[oanp-l] Responses to billing shrinkers in-pt
Rick
Description
Collection
Title:
[oanp-l] Responses to billing shrinkers in-pt
Creator:
Rick
Date:
11/14/2019
Text:
Good day list, As Always....thank you very much for sharing.Original post:It is my understanding that shrinkers are part of consolidated billing so that when a person is an in-patient in a hospital or rehab facility we must obtain a purchase order & bill the facility...correct?
Seems to be an area practice by a multi-state, multi-office provider to give shrinkers to persons in facilities without obtaining a PO# only to bill the person's insurance post discharge (seen 1st hand on patient's EOBs & explained to me by a local PT in one of these rehabs). I am thinking this is fraud, but have yet to get a patient to report this behavior. It is obviously detrimental to other providers as when we ask for a PO#, the facility either delays providing the PO until the person is discharged or calls in the company that provides shrinkers for free !!!
Why should we be forced to provide goods for free just because someone else doesn't play by the rules? Mine WOULD be FREE b/c I will not bill the insurance on a fraudulent delivery date.
Any thoughts on a good course of action would be greatly appreciated.
RickMORE to this Story: The CPO from that company in question just showed up at this pt's room & told him he was there to fit him with shrinkers. pt informed him that he already has a prosthetic provider & told him to leave. pt reported that this CPO ...got very pushy, came up to my wheelchair & said that He was told to provide the shrinkers ! pt told him to Get Out! pt is being discharged Saturday & has an appt at my office for shrinkers.
Responses:You are correct.Unknown credentials+++++++++++++Get a PO prior to delivery...... if they refuse to give a PO, let the patient know what needs to happen prior to you delivering the shrinker and why. Either the physician or patient may get upset enough with the facility to make a stink and force the issue of a PO. Just a thoughtCP++++++++++++I would love any feedback you receive.
We were recently told the exact same thing by a rehab facility. The rehab ended up issuing us a check and a purchase order even though other providers give it for “free”.
Unknown credentials++++++++++++++
The patient doesn’t report fraud, waste or abuse of medicare billing. The provider who recognizes it does. Anonymously, if he has any care for his future business.
Shrinkers for inpatients in rehab facilities should bill part B, if I am not mistaken. You could get a SOR on the date delivered there. Again, if I am not mistaken. Ask Jim at oandpedu or consultants prn….
Inpatients in hospitals are part A and therefore must go through the PO # to the provider from the prison, oh, I mean hospital….
Inpatients in hospitals that are having “outpatient surgery” can also bill through part B or to the hospital.
Clear as mud, hunh?
Unknown credentials
++++++++++++++++++
Yeah, that’s a shit situation……. Hanger will be the death of the field……Hospital employee mentality is always the same, very few take responsibility, always someone else’s fault. I am lucky that we have little competition. Best of luck!
CP
+++++++++++++++++
As a biller I agree with your thought process on this. Some of it may come down to what is considered the company's standard operating procedure, which Medicare is big on. The O&P company I previously worked for did their billing by individual items. They'd get a DWO with everything they wanted to eventually give the patient, but would only have them sign for and bill what they actually received at delivery that day. Sometimes it was 6 socks instead of 12, or only 1 liner instead of 2, but they would have the patient sign for the additional items when they were actually delivered (maybe the other 6 socks were delivered later on in the year). I personally agree with you that this is the safest and most accurate policy, but it was hard to keep track of what we had orders for vs what was already delivered and when.
The company I work for now, and am aware that MANY other companies do the same thing, bills for everything on the DWO on the same date regardless of when it was actually put in the patient's hand. Maybe they gave the patient 2 shrinkers during the initial evaluation post amp or ordered a liner to do the casting and let the patient take it home. When the prosthesis is delivered all of the items provided are on the POD and signed for. We do this for all patients with the expectation that they will be following up with us for their prosthesis. What we do NOT do is purposefully give a patient shrinkers or supplies as a means of getting around the consolidated billing policy or only provide these for Medicare patients. That IS considered fraud and/or gifting.
If you provide supplies without obtaining prior auth, checking same/similar, getting a PO or taking other steps to ensure you'll get reimbursed for it you're definitely putting yourself at risk for NOT being paid for that supply. I've run into cases where we knew a patient saw another provider and received a liner that required prior auth, but because we had requested auth before the other provider did, their request was denied and they eventually would have lost out on reimbursement. The documentation LCD does state the delivery date must be the date that the DMEPOS item was received by the beneficiary or designee. It also states the date the beneficiary received the DMEPOS supply must be the DOS on the claim. I think some people have taken liberty with that second sentence and feel the patient is accepting delivery for all those items when they sign the POD for the final prosthesis. It seems cut and dry to me, and I see Medicare's intent, but I also see how providers can put it all together and consider it a final delivery. Not sure how you do your billing, but do you bill each check socket on the service date it was either fit and rejected or fit and accepted? Or do you bill the check socket(s) with the same service date as the finished prosthesis? Something to consider, I suppose. Anyway, sorry this is such a long response!! And your frustration with the situation is definitely understood! The whole well so-and-so never makes us do that is really irritating and it causes those of us that want to do it the right way look bad. Billing Specialist++++++++++++++++++++++
I understand your frustration. I have run into this same situation where a facility will say, the other place doesn't need a PO!I have for the most part been giving out free shrinkers to compete. I do bill for shrinkers at delivery but always provide an additional set. Many patients need a smaller size by that point and the insurace only covers 2.
I will be interested in any other responses you receive. Unknown credentials++++++++++++++++++I would continue to let the prescribing Dr. and the facility know that they will be responsible for payment of any soft goods IF the patient is currently residing under the Medicare 100 day rule after discharge. If a patient is a permanent resident then you can bill his insurance after delivery. If you deliver to patient in the hospital and he is using it in the hospital, then that is billed back to the hospital. If the patient receives it in the hospital for use after discharge and goes home, bill his insurance directly. If the patient is discharged to a SNF, then the hospital is billed. (see attachment).
Sometimes a patient is in a SNF under the 100 day umbrella and they heal quickly and are ready to proceed with the prosthetic but they still need PT/OT and the therapists want him to be using the prosthesis for PT/OT (sometimes the patient won't be released to go home until they receive their prosthesis), then we can deliver it to the patient either in the SNF (HOWEVER, any soft goods associated with that order should still be billed to the SNF) or in the clinic and bill the patient's insurance for everything.
You are correct in that it is insurance fraud to just wait and bill after the patient leaves the facility since that is not the date or place of delivery.
Office Manager+++++++++++++++++++++++++
I don’t think there is anything we can do. I was told, in a group of colleague’s, by a regional director of Life Care Centers in my area that they can choose to not release a PO, it’s their prerogative. I am guessing it’s somewhere in the fine print?Unknown credentials++++++++++++++++That’s so ethically wrong and legally wrong. So many things in this industry are upside down it’s exhausting!Unknown credentials+++++++++++++++++Good for you Rick! I agree. Too many are doing fraudulent practice to get preferential treatment. It's because too many of us look away. Hospitals and SNFs don't care as it doesn't hurt them. But it affects our profession as a whole. Im with you.
LCPO+++++++++++++++Yes, if they provide that service in the facility and bill after discharge, it is Medicare fraud - for both the provider and the facility. If there is an Rx while in the facility and the facility refuses to fill that Rx, they are also breaking Medicare regulations. No rules on
give-aways unfortunately. Tough because both the PT and the facility are part of the problem.
CPO
Rick Milen, CPO/L
NEXSTEP, Inc.
West Lawn, PA
and
Zombie Buck Designz
Bernville, PA
Seems to be an area practice by a multi-state, multi-office provider to give shrinkers to persons in facilities without obtaining a PO# only to bill the person's insurance post discharge (seen 1st hand on patient's EOBs & explained to me by a local PT in one of these rehabs). I am thinking this is fraud, but have yet to get a patient to report this behavior. It is obviously detrimental to other providers as when we ask for a PO#, the facility either delays providing the PO until the person is discharged or calls in the company that provides shrinkers for free !!!
Why should we be forced to provide goods for free just because someone else doesn't play by the rules? Mine WOULD be FREE b/c I will not bill the insurance on a fraudulent delivery date.
Any thoughts on a good course of action would be greatly appreciated.
RickMORE to this Story: The CPO from that company in question just showed up at this pt's room & told him he was there to fit him with shrinkers. pt informed him that he already has a prosthetic provider & told him to leave. pt reported that this CPO ...got very pushy, came up to my wheelchair & said that He was told to provide the shrinkers ! pt told him to Get Out! pt is being discharged Saturday & has an appt at my office for shrinkers.
Responses:You are correct.Unknown credentials+++++++++++++Get a PO prior to delivery...... if they refuse to give a PO, let the patient know what needs to happen prior to you delivering the shrinker and why. Either the physician or patient may get upset enough with the facility to make a stink and force the issue of a PO. Just a thoughtCP++++++++++++I would love any feedback you receive.
We were recently told the exact same thing by a rehab facility. The rehab ended up issuing us a check and a purchase order even though other providers give it for “free”.
Unknown credentials++++++++++++++
The patient doesn’t report fraud, waste or abuse of medicare billing. The provider who recognizes it does. Anonymously, if he has any care for his future business.
Shrinkers for inpatients in rehab facilities should bill part B, if I am not mistaken. You could get a SOR on the date delivered there. Again, if I am not mistaken. Ask Jim at oandpedu or consultants prn….
Inpatients in hospitals are part A and therefore must go through the PO # to the provider from the prison, oh, I mean hospital….
Inpatients in hospitals that are having “outpatient surgery” can also bill through part B or to the hospital.
Clear as mud, hunh?
Unknown credentials
++++++++++++++++++
Yeah, that’s a shit situation……. Hanger will be the death of the field……Hospital employee mentality is always the same, very few take responsibility, always someone else’s fault. I am lucky that we have little competition. Best of luck!
CP
+++++++++++++++++
As a biller I agree with your thought process on this. Some of it may come down to what is considered the company's standard operating procedure, which Medicare is big on. The O&P company I previously worked for did their billing by individual items. They'd get a DWO with everything they wanted to eventually give the patient, but would only have them sign for and bill what they actually received at delivery that day. Sometimes it was 6 socks instead of 12, or only 1 liner instead of 2, but they would have the patient sign for the additional items when they were actually delivered (maybe the other 6 socks were delivered later on in the year). I personally agree with you that this is the safest and most accurate policy, but it was hard to keep track of what we had orders for vs what was already delivered and when.
The company I work for now, and am aware that MANY other companies do the same thing, bills for everything on the DWO on the same date regardless of when it was actually put in the patient's hand. Maybe they gave the patient 2 shrinkers during the initial evaluation post amp or ordered a liner to do the casting and let the patient take it home. When the prosthesis is delivered all of the items provided are on the POD and signed for. We do this for all patients with the expectation that they will be following up with us for their prosthesis. What we do NOT do is purposefully give a patient shrinkers or supplies as a means of getting around the consolidated billing policy or only provide these for Medicare patients. That IS considered fraud and/or gifting.
If you provide supplies without obtaining prior auth, checking same/similar, getting a PO or taking other steps to ensure you'll get reimbursed for it you're definitely putting yourself at risk for NOT being paid for that supply. I've run into cases where we knew a patient saw another provider and received a liner that required prior auth, but because we had requested auth before the other provider did, their request was denied and they eventually would have lost out on reimbursement. The documentation LCD does state the delivery date must be the date that the DMEPOS item was received by the beneficiary or designee. It also states the date the beneficiary received the DMEPOS supply must be the DOS on the claim. I think some people have taken liberty with that second sentence and feel the patient is accepting delivery for all those items when they sign the POD for the final prosthesis. It seems cut and dry to me, and I see Medicare's intent, but I also see how providers can put it all together and consider it a final delivery. Not sure how you do your billing, but do you bill each check socket on the service date it was either fit and rejected or fit and accepted? Or do you bill the check socket(s) with the same service date as the finished prosthesis? Something to consider, I suppose. Anyway, sorry this is such a long response!! And your frustration with the situation is definitely understood! The whole well so-and-so never makes us do that is really irritating and it causes those of us that want to do it the right way look bad. Billing Specialist++++++++++++++++++++++
I understand your frustration. I have run into this same situation where a facility will say, the other place doesn't need a PO!I have for the most part been giving out free shrinkers to compete. I do bill for shrinkers at delivery but always provide an additional set. Many patients need a smaller size by that point and the insurace only covers 2.
I will be interested in any other responses you receive. Unknown credentials++++++++++++++++++I would continue to let the prescribing Dr. and the facility know that they will be responsible for payment of any soft goods IF the patient is currently residing under the Medicare 100 day rule after discharge. If a patient is a permanent resident then you can bill his insurance after delivery. If you deliver to patient in the hospital and he is using it in the hospital, then that is billed back to the hospital. If the patient receives it in the hospital for use after discharge and goes home, bill his insurance directly. If the patient is discharged to a SNF, then the hospital is billed. (see attachment).
Sometimes a patient is in a SNF under the 100 day umbrella and they heal quickly and are ready to proceed with the prosthetic but they still need PT/OT and the therapists want him to be using the prosthesis for PT/OT (sometimes the patient won't be released to go home until they receive their prosthesis), then we can deliver it to the patient either in the SNF (HOWEVER, any soft goods associated with that order should still be billed to the SNF) or in the clinic and bill the patient's insurance for everything.
You are correct in that it is insurance fraud to just wait and bill after the patient leaves the facility since that is not the date or place of delivery.
Office Manager+++++++++++++++++++++++++
I don’t think there is anything we can do. I was told, in a group of colleague’s, by a regional director of Life Care Centers in my area that they can choose to not release a PO, it’s their prerogative. I am guessing it’s somewhere in the fine print?Unknown credentials++++++++++++++++That’s so ethically wrong and legally wrong. So many things in this industry are upside down it’s exhausting!Unknown credentials+++++++++++++++++Good for you Rick! I agree. Too many are doing fraudulent practice to get preferential treatment. It's because too many of us look away. Hospitals and SNFs don't care as it doesn't hurt them. But it affects our profession as a whole. Im with you.
LCPO+++++++++++++++Yes, if they provide that service in the facility and bill after discharge, it is Medicare fraud - for both the provider and the facility. If there is an Rx while in the facility and the facility refuses to fill that Rx, they are also breaking Medicare regulations. No rules on
give-aways unfortunately. Tough because both the PT and the facility are part of the problem.
CPO
Rick Milen, CPO/L
NEXSTEP, Inc.
West Lawn, PA
and
Zombie Buck Designz
Bernville, PA
Citation
Rick, “[oanp-l] Responses to billing shrinkers in-pt,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/209782.
