Texas Medicaid and hand splints
Kevin Matthews
Description
Collection
Title:
Texas Medicaid and hand splints
Creator:
Kevin Matthews
Date:
8/20/2008
Text:
This question is intended for Texas practitioners but please feel free to reply if you have a comment.
My name is Kevin Matthews. I'm an orthotist and small family practice owner in San Antonio. I've recently had two run-ins with Medicaid and wonder if any have experiences similar to mine.
Case 1: I have a child I work with that needed bilateral Benik hand splints. He's a little guy and between sizes, so I have to measure and pay custom pattern fee. I can usually fit kids in a standard size splint and make about $5.00 profit (not including admin. efforts). The -L3923 codes reimburses at $28.50 @. Since I had to custom measure the child I billed L3919. It's a money loser if billed as L-3923. I billed $174 for the pair of splints. The allowable is $184.18 @ or $368 a pair. I think my charge was in line with accepted practice.
I did everything right. I got a preauthorization (which is not a promise of reimbursement).?. ?? When we billed the splints we were denied because they only pay that particular code for infants 0-20 days old. Period. No appeal unless you want to petition the state to change the law. Why do the pre-auth and the claims department not have the same information? Someone should tell the pre-auth department that, no?
Case 2: I fit a child with bilateral WHFO's. I fit the Lynx from Sammons at a cost of <Email Address Redacted> I billed the medicare allowable for the L3907, $197 each.. I found out later that Medicaid doesn't have a reimbursement rate for that L-Code. They denied their preauthorized WHFO purchase, on which had the price was listed. They said when we called about the denial I could submit an invoice and they would pay the cost of the splints less a percentage, I think it was cost less 15%. I have to pay for the privilege of providing care to this adorable child. Cost less % ????? They said I could add an amount for my time, and my time only, not administrative time. I ended up getting paid cost plus 20%. WOW. Better than nothing.
I am going to appeal case #1 and would like to add your responses to my appeal letter. It is not about the money. This is already a loser, it is only a statement in protest within an appeal. I will only include responses with a name and verifiable detail like business or phone number. Preferably a signature block. If no name I'll not post.
I'll post replies to the list. I'll include signed responses in my appeal to medicaid. Please include some type of contact info (business name, Tx. license #...). I will not contact you, that is just as added credibility to medicaid.
Thanks for your time.
Kevin C. Matthews, CO/LO
Certified/Licensed Orthotist
Advanced Orthopedic Designs
12315 Judson Rd. Suite 206
San Antonio, TX 78233
Phone: 210-657-8100
Fax: 210-657-8105
www.AdvancedOrthopedicDesigns.com
My name is Kevin Matthews. I'm an orthotist and small family practice owner in San Antonio. I've recently had two run-ins with Medicaid and wonder if any have experiences similar to mine.
Case 1: I have a child I work with that needed bilateral Benik hand splints. He's a little guy and between sizes, so I have to measure and pay custom pattern fee. I can usually fit kids in a standard size splint and make about $5.00 profit (not including admin. efforts). The -L3923 codes reimburses at $28.50 @. Since I had to custom measure the child I billed L3919. It's a money loser if billed as L-3923. I billed $174 for the pair of splints. The allowable is $184.18 @ or $368 a pair. I think my charge was in line with accepted practice.
I did everything right. I got a preauthorization (which is not a promise of reimbursement).?. ?? When we billed the splints we were denied because they only pay that particular code for infants 0-20 days old. Period. No appeal unless you want to petition the state to change the law. Why do the pre-auth and the claims department not have the same information? Someone should tell the pre-auth department that, no?
Case 2: I fit a child with bilateral WHFO's. I fit the Lynx from Sammons at a cost of <Email Address Redacted> I billed the medicare allowable for the L3907, $197 each.. I found out later that Medicaid doesn't have a reimbursement rate for that L-Code. They denied their preauthorized WHFO purchase, on which had the price was listed. They said when we called about the denial I could submit an invoice and they would pay the cost of the splints less a percentage, I think it was cost less 15%. I have to pay for the privilege of providing care to this adorable child. Cost less % ????? They said I could add an amount for my time, and my time only, not administrative time. I ended up getting paid cost plus 20%. WOW. Better than nothing.
I am going to appeal case #1 and would like to add your responses to my appeal letter. It is not about the money. This is already a loser, it is only a statement in protest within an appeal. I will only include responses with a name and verifiable detail like business or phone number. Preferably a signature block. If no name I'll not post.
I'll post replies to the list. I'll include signed responses in my appeal to medicaid. Please include some type of contact info (business name, Tx. license #...). I will not contact you, that is just as added credibility to medicaid.
Thanks for your time.
Kevin C. Matthews, CO/LO
Certified/Licensed Orthotist
Advanced Orthopedic Designs
12315 Judson Rd. Suite 206
San Antonio, TX 78233
Phone: 210-657-8100
Fax: 210-657-8105
www.AdvancedOrthopedicDesigns.com
Citation
Kevin Matthews, “Texas Medicaid and hand splints,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 24, 2024, https://library.drfop.org/items/show/229770.
