How are you handling this type of situation?

How are you handling this type of situation?

Melissa A. Bolton, Admin. Dept.

6/6/2013

Here is a question:

We have a patient that was prepay audited, then denied, and I am now in
redetermination appeal stage. He was delivered a preparatory prosthesis and is
coming up to the point at which he will need his definitive. However, Medicare
denied his prep.

My concern is that once the 90 days period is up and he needs repairs or he
needs his definitive, Medicare will deny repairs because they didn't pay for the
prep or deny the definitive and we will be waiting for payment for two
prosthetic devices for one patient. However, there is the fine line of
providing what is medically necessary for the patient. I am also concerned that
even if the repairs or definitive prosthesis processes through and pays, there
is a chance that Medicare will come back and audit at a later date due to not
having paid for the initial preparatory prosthesis.

Anyway, I was curious as to how other companies are handling these types of
situations.

Thanks!

Melissa Bolton
Funding Assistant