Responses to billing for custom orthoses that have not been delivered to patient.
Paula Martinek
Description
Collection
Title:
Responses to billing for custom orthoses that have not been delivered to patient.
Creator:
Paula Martinek
Date:
6/30/2009
Text:
Thanks to all who have responded to my inquiry on billing for devices not delivered:
Original post: Hello all I am sure this has been covered before but I can't find the
information right now. A set of custom orthoses have been fabricated for a
patient. We have tried several times to contact the patient without
success. Can we bill Medicare for part or all of the cost and if so how do
we go about it? Do we need to contact the patient in writing that the
orthoses are here for him? Thank you and I will post the replies. Paula Martinek, LPO
I run into this all the time. I enclose a letter stating that we have tried
to reach the patient numerous times and that our policy is to ship the items
in this situation to assure the RX/approval doesn't expire. I also state
that the patient MUST come into the office prior to wearing the device to
have the fit and function evaluated, We then use the shipping date as the
date of delivery.
Below I have pasted a segment from Chapter 15 of the Medicare Benefit Policy Manual which addresses custom items ordered but not furnished. You may bill for a custom item if the beneficiary dies, has a change in condition, or if the order was canceled by the beneficiary. I would recommend you have documentation to support your position the patient has not responded to your efforts to schedule delivery.
20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished
(Rev. 1, 10-01-03)
B3-2005.3
A. Date of Incurred Expense
If a custom-made item was ordered but not furnished to a beneficiary because the individual died or because the order was canceled by the beneficiary or because the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made based on the supplier’s expenses. (See subsection B for determination of the allowed amount.) In such cases, the expense is considered incurred on the date the beneficiary died or the date the supplier learned of the cancellation or that the item was no longer reasonable and necessary or appropriate for the beneficiary’s condition. If the beneficiary died or the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made on either an assigned or unassigned claim. If the beneficiary, for any other reason, canceled the order, payment can be made to the supplier only.
B. Determination of Allowed Amount
The allowed amount is based on the services furnished and materials used, up to the date the supplier learned of the beneficiary’s death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate. The Durable Medical Equipment Regional Carrier (DMERC), carrier or intermediary, as appropriate, determines the services performed and the allowable amount appropriate in the particular situation. It takes into account any salvage value of the device to the supplier.
Where a supplier breaches an agreement to make a prosthesis, brace, or other custom-made device for a Medicare beneficiary, e.g., an unexcused failure to provide the article within the time specified in the contract, payment may not be made for any work or material expended on the item. Whether a particular supplier has lived up to its agreement, of course, depends on the facts in the individual case.
Below is a link to the Medicare Benefit Policy Manual:
<URL Redacted>
We have been told that you would file that paper claim and write salvage
claim in large print at the top of the claim. Ethically speaking I don't
think you would bill Medicare for the total allowable but only for recouping
your cost. I would recommend contacting AOPA on how to calculate this
amount. WE have only had this occur a few times and it was in the event a
patient passed away - which you would use the day they passed away as the
date of service.
Besides the three attempts by phones or emails and the other three attempts need to be written. Then I think you can submit with a certain form!
According to Medicare, you MUST bill them for custom devices. If there are
parts of it than can be utilized somewhere else--e.g. non-modified shoes
(stirrups not installed) then you cannot bill for the re-usable part. A
custom fabricated AFO must be billed to them. You must document in your
record the attempts to contact the patient and their lack of reply.
Original post: Hello all I am sure this has been covered before but I can't find the
information right now. A set of custom orthoses have been fabricated for a
patient. We have tried several times to contact the patient without
success. Can we bill Medicare for part or all of the cost and if so how do
we go about it? Do we need to contact the patient in writing that the
orthoses are here for him? Thank you and I will post the replies. Paula Martinek, LPO
I run into this all the time. I enclose a letter stating that we have tried
to reach the patient numerous times and that our policy is to ship the items
in this situation to assure the RX/approval doesn't expire. I also state
that the patient MUST come into the office prior to wearing the device to
have the fit and function evaluated, We then use the shipping date as the
date of delivery.
Below I have pasted a segment from Chapter 15 of the Medicare Benefit Policy Manual which addresses custom items ordered but not furnished. You may bill for a custom item if the beneficiary dies, has a change in condition, or if the order was canceled by the beneficiary. I would recommend you have documentation to support your position the patient has not responded to your efforts to schedule delivery.
20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished
(Rev. 1, 10-01-03)
B3-2005.3
A. Date of Incurred Expense
If a custom-made item was ordered but not furnished to a beneficiary because the individual died or because the order was canceled by the beneficiary or because the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made based on the supplier’s expenses. (See subsection B for determination of the allowed amount.) In such cases, the expense is considered incurred on the date the beneficiary died or the date the supplier learned of the cancellation or that the item was no longer reasonable and necessary or appropriate for the beneficiary’s condition. If the beneficiary died or the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made on either an assigned or unassigned claim. If the beneficiary, for any other reason, canceled the order, payment can be made to the supplier only.
B. Determination of Allowed Amount
The allowed amount is based on the services furnished and materials used, up to the date the supplier learned of the beneficiary’s death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate. The Durable Medical Equipment Regional Carrier (DMERC), carrier or intermediary, as appropriate, determines the services performed and the allowable amount appropriate in the particular situation. It takes into account any salvage value of the device to the supplier.
Where a supplier breaches an agreement to make a prosthesis, brace, or other custom-made device for a Medicare beneficiary, e.g., an unexcused failure to provide the article within the time specified in the contract, payment may not be made for any work or material expended on the item. Whether a particular supplier has lived up to its agreement, of course, depends on the facts in the individual case.
Below is a link to the Medicare Benefit Policy Manual:
<URL Redacted>
We have been told that you would file that paper claim and write salvage
claim in large print at the top of the claim. Ethically speaking I don't
think you would bill Medicare for the total allowable but only for recouping
your cost. I would recommend contacting AOPA on how to calculate this
amount. WE have only had this occur a few times and it was in the event a
patient passed away - which you would use the day they passed away as the
date of service.
Besides the three attempts by phones or emails and the other three attempts need to be written. Then I think you can submit with a certain form!
According to Medicare, you MUST bill them for custom devices. If there are
parts of it than can be utilized somewhere else--e.g. non-modified shoes
(stirrups not installed) then you cannot bill for the re-usable part. A
custom fabricated AFO must be billed to them. You must document in your
record the attempts to contact the patient and their lack of reply.
Citation
Paula Martinek, “Responses to billing for custom orthoses that have not been delivered to patient.,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/230423.
