Response's to Billing before Date of Delivery
Andreena Pulak
Description
Collection
Title:
Response's to Billing before Date of Delivery
Creator:
Andreena Pulak
Date:
8/29/2012
Text:
Here are the suggestions I have received to the question I was inquiring
about billing a private insurance before the Date of Delivery
Post 1:
We have done exactly what you are looking to do, first you have to look
at each insurance companies policy manual (contract) concerning payment
of Orthotic and Prosthetic services. We have a few insurance companies
that do not state in their policy manual that we have to have a signed
delivery receipt or bill after delivery. If we call them they will say
yes you have to have signed receipt but in their policy manual it does
not state a delivery receipt is necessary, so we bill using the casting
or evaluation date as date of service. We have been successful with a
few insurance companies but any that specifically state that you have to
have a signed delivery receipt will not pay without the delivery
receipt.
Post 2:
I see no problem billing a non-contracted private insurance with the DOS
being the date of casting/measurement (start date). Even one of our
medicaids will allow us to bill with the start date if it is a custom
item
and the patient loses their coverage prior to delivery date. The only
reason
we don't normally bill with start date in that case is because sometimes
we
don't deliver one or two of the codes, which creates a bit of a mess
having
to refund for a code or two. If there is no contract specifying the DOS
has
to be the date of delivery, then I don't see any reason why you can't.
Post3:
thanks for clarification. Receipt of authorization or notification
number or similar does not mean that items are covered. Most insurance
companies quote this disclaimer on the phone and print it on the paper
authorization. You have to check deductible & coinsurance from one
person, see if auth is needed from another person, but you need to go a
step further and find out if the item is covered for the
diagnosis/condition the patient has. The healthplans will only answer
questions you ask, they do not volunteer information. I've had
instances where an insurance has told us and patient that a certain code
was covered if it's medically necessary. We found out later that the
item was only covered if the diagnosis was diabetes. You have to ask
more questions (is it covered for all patients or only in certain
conditions). See if they publish clinical bulletins online. See if
they publish employee benefits online, look at exclusions.
ABN's should work for people with all conditions, we modified the one
suggested by Medicare to fit all insurance issues. Sometimes when we
simply don't know if an item is covered we ask for deposit.
Post4:
I don't think anybody will tell you it's ok, however I m sure there were
instances when we all did that. I don't know what kind of answer you are
expecting - legally it's wrong.
Post 5:
I believe you may misunderstand me in thinking you cannot use a non-
Medicare ABN for commercial (private insurances)
We do this all the time if the situation seems iffy as far as payment or
prior auth is concerned. If you bill the insurance before
actual delivery of item this could be called questionable practice by
the insurance. I feel your pain as a practicing CPO
and wish you success in your efforts.
Post6:
I had my own practice for many years. In the real world you are billed
and incur debt from the moment you order anything custom, made to order.
A suit, auto,home, you name it. I would routinely bill private ins when
a patient was measured and I knew exactly what the codes were. If
there is any doubt to the exact coding I would wait for a fitting or two
before billing. You do not want to go back to the ins co and explain why
your changing codes.
Post7:
Interesting question giving all the variables involved that could
happen. Before retirement when I was with the VA we would not authorize
payment for a prosthesis until it has been approved by medical
professional knowledgeable about prostheses. Even the amputee’s
acceptance of the product was not always sufficient to authorize payment
given the complexity of prostheses.
Post8:
What it sounds like you are referring to is a predetermination of
services. Medicare used to have a predetermination in the past but did
away with it. We are contracted providers for specific insurance
companies are are thus required to bill for items we deliver, not items
we will be delivering. This is the only industry where a contracted
provider delivers service or an item and hopes to get reimbursed. The
bottom line as I understand it is we are unable to bill UNLESS we
deliver an item. Hope this helps but please post responses.
Post9:
No, you cannot bill for service before the product has been delivered.
That would be considered fraud and you may go to jail.
Thank you all for your help,
Andreena Pulak
Billing Personnel
about billing a private insurance before the Date of Delivery
Post 1:
We have done exactly what you are looking to do, first you have to look
at each insurance companies policy manual (contract) concerning payment
of Orthotic and Prosthetic services. We have a few insurance companies
that do not state in their policy manual that we have to have a signed
delivery receipt or bill after delivery. If we call them they will say
yes you have to have signed receipt but in their policy manual it does
not state a delivery receipt is necessary, so we bill using the casting
or evaluation date as date of service. We have been successful with a
few insurance companies but any that specifically state that you have to
have a signed delivery receipt will not pay without the delivery
receipt.
Post 2:
I see no problem billing a non-contracted private insurance with the DOS
being the date of casting/measurement (start date). Even one of our
medicaids will allow us to bill with the start date if it is a custom
item
and the patient loses their coverage prior to delivery date. The only
reason
we don't normally bill with start date in that case is because sometimes
we
don't deliver one or two of the codes, which creates a bit of a mess
having
to refund for a code or two. If there is no contract specifying the DOS
has
to be the date of delivery, then I don't see any reason why you can't.
Post3:
thanks for clarification. Receipt of authorization or notification
number or similar does not mean that items are covered. Most insurance
companies quote this disclaimer on the phone and print it on the paper
authorization. You have to check deductible & coinsurance from one
person, see if auth is needed from another person, but you need to go a
step further and find out if the item is covered for the
diagnosis/condition the patient has. The healthplans will only answer
questions you ask, they do not volunteer information. I've had
instances where an insurance has told us and patient that a certain code
was covered if it's medically necessary. We found out later that the
item was only covered if the diagnosis was diabetes. You have to ask
more questions (is it covered for all patients or only in certain
conditions). See if they publish clinical bulletins online. See if
they publish employee benefits online, look at exclusions.
ABN's should work for people with all conditions, we modified the one
suggested by Medicare to fit all insurance issues. Sometimes when we
simply don't know if an item is covered we ask for deposit.
Post4:
I don't think anybody will tell you it's ok, however I m sure there were
instances when we all did that. I don't know what kind of answer you are
expecting - legally it's wrong.
Post 5:
I believe you may misunderstand me in thinking you cannot use a non-
Medicare ABN for commercial (private insurances)
We do this all the time if the situation seems iffy as far as payment or
prior auth is concerned. If you bill the insurance before
actual delivery of item this could be called questionable practice by
the insurance. I feel your pain as a practicing CPO
and wish you success in your efforts.
Post6:
I had my own practice for many years. In the real world you are billed
and incur debt from the moment you order anything custom, made to order.
A suit, auto,home, you name it. I would routinely bill private ins when
a patient was measured and I knew exactly what the codes were. If
there is any doubt to the exact coding I would wait for a fitting or two
before billing. You do not want to go back to the ins co and explain why
your changing codes.
Post7:
Interesting question giving all the variables involved that could
happen. Before retirement when I was with the VA we would not authorize
payment for a prosthesis until it has been approved by medical
professional knowledgeable about prostheses. Even the amputee’s
acceptance of the product was not always sufficient to authorize payment
given the complexity of prostheses.
Post8:
What it sounds like you are referring to is a predetermination of
services. Medicare used to have a predetermination in the past but did
away with it. We are contracted providers for specific insurance
companies are are thus required to bill for items we deliver, not items
we will be delivering. This is the only industry where a contracted
provider delivers service or an item and hopes to get reimbursed. The
bottom line as I understand it is we are unable to bill UNLESS we
deliver an item. Hope this helps but please post responses.
Post9:
No, you cannot bill for service before the product has been delivered.
That would be considered fraud and you may go to jail.
Thank you all for your help,
Andreena Pulak
Billing Personnel
Citation
Andreena Pulak, “Response's to Billing before Date of Delivery,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/234306.
