Invoice Response 1

Invoice Response 1

rick

4/28/2004

List,

 

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:

 

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.

 

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.

 

Again, I would first contact the insurance company to see if it was
billed correctly and then go from there. Good luck!!

 

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

 

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.

 

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

this can help you.

 

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.

 

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.

 

As the manufacturer of the prosthesis, the bill you sent them for the

prosthesis is, in fact, the manufacturer's invoice. Many of the claims

processors have no clue what goes on in an O&P Laboratory and they need
to

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

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.

They are so used to dealing with DME companies they think we are vendors
of

products just like the DME's.

 

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.

 

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.

 

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.

 

Good luck!

 

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.

 

Thanks to all,

 

Rick Stapleton, CP

President

Tidewater Prosthetic Center, Inc.

150 Burnett's Way, Ste. 300

Suffolk, VA 23434

Ph: 925-4844

Fax: 925-4793