating notes with the ordering physician (most cases MD writes a simple Rx for a device but no notes backing up all the lcodes) what is going to be the modifier?

If a the device is covered under Medicare and medically necessary but the claim is denied payment because Dr note lacks proper documentation we get stuck holding the bag. Can a ABN be used telling the patient and Medicare we don’t have DR note as policy under Medicare guideline and the patient will have to self pay do to lack of documents as described by Medicare

Best regards.

Albert Garney,CPO
Prince William Orthotics & Prosthetics
8644 Sudley Rd Suite 305
Manassas VA 20110

www.pwop.net

Office. 703-368-7967
Cell. 571-247-8641

On Nov 12, 2012, at 10:44 AM, Wil wrote:

> Hello Colleagues and Guests,
>
> There have been questions regarding the possibility of our group merging with the recent American Hospital Association (AHA) Medicare lawsuit. The answer is that we will not be able to do that.
>
> With that said, important information is being shared with us regarding the possibility of us filing our own lawsuit at some point in time. Hopefully, we will get these issues resolved before that is necessary. But, just in case it comes to that, we need to research the law and point out the illegality of Medicare’s enforcement of same when we get to the administrative law judge (ALJ) suit venue. In other words, when we get to the ALJ, we need to be able to show them where federal law is being violated. Perhaps, this may be found in several different places, but I am not suggesting that at this point. We will need legal opinions about these matters. An example, however, may be that Small Business Administration, Ombudsman legislation (statutes) are being violated by the sheer financial impact of the Medicare auditors on our practices. What, for example, defines random audits and at what point in a revenue stream does an audit become excessive and unreasonable for the small!
business involved? I feel certain there are other areas within the federal statutes that will surface as we investigate Medicare law. We have been told that unless we can show where the statutes are being violated, and present this information to the ALJ, we will have little chance of making progress in these matters when we get to that point. That does not mean that ALJ decisions will not be overturned in our favor without such information, but it will add to the credibility of a potential law suit holding those responsible for our burdens accountable. When RAC auditors make incorrect decisions, should they not be held financially accountable for their actions?
>
> We still believe that the best long term solution will be that the professional orthotist and prosthetist be given the authority to write, in consultation with the prescribing physician, the definitive Medicare prescription. This will not downgrade the physicians important role in the process in any way. If anything, it will enhance the communication between the prescribing physician, the professional orthotist and prosthetist, Medicare and last, but not least, the patient. It will also open opportunities for better communication between the O&P practitioner and physical and occupational therapists. How could this not be a win-win situation?
>
> As we move toward that goal, several important pieces of the puzzle must be obtained and successfully presented to the appropriate people. If, and I repeat, if we are successful along the way, we believe we will have a good chance of effecting appropriate change within the Medicare system. As most of you know, what happens with Medicare eventually trickles downstream to other insuring agencies. We are moving toward that goal, albeit slowly at this point, but nevertheless we are moving.
>
> If I have sounded negative at times during this process, it is simply because I (we) are fed up with the inattentive bureaucracy and largely BS that seems to prevail within our government from both sides of the isle. If that message does not ring loud and clear as you read the AHA federal lawsuit against the Secretary of Health and Human Resources, then I suppose we are in big trouble. But beyond the federal statute violation issues, there are other administrative decisions that come from Medicare that are simply wrong. Medicare is telling us that we are responsible for educating the physicians and ensuring that they comply with Medicare O&P regulations. Without a valid explanation, that is one of the most stupid federal policies that I have ever heard and it certainly helps make the case for who should be writing the definitive Medicare prescriptions.
>
> At the end of the day, our hope is that we will be able to join forces with several of our state and national associations, other professional groups, and patient groups to make a united stand to help get these problems solved. Will that happen? Time will tell.
>
>
> Wil Haines, CPO
> MaxCare Bionics
> Avon, IN 46123
>
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