Thank you to all who responded about the request for invoices. To clarify, the L5999 code was used because there is truly not another code that we can use from both an ethical and legal standpoint. The patient was also well aware that this would be a challenge and medical necessity was well documented and not challenged.
The short summary is that in general, practitioners are responding to these requests but the response to the requests are varied. Some have also tried sending the MSRP, some have sent the invoice with a standard markup, some have sent the pure invoice only to have a payment of 3%-4% above cost. Some have also sent an invoice with their cost removed, sending it as proof that the item was ordered for the patient. Feedback also indicates that practitioners are always submitting the information and the legality of compliance with an invoice request has not been questioned.
Regardless of how we end up addressing the issue immediately set before us, I believe it is still something to be discussed and investigated among our profession. We all know that a manufacturer invoice of a particular item does not accurately represent the true cost of supplying the patient with a given technology. As many others have recently posted on the listserv, our profession continues to take a beating from the insurance companies and that is a problem for our future.
Susan Stenman, CP, MSBME
Here are some of the responses written in their own words:
Tell them that their request would be reasonable if they were simply receiving an arm from Amazon in a box, but not when it is used as a part of a treatment plan for a patient. If they would like an invoice on the part, they must also accept your invoices for billing time, administrative time, authorization time, evaluation time, casting time, laminating time, etc. as valid invoices. With the price being set as a standard, we as clinicians are more motivated to accomplish the job efficiently, wasting less time for the patient and other medical professionals.
All Workmen’s Comp Insurance companies all require an invoice on anything items bought in New Mexico
I had the same thing happen. I sent in our invoice and insurance paid $162
above my cost….on and item that cost me over $4000.
Unfortunately, Insurance companies are notorious for providing a very minimal markup (like 10%) above invoice which doesn’t cover our costs for providing technology. This happens a lot with repairs. Therefore, I avoid using “99” codes if I expect to get paid for service performed.
You have to send the invoice if you want to be paid, but a letter should accompany the invoice letting them know that invoice is for the raw cost, and does not into the implementation, education to learn the technology or liability, overhead, support staff ect…
Good luck
I have had the same experience, especially when billing for parts & labor. I have yet to be denied when providing an items cost (what we pay for it) plus our mark up. I believe it is legal as Medicare has requested the same & I have provided the info making sure to point out/incld shipping fees. As long as your mark up % is reasonable & routine across the board, you should be paid. Honesty does work, but sometimes you REALLY have to make them see that you are being fair.
As far as it being contractually legal, that would depend on your contract
with that company and if, somewhere in there, it does allow them to ask for
or audit your costs.
The way we have dealt with this issue is to explain to the payor all that is
involved with provided that service. The time in evaluation, fabrication,
fitting, and follow up. The benefits of the procedure, and how this service
will provide the patient with the least costly most appropriate care.
There have been some times that the insurance has held firm on their
position for an invoice…with custom compression garments, and we explained
the situation to the patient and offered to provide the service if they were
willing to pay.
Because these services do not have a set procedure code and fee, you are
typically not required to accept what the insurance company wishes to pay.
Check your contract to be sure this applies.
