List,
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Thanks to all of you who have taken the time to respond to my post. To clarify several questions that were asked I can tell you the carrier was not Medicare. In fact, it is a workman’s compensation case with another company who is representing the actual insurance company. I am also not new to O&P; I have been owner/manager of this practice since 1997 and have been in O&P since 1980. Here are all of the responses except for a few who didn’t want their responses posted:
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I have experienced a denial similar to what you are describing. In this instance, a state Medicaid program was requesting invoices for L-codes and were going to pay a certain percentage above the invoice for each code. It was then discovered that the bill had been submitted with the wrong modifier. Medicaid viewed the RP modifier attached to the codes as a repair and not a replacement. The correct modifier was NU for a new prosthesis. You may want to contact the insurance company and make sure modifiers are correct or if one is needed to correctly process your claim. =20
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Initially, I was told that any code that is generally custom fabricated as the base code would be, you would have to itemize product used and labor used to create that specific code. They would then pay the same percentage over and above that cost as they would with the invoice you provide for the other codes. It is unfair at best. They do not factor in the cost of your facility, liability insurance, etc that is all a part of running an O&P facility. This could set a dangerous precedent and is something that needs to be addressed.
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Again, I would first contact the insurance company to see if it was billed correctly and then go from there. Good luck!!
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Are you in Region C? I was under the understanding that they are
targeting replacement socket and total contact codes. We have been submitting documentation to support these but not invoice info since these are fabricated in-house. We are still fighting. Also, we have had ALOT of difficulty reaching palmetto. Please post your replies
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New to O$P I see. Here’s what we do when an insurance company asks for a ridiculous administrative dance before paying (as in an invoice for a base code): I send them an invoice from my clinical practice with itemized costs for all the components, labor, overhead, administrative time and profit (20%). this amount usually exceeds or is very close to what they were charged or… I send them the last invoice for every raw material in quantity that goes into the base code, including labor bills, administrative costs and a small profit (20%). It works, rarely do they ask again. If they do, I send the exact same thing. If they think something is fishy, I say prove it and then I have them because they have to sit down and listen to me and understand my business – something they would rather not do. good luck with “the game.”
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Hi, I have never been asked for invoices from as insurance company
other than Medicare. What I do is to send the invoice of the specific component such as the foot or knee to prove that it was purchased for that patient. HOWEVER, I white out the prices. I usually order the foot and knee for the patient when needed and the P. O. has the name of the patient. Therefore, I can prove that the components were ordered for that patient. I do not try to send invoices for every component.
So far this has helped me with Medicare inquiries. Hope=20
this can help you.
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Send them the packing slip that identifies the components in question, but make sure it does not include any cost per item. Also it may be advantageous to remove any acct. number as well as any phone number to the manufacture. What the insurance companies can do (all in the name of protecting from false claims, which is admirable but injures those of us who are honest) is acquire the actual cost per item and begin to adjust their payable. It is a shame that our field does not work together … it seems as if the insurance companies are against us but will willing pay a sales rep for service supposedly rendered … the manufacturers will not set guide lines to remove their reps from our referrals and every ‘Jo Shmoe’ is considered a provider … take care I hope this works.
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I would try talking to a “real person” at the insurance company (who has some authority) and explaining to them the nature of a base code and the service components involved. At the very least, itemize everything included in the service component of the base code, as well as the product components. Remember, you will be documenting hours and hours of time that will be devoted not only to measurement and modifications, but follow-ups and adjustments during your warranty period. Also, itemize the appropriate percentage of other expenses involved in providing the base code, i.e.: liability insurance, general overhead, corporate wages, actual components, etc., etc. These are all viable costs derived from traditional cost accounting methods for providing the service. When all is said and done- your total base code costs will be close to (or depending on your contract with the insurance company) maybe more than the reimbursement allowable. Good luck.
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As the “manufacturer” of the prosthesis, the bill you sent them for the=20
prosthesis is, in fact, the manufacturer’s invoice. Many of the claims=20
processors have no clue what goes on in an O&P Laboratory and they need to=20
be educated. I have made that explanation and it has been accepted many
times in the past. I simply go on to welcome them to my facility to receive=20
an education in how we do patient evaluation, design and fabrication the
prosthetics which we provide to patients. We don’t buy them from someone. =20
They are so used to dealing with DME companies they think we are vendors of=20
products just like the DME’s.
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We have had very similar circumstances. As a rule I try to NEVER give an insurance company an actual manufacturers invoice. I agree, it is none of their business how, and with who, I run my business. When they insist on an invoice to process a claim, I give them one. We create our own invoice which shows both labor and materials. This is especially fun when they want an invoice for a custom orthosis.
Good luck.
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I recently had an insurance company pay me on some of the prosthetic codes but not on the base code and a few other codes. It did not make sense. We had to communicate with the carrier a number of times before we received payment. I’m not sure this was an honest mistake or intentional.=20
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I have also experienced in the past where they would ask for a copy of the cataloged page of the components involved and a copy of the invoices. I wasn’t comfortable with their request, but sent it in anyway. I’m not sure of our legal rights in this situation.
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Good luck!
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I have privately held the same belief. Medicare, as I am sure you know, has begun asking for invoices from us for repairs and now for the Universal Audits that have begun. I do not know if there is some reference in the Medicare Policy Manual that gives Medicare “the right”
to “request” this info or not. I am sure that if I do not supply this information, our claims will be denied. Our private insurers have not yet begun this same tactic, but if Medicare is able to do it, they can’t be far behind. This is a big concern to me, the direction that this is going is very alarming.
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Thanks to all,
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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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