Review of Responses to Billing Question
Gary Yackley CP
Description
Collection
Title:
Review of Responses to Billing Question
Creator:
Gary Yackley CP
Date:
8/27/2014
Text:
Hey There List,
Below is my initial question and the many (2) responses that I received. It was requested my more than two list folks that I post these responses.
Two quality responses in my opinion.
G.M. Yackley CP, BOCO
---------------------------------------------------------------------------------------
What is you experience in getting paid for microprocessor knee service and/or
repairs with MCR as the party billed?
What sort of documentation do you need to justify the repair to MCR?
What if the patient claims malfunction and yet no issues are found by the
manufacturer during the repair? (devil's advocate here) Any special formulas or
such?
As always, thanks.
As an insurance biller, I have found that the best way to ensure you get paid
for repairs/replacement items/unlisted codes is to be as detailed as possible in
your explanation to Medicare. When filing the claim electronically, put in the
HA0 field exactly what you did. There are only 80 characters available, but
there is an additional documentation section & you can use that for full
explanation, even if you need to use that tab 4 times (I usually have to
continue on 3-4 additional doc tabs to get the full explanation to transmit. I
get paid the first time every time with detailed documentation of what was done,
i.e. hydraulic cylinder rebuilt in microprocessor controlled knee on left
transfem prosthesis by removing microprocessor controlled knee from prosthesis,
disassembled & removed hydraulic cylinder. O rings, top cap, bezel, air fill
plug bladder, polymer bearings, shim all rebuilt, knee reassembled and placed
back in prosthesis. I abbreviate words as much as possible by leaving out
vowels when I can.
I have never experienced the manufacturer finding no issues, but I would
document as above your time in disassembling & reassembling the knee, as well as
manufacturer time.
Hope this helps!
-----------------------------------------------------------------------------
Call the insurance company!! Find out their policy on the prosthetic repair
codes. Find out what their max allowed is per unit.
Eg. Don’t submit a 1 unit for $5k if their max is $2k per unit. I would bill 5
units of $1k.
Itemize each part of the repair and tie it to the invoice your will get from the
manufacture. Don’t expect an invoice repaired knee...$3000.00 from the
manufacture. Most likely the insurance will ask for itemized repair invoice and
they will allow some sort of % above your cost. Try to find that %. I know for
blue cross, they generally will pay 70% of what is billed if it's at a
reasonable U/C charge. Insurance companies know what these repairs cost just
know their policy to maximize your payment but more importantly so there is no
hassle or delay in getting paid.
As far as documentation, if you have broken parts on the knee, obviously that
could cause harm to the patient which would justify medical necessity to either
repair or replace the knee.
If there is nothing wrong with the knee but the patient is having issues,
reprogram the knee to make it safer.
--------------------------------------------------------------------------------------------------------------------------
Below is my initial question and the many (2) responses that I received. It was requested my more than two list folks that I post these responses.
Two quality responses in my opinion.
G.M. Yackley CP, BOCO
---------------------------------------------------------------------------------------
What is you experience in getting paid for microprocessor knee service and/or
repairs with MCR as the party billed?
What sort of documentation do you need to justify the repair to MCR?
What if the patient claims malfunction and yet no issues are found by the
manufacturer during the repair? (devil's advocate here) Any special formulas or
such?
As always, thanks.
As an insurance biller, I have found that the best way to ensure you get paid
for repairs/replacement items/unlisted codes is to be as detailed as possible in
your explanation to Medicare. When filing the claim electronically, put in the
HA0 field exactly what you did. There are only 80 characters available, but
there is an additional documentation section & you can use that for full
explanation, even if you need to use that tab 4 times (I usually have to
continue on 3-4 additional doc tabs to get the full explanation to transmit. I
get paid the first time every time with detailed documentation of what was done,
i.e. hydraulic cylinder rebuilt in microprocessor controlled knee on left
transfem prosthesis by removing microprocessor controlled knee from prosthesis,
disassembled & removed hydraulic cylinder. O rings, top cap, bezel, air fill
plug bladder, polymer bearings, shim all rebuilt, knee reassembled and placed
back in prosthesis. I abbreviate words as much as possible by leaving out
vowels when I can.
I have never experienced the manufacturer finding no issues, but I would
document as above your time in disassembling & reassembling the knee, as well as
manufacturer time.
Hope this helps!
-----------------------------------------------------------------------------
Call the insurance company!! Find out their policy on the prosthetic repair
codes. Find out what their max allowed is per unit.
Eg. Don’t submit a 1 unit for $5k if their max is $2k per unit. I would bill 5
units of $1k.
Itemize each part of the repair and tie it to the invoice your will get from the
manufacture. Don’t expect an invoice repaired knee...$3000.00 from the
manufacture. Most likely the insurance will ask for itemized repair invoice and
they will allow some sort of % above your cost. Try to find that %. I know for
blue cross, they generally will pay 70% of what is billed if it's at a
reasonable U/C charge. Insurance companies know what these repairs cost just
know their policy to maximize your payment but more importantly so there is no
hassle or delay in getting paid.
As far as documentation, if you have broken parts on the knee, obviously that
could cause harm to the patient which would justify medical necessity to either
repair or replace the knee.
If there is nothing wrong with the knee but the patient is having issues,
reprogram the knee to make it safer.
--------------------------------------------------------------------------------------------------------------------------
Citation
Gary Yackley CP, “Review of Responses to Billing Question,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 26, 2024, https://library.drfop.org/items/show/236687.
