Out of warranty Medicare repairs

Out of warranty Medicare repairs

Rick Stapleton

2/3/2009

List-serve,

Oops, I had originally sent this message out on 01/29/09 but without a
subject line (my bad.) I just got an e-mail from Paul to resend (sorry
Paul):

Here are the responses to my question about billing Medicare for out of
warranty C-leg repairs. Some responders either misread or didn't
understand my post and thought I was trying to bill Medicare for
warranty repairs. As stated in my second post, I do not bill Medicare
(or any Insurance company) for warranty repairs. I don't even bill for
the labor (according to Medicare labor is also included in warranty
servicing) involved in swapping components, installing computer settings
on loaner units, etc. For those of you who have not been exposed to Otto
Bock's out of warranty repair quote, you will get one quote that comes
with a 90 day warranty and one quote that comes with a one year
warranty. All of the repairs usually cost in the mid to high 4 digit
range for the 90 day warranty and low 5 digit range for the one year
warranty.

Here are the responders that gave their advice on how they approached
billing Medicare:

Submit 1st electronically and then after denial we submitted with
manufacturer's invoice. Only has happened 2 x's and it has been several
years. we are a small facility and do not fit many of them so few
warrenty issues. We did use L5999 because felt L7510 was for more minor
repairs. Do not recall actual amount reimbursed other than the repairs
were not cheap.

 

I did not read your original post & I have yet to have to submit for
c-leg repairs, however...I would handle it like any other repair
service. I would (& will) include a letter explaining the services
required with details of what was done, plus I would include copies of
my costs with my customary fees. It is unfortunate that sending this
high-dollar item into the manufacturer for routine checks &/or
maintenance is not a covered service. But, that would only make sense;
preventative 'medicine' is not highly looked upon in this country
(yet!). Anyway, I have found almost all insurance coverages will pay
something above your costs when you provide logical & justifiable
evidence of the need. You may also want to point out safety rationales
as well as what their costs would be to replace the entire limb, knee
unit or whatever. When discussing reimbursement for justifiable services
with insurance 'reps' (clerks) on the phone & you're not getting
anywhere, before you ask to speak to their supervisor, hang up & call
back. 9 times out of 10 someone else answers & although you have to go
through your entire story again, this person may be more amenable. We
have even requested a different medical director to review the case.

 

According to the Medicare region C manual Chapter 5 page 12: However,
more extensive maintenance which, based on the manufacturers'
recommendations,
is to be performed by authorized technicians, is covered as repairs for
medically necessary equipment which a beneficiary owns. This might
include, for example, breaking down sealed
components and performing tests which require specialized testing
equipment not available to the beneficiary. Even though not specifically
required, I would copy and paste this onto a Rx signed by the MD and
also attach it to the claim and medical records. Electronic filling
will only allow 80 characters with the extra narrative so you may have
to paper claim or appeal. Just make sure to quote Medicare's words
instead of using logic to appeal it.

 

In dealing with C-Leg repairs after warranty coverage has ended, is
actually a very difficult process with Medicare because they will need
to see the manufacturers estimate of repairs and then they can weigh
that against the cost of replacing vs. repairing prosthetic knee.
Depending on who is doing the review also dictates how much information
they will ask for. In the two cases that I had we were paid but only
after submitting definitive documentation from Otto Bock Tech center
with item by item identification of work and parts. These repairs ,
fortunately were not in the 4 figure range so it was probably easier for
the reviewer to pay after our first appeal. What I've tried to do with
new patients is to have them invest in an extended warranty so that the
coverage window goes to five years. In the end if the patient doesn't
have secondary coverage they save money on the first repair.

 

 

 

I would like to thank everyone who responded. It is a big help and very
important for all of us to be consistent with all the insurers when
dealing with billing issues. We must have a consistent and united voice
in dealing with these difficult but necessary issues. It is unfortunate
that we have to submit electronically knowing that Medicare will reject
the claim because they don't have the means to allow us to provide the
necessary documentation electronically. We then have to appeal and file
paper then wait to get paid, yet the manufacturers want their bills paid
on time from the date of service.

 

Sincerely,

 

Rick, CPO