Reply Summary - USA Region B Medicare issue?
Description
Collection
Title:
Reply Summary - USA Region B Medicare issue?
Date:
1/26/2013
Text:
My original posting:
We have recently begun to see rejections of roll-on liners as not medically necessary whether they are replacements or accompany a new socket / prosthesis that is paid for. The staff at AOPA have told us they are not aware of a pattern in this area. One other prosthetist in Michigan has told me he is seeing the same thing. Is this a widespread issue? Are other facilities seeing the same thing?
Responses follow:
====================================
We are also seeing this happen in Iowa, you are not alone.
----------------------------------------------------------------
We have not seen this to date (Grand Rapids, MI)
----------------------------------------------------------------
Yes recently i have one patient they pay for prosthesis after pre payment audit but did not pay for test socket and liners but i am fighting it.
(Troy, MI)
----------------------------------------------------------------
The only thing that I have seen in OH/MI are the RAC audits being done on liners and they are only on claims where more than 3 liners were provided (with vacuum systems).
Otherwise, I have not seen any in our market. I am now handling all of the audits for all of the offices in OH/MI so I am seeing a lot of stuff.
----------------------------------------------------------------
the rejection we have seen is for 2 of a code l5679 for example.
they would pay for one...
----------------------------------------------------------------
We recently had the same rejection from Medicare in California.
----------------------------------------------------------------
We have had this happen to us a few times. NW indiana.
----------------------------------------------------------------
We are seeing similar in WA state (region D). Replacements apparently need RA modifyer and justification. Are your new sockets within a year or 2 years of previous supplying of liners? That could be the issue as well. This morning I read region D is now going to prepayment audit L5980, L5981, and L5987
This is all going to kill the little guys.
----------------------------------------------------------------
Ted, you are just seeing the tip of the iceberg. Medicare's recent
auditing program has created a nightmare that is not about to stop soon.
Even private insurance companies are using every loophole in the book to
claw back money. If we don't get this turned around soon, the O&P
profession will vaporize in front of our eyes. Part of this is our own
fault for not paying more attention to L-Code descriptions and allowing
others to rewrite the intent and purpose for many of the codes. This has
not been as prevalent in prosthetics, but it is coming. The liners are
just the beginning. My guess is that the liners will be a bid item
within the CMS system before it's all said and done. After all, no
fitting or professional expertise is required. Right?
Hope you get things worked out with this.
----------------------------------------------------------------
Hi, we are not sure if this helps we are in jurisdiction C but we were having the same problem with liners being rejected and we too called AOPA. We spoke to a Devin Bernard at AOPA # 571-431-0876 and he informed us that Medicare is only allowing the patient two liners in a consecutive year.
----------------------------------------------------------------
No such issues that I've heard about in region C. Personally I've not had a issue with being paid for gel liners. Thanks for the heads up.
----------------------------------------------------------------
I haven't seen this YET in CALIF
----------------------------------------------------------------
Ted, please post response, Thanks
===================================
End of responses.
Just for clarification we have seen this in both single liners and pairs. Not certain if any of these folks were over a year since the last liner was billed.
Also just in case any orthotists are feeling like they are not a part of this, we just got a pre-payment audit on a pair of bilateral KAFO's.
Ted A. Trower CPO,
A-S-C Orthotics & Prosthetics
Jackson, MI
www.amputee.com
We have recently begun to see rejections of roll-on liners as not medically necessary whether they are replacements or accompany a new socket / prosthesis that is paid for. The staff at AOPA have told us they are not aware of a pattern in this area. One other prosthetist in Michigan has told me he is seeing the same thing. Is this a widespread issue? Are other facilities seeing the same thing?
Responses follow:
====================================
We are also seeing this happen in Iowa, you are not alone.
----------------------------------------------------------------
We have not seen this to date (Grand Rapids, MI)
----------------------------------------------------------------
Yes recently i have one patient they pay for prosthesis after pre payment audit but did not pay for test socket and liners but i am fighting it.
(Troy, MI)
----------------------------------------------------------------
The only thing that I have seen in OH/MI are the RAC audits being done on liners and they are only on claims where more than 3 liners were provided (with vacuum systems).
Otherwise, I have not seen any in our market. I am now handling all of the audits for all of the offices in OH/MI so I am seeing a lot of stuff.
----------------------------------------------------------------
the rejection we have seen is for 2 of a code l5679 for example.
they would pay for one...
----------------------------------------------------------------
We recently had the same rejection from Medicare in California.
----------------------------------------------------------------
We have had this happen to us a few times. NW indiana.
----------------------------------------------------------------
We are seeing similar in WA state (region D). Replacements apparently need RA modifyer and justification. Are your new sockets within a year or 2 years of previous supplying of liners? That could be the issue as well. This morning I read region D is now going to prepayment audit L5980, L5981, and L5987
This is all going to kill the little guys.
----------------------------------------------------------------
Ted, you are just seeing the tip of the iceberg. Medicare's recent
auditing program has created a nightmare that is not about to stop soon.
Even private insurance companies are using every loophole in the book to
claw back money. If we don't get this turned around soon, the O&P
profession will vaporize in front of our eyes. Part of this is our own
fault for not paying more attention to L-Code descriptions and allowing
others to rewrite the intent and purpose for many of the codes. This has
not been as prevalent in prosthetics, but it is coming. The liners are
just the beginning. My guess is that the liners will be a bid item
within the CMS system before it's all said and done. After all, no
fitting or professional expertise is required. Right?
Hope you get things worked out with this.
----------------------------------------------------------------
Hi, we are not sure if this helps we are in jurisdiction C but we were having the same problem with liners being rejected and we too called AOPA. We spoke to a Devin Bernard at AOPA # 571-431-0876 and he informed us that Medicare is only allowing the patient two liners in a consecutive year.
----------------------------------------------------------------
No such issues that I've heard about in region C. Personally I've not had a issue with being paid for gel liners. Thanks for the heads up.
----------------------------------------------------------------
I haven't seen this YET in CALIF
----------------------------------------------------------------
Ted, please post response, Thanks
===================================
End of responses.
Just for clarification we have seen this in both single liners and pairs. Not certain if any of these folks were over a year since the last liner was billed.
Also just in case any orthotists are feeling like they are not a part of this, we just got a pre-payment audit on a pair of bilateral KAFO's.
Ted A. Trower CPO,
A-S-C Orthotics & Prosthetics
Jackson, MI
www.amputee.com
Citation
“Reply Summary - USA Region B Medicare issue?,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 23, 2024, https://library.drfop.org/items/show/234574.
