Responses-Burned by Medicare policy

Responses-Burned by Medicare policy

Randall McFarland, CPO

Original post
    We have had more than one case where the client didn't tell us you that
he received the identical or similar device within the past year. A couple of
times it was a language barrier. The other cases, we didn't ask and nothing
was said by the client.
    I understand it's not permissible to routinely ask all Medicare
beneficiaries to sign the probable denial form.
    It would seems that a disclaimer would be prudent, not only to warn
clients to not try seeking duplicate devices from different providers, but
also to protect the unknowing providers. In our situations, it was probably
unintentional but we still had to eat the device and the time spent,
because we couldn't legally bill the client without the probable denial
form being signed by the client.
   From now on, I will not only ask what has been provided previously, but
I'll ask when it was provided.
   Just passing along something I learned today.....
Randy McFarland, CPO

Responses- separated by blank line. Thanks to all respondents!!

Note- I'll get Kathy Dodson's input on this when she returns next week.

 I actually had a patient, who was an MD, deny having received a TLSO
previously. He discussed a friend who had a TLSO of a different design than
the one I was providing. I fought it with Medicare and got paid for the one I
provided because I was lead to believe that his previous device was a Warm
and Form and then he donated his previously obtained TLSO so that we could
donate it to Mexico.
He had lied to me when I originally asked about his earlier treatment.
Always have them sign the possible/probable denial form.

I work for a Rehab Hospital O & P department and we always have the Medicare
patient sign the possible denial form. This is something we do with every
Medicare patient. I have not heard of this not being permissible. Where did
you hear that? Do others out there have that same understanding. Please let
me know. We will look into this on our end as well.

I have also been burnt several times by this policy. What is wrong with using
the probable denial form with all patients.

After we learned of Medicare's policy on prosthetic devices- complete
replacement between 3-5 years- we added a question on our general eval form
(after existing appliance) that asks the age of existing appliance. This
ensures that EVERY practitioner is asking the right questions, not just the
one who got burned! :-) We've all been there.
     I currently have a case in appeal to Region D.
     87yo female fell at home, presented to an Urgent Care Clinic. Was
treated and returned home.
2 months later patient went to Orthopod and was prescribed a Hyperextension
brace for her T11 comp Fx. Referred to my office, we rendered servcies and
accepted assignemtn in this case. Calim was denied as patient had received
same or similar device. We appealed and lost. Found out after the fact that
pt had received an elstic binder from Urgent Care clinic. HCFA deemed this to
be same type of device. Hyeprextension brace was denied as not
necessary.Telephone appeal is pending.
We have no recourse other than appeal, no way to check whether patient has
previously received similar device.As the OP provider you are AT RISK with
many services. We have become very careful when we accept assignment. Would
prefer not to provide the servcie than not get paid.
My office name does NOT include BANK any where in the name.

You just might be passing along some really poor information. The Medicare
law is based on Medically necessary. Did you make these devices just for
the halibut, ( yeah, not real funny but I like it) or were they Medically
Necessary? If they were medically necessary, and the doctor will document
and you can document that necessity, ten by all means, ask for a review.
When it's denied, ask for a fair hearing. The one per year rule can be
dealt with in several ways by Medicare. If the patient is shopping for
something new and different and you bit, then it's S.O.L. for you. If,
however, there was poor fittings that can be documented by both you and the
doctor, Medicare has the right to demand the money back from the first
provider, if they choose. If there has been dramatic volumn changes, or a
subsequent surgery, then you have Medical Necessity on your team. Fight
for it, you'll win, if you have Medical Necessity going for you. Don't let
the claims sit, there is a time limit.