I have an in person fair hearing scheduled over a small charge which
has been reviewed and denied. The charge is foe the replacement of a
footshell on a Cadence HP foot. Palmetto has denied the claim due to
the fact that I have not given them the actual cost of the
footshell. Do any of you have experience with the request for your
cost for components?
It is my belief that as the end provider, my actual cost for the
“part” is none of medicare’s concern. I could have not replaced the
part and allowed the patient to damage the foot itself beyond repair
and then replaced the entire Cadence at a significant cost to CMS.
Do you regularly provide these folks with actual invoices? What if
the “big boys” get a huge discount and I do not? Does that mean that
the specific item has a value to CMS that I will be paid based on the
info provided by the cheapest invoice in the land?
No healthcare provider is asked how much did you pay for the needle
and syringe to give the patient a shot. Neither are they asked how
much they paid for the medication provided.
I am becoming more disenchanted with my inability to be reimbursed
and fighting for what is rightfully owed to me. I know of no
profession which operates in a manner where they are required to
provide services at their own expense and legally bound to not bill
anyone ever for the expenses incurred because some clerk has decided
to hold up the payment for months and then deny coverage based on “my
cost”. The next thing we know will be how much did you pay for the
raw materials required to fabricate the prosthesis? How much did the
provider pay for a pair of shoes or knee or pylon or whatever.
Any help would be most helpful (after thirty years I have yet to lose
an in person hearing). I don’t want to start now.
Greg Kidder C.P.O./L
Kidder Orthopedic
Crystal River, Fl.
