Invoice Response 2

Invoice Response 2

rick

4/28/2004

Second page:

 

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.

 

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.

 

 Good luck!

 

I agree with you completely. This is very dangerous.

 

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'.

 

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.

 

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

 

You are not alone. I did insurance billing for an independant

facility that has closed up in the past few months. Insurance

companies have made the request of invoices. I do not think an

invoice from a manufacturer for a foot, pylon or anything associated

with a prosthesis, (or Orthosis) describes the labor by the

prosthetist/Orthotist nor the research involved by the practitioner.

I once had an insurance company request a complete itemized

statement. I broke it down to the last nut/bolt and second of labor I

could. I got an additional allowance from them, but was it worth it?

 

Before entering the O & P field 8 years ago, I worked in a physicians

office for 20 years. Yes, the physician community has been affected

greatly by the change in health care. But believe me, the O & P field

takes the BACK seat in the bus when it comes to reimbursement.

 

I realize the MCO's, PPO's, HMO's are the way of life in the United

States Health Care industry, but to me, it is only socialized medicine

in a way. My opinion, someone is getting fat and you and I and the

patient, are getting the royal axe.

 

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.

 

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

 

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.

 

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!

 

 

Rick Stapleton, CP

President

Tidewater Prosthetic Center, Inc.

150 Burnett's Way, Ste. 300

Suffolk, VA 23434

Ph: 925-4844

Fax: 925-4793