Second page:
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I have in the past used selected photocopies of other insurance company EOB’s that show reasonable payments for certain codes…i.e. I used a Medicare EOB that showed how much Medicare would pay for a BK base code
L5301 and make sure to mention to the non-paying insurer that Medicare is now below the national average for this particular cost.
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Usually, I too will refuse to send invoices (why not ask us to just donate all our blood at the same time!) and the only insurance that has demanded it for reimbursement thus far is our Massachusetts Medicaid – the good news is, they let us use a percentage multiplier number to get paid reasonably, so that for instance, if you need to put a heavy duty foot on someone, just write up a note along with using the new Heavy Duty code and attach a copy of the invoice with a 1.4% markup or whatever you think is reasonable based on other payments. I don’t know what region you are in, but you could also print up copies from the DMERC web sites showing the regional payment allowance and ceilings.
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Good luck!
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I agree with you completely. This is very dangerous.
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What I have done with requests like this is to send and invoice from –“your central-fab” this could be ‘Rick’s Arms and Legs” or “Limbcrafters Central Fabrication” . Make the invoice reflect what you deem that component would cost if you were to purchase it from yourself–you have time, raw materials, overhead and a profit margin which all go into the cost of an ‘L5301′. =20
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Even on the items which you have and actual invoince on you can give a “limcrafters central fab’ invoice–again just like if you would are purchasing the item from a central fab–which has to have a mark up for shipping/handling, overhead, etc. Make your central fab, be your ‘middle man’ who needs a cut of the overall price of the item.
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How you respond will be a function of who is asking. If Medicare is asking, they are aware that the base code includes Prosthetist time, Materials, Technician time, along with a margin of profit. They also are aware that the “add-on” codes for components also are cost inclusive of the component, and time that the Prosthetist and Technician spend to inspect, attach, biomechanically align, and finalize in the Prosthesis [locktite, torque, and any finishing requirement]. With other insurance companies, this is to be explained in an educative manner. I have done this many times to the satisfaction of the requester.
The essence of the information that insurance companies want is to have something in the file to satisfy the claims adjusters superior.
When you provide information that the charge for the L-Code is your “UNC” Usual and Customary charge for that Code, and it has been accepted by Medicare, BCBS, the Veterans Administration, Workers Compensation insurers throughout the Nation, and health insurance companies for many years now, and that these L-codes have been in effect for many years, you ought to satisfy even the most recalcitrant claims person.
If you want to talk on the phone and get more input, feel free to call me
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You are not alone. I did insurance billing for an independant=20
facility that has closed up in the past few months. Insurance=20
companies have made the request of invoices. I do not think an=20
invoice from a manufacturer for a foot, pylon or anything associated=20
with a prosthesis, (or Orthosis) describes the labor by the=20
prosthetist/Orthotist nor the research involved by the practitioner. =20
I once had an insurance company request a complete itemized=20
statement. I broke it down to the last nut/bolt and second of labor I=20
could. I got an additional allowance from them, but was it worth it? =20
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Before entering the O & P field 8 years ago, I worked in a physicians=20
office for 20 years. Yes, the physician community has been affected=20
greatly by the change in health care. But believe me, the O & P field=20
takes the BACK seat in the bus when it comes to reimbursement. =20
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I realize the MCO’s, PPO’s, HMO’s are the way of life in the United=20
States Health Care industry, but to me, it is only socialized medicine=20
in a way. My opinion, someone is getting “fat” and you and I and the=20
patient, are getting the royal axe.
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It has been my experience when invoices are requested to create a invoice from our personal computer. We create a invoice and breakdown the code by description and also show labor cost. We do not show our actual invoices from the vendor. Creating our own prices including labor. Since there are many components to create a prosthesis we generate them ourselves and create the pricing to justify our price. I hope this helps…Quick books or an excel program will create a invoice template for you.=20
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The way our company handles those situations is we make up an invoice from our own company listing all the codes and our normal customary charges. As long as we submit in that form we have always been paid
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We have had the same request. This is like asking how much the wood cost to determine the price of a house. We never share invoices with insurance companies, and we let them know that it is an inappropriate request. We also explain that our fees are based on medicare allowables which have been researched and deemed as reasonable charges, and that we expect payment for our services. This seems to work for now.
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Are they requesting an invoice with your cost on it? If not, do what I do, white out the pricing and send them the rest; they only need to know that we provided a new item, not used. You’re right, it’s none of their business what we pay for an item!
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Rick Stapleton, CP
President
Tidewater Prosthetic Center, Inc.
150 Burnett’s Way, Ste. 300
Suffolk, VA 23434
Ph: 925-4844
Fax: 925-4793
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