Fw: Billing before final - responses.
Description
Collection
Title:
Fw: Billing before final - responses.
Date:
4/23/2015
Text:
I believe these may be the last of the responses. I think there are clinics
out there that are interpreting the very long standing rule incorrectly, my
advise is to get with your
Jurisdiction representative on the phone and get clarity.
_____________________________________________________________________________
_____
Michelle,
I agree with your final assessment and it is very well written. As someone
who sees a great deal of finished bills and then see the patient with the
prosthesis that should match and I see them for other than Prosthetic
Treatment, I have found a large number of fraudulent billings. The most
frequent one I have found are the cosmetic cover and skin. Some billings
have been for two test sockets, when the client has told me that there was
only one and there is only one in the patient file. If there is a second
test socket, it should have justification in the patient file, but this has
never been found by me.
I say all of this only to protect our Profession from being caught in a lie
and bringing down the 85% that do all of this honestly and properly. I have
found this in even the larger companies that have internal check systems
that are supposed to catch these mistakes.
_____________________________________________________________________________
_________________________________________________________________________
Your understanding is correct.
The work around that I've seen in the Portland, OR area is facilities
delivering what I would consider to be a check socket. They are not making a
laminated socket. The patient is provided a plastic socket and that is the
final delivery. I have even seen facilities that make a plastic socket, use
it as the check socket, and if fit is good then wrap that check socket in
fiberglass tape and tell the patient it is the final product. As long as
they don't bill for carbon fiber and acrylic resin it seems to be a loophole
that some companies are willing to exploit.
_____________________________________________________________________________
___________________________________________________________________________
If the pt leaves your facility with prosthetic components in varying states
of completion, then you should have them sign a delivery ticket. If they
never return you will have standing to take whatever action required, such
as billing, prosecution for grand theft, or whatever. You can only control
what you can control, CYA!
To avoid be accused of unbundling one should not bill haphazardly, and be
accurate and true to the products and professional services rendered, and
ask yourself is it justifiable and supported in the medical record.
Thank you for the insight...
-------Original Message-------
From: <Email Address Redacted>
Date: 4/21/2015 1:54:29 PM
To: <Email Address Redacted>
Subject: Fw: Billing before final - responses.
A couple more responses.
Your process that you've been following is the same process we follow. I
Have heard of other facilities billing out everything except the acrylic
Or ultra-lite, however, since those codes are considered to be add-on
Codes, they have to be added on to something that includes a base code.
Therefore, we do not bill out walking test sockets and then bill the
Acrylic and/or ultra-lite at a later date. It is billed all at one time.
If the patient receives socks and/or liners prior to the delivery date of
The finalized prosthesis, we will bill those out independently just as we
Would if we provided them regardless if the patient was receiving a
Prosthesis or replacement socket, etc.
-----------------------------------------------------------------------------
---------------------------
Following...
We understand, interpret and follow the billing rules as you indicated your
clinic does/has. I am regularly surprised about other billing methods I am
told about.
Especially the scenario you described :Full billing with test socket trial.
I will be anxious to hear the results of your post.
-------Original Message-------
From: <Email Address Redacted>
Date: 4/21/2015 10:31:41 AM
To: <Email Address Redacted>
Subject: Billing before final - responses.
Good morning List,
It seems, there are many of us that interpret the OLD rule just like it was
written. No billing till the treatment is complete. Then there are some
that have interpreted it in a slightly different way. As a facility that
DOES use the Test Socket protocol and I believe John was one of the founders
of this protocol back in the early 90's. We NEVER go to a final until the
patient has reduced to Zero ply sock. We have patients out there that are
going past a year+ and they are in their 2nd or even third TS. That means No
billing during this time, That's why our very small one man clinic has
Loaner components. For those that are skeptical about the TS protocol, in
22 years and 100's maybe 1000's of patients neither of our clinics has ever
had a Catastrophic fail or claim. Its about education and safety..the
products that we use could likely keep a wing on a boeing...expensive but
worth it for the patient. But I degress..Here is the synopsis of the
responses.
No, it has not changed. At the AOPA conference in October, this was
discussed in great detail. It is not appropriate at any time to bill for a
patient sent out in a test socket. This was followed by a discussion of the
liability of sending a patient out in TS in the first place.
Your understanding is correct. The only time that you should waiver is for
death or cancellation of an order which needs to be clearly documented.Some
practices have decided that they can provide a patient with a walking check
socket and bill it. A walking check socket is not a final product.
Unfortunately, they get by with it because most patients don't have a clue
We had a patient that was billed (by another practice that was later shut
down by Medicare) fir a complete prosthesis when they were measured. They
did not actually receive anything until a year later.It's disgusting for
those trying to survive in this ugly system.
Smells like rotten fish
I've been advised by AOPA that I am able to bill work done with appropriate
documentation of occurrence. What we as practitioners refuse to
understand, is Medicare views all payees as fraudulent. I have my
practitioners document everything. I have billed and been reimbursed via
Medicare in your very circumstance, having proved our work and expense to
date' we were compensated. If you'd like to talk further please feel free
to call me at my office.
You are supposed to bill test sockets with the date that the final
prosthesis is delivered. That does not mean that every practice does so and
that they do not sometimes get paid when they shouldn't. I see practices
bill test sockets all the time prior to delivery. But, just because you get
paid for something doesn't mean that you are doing it correctly. I could
give multiple reasons why you should not, from a billing and liability
perspective, do a dynamic/walking check socket that leaves your office
before the final delivery. Most practices are getting away from this
practice because of the liability. There are still some practitioners who
insist upon it and they do it knowing the liabilities involved and the
potential loss. There really is not any protection of your financial
interest if the patient chooses not to return with your check socket. You
can however bill salvage value for custom componentry when a patient passes
away before delivery and you have already fabricated custom components. All
returnable components must be returned. The problem with this philosophy
with a walking check socket is... Good luck returning a knee or a foot once
it has been worn by the patient outside of your office.
You are correct. A facility can deliver a device, but cannot legally bill
Medicare until the detailed written order is received and all delivery
paperwork is signed. And you can only bill for what you actually delivered.
In our facility, for example, those amputees desiring a cover are usually
provided the prosthesis for a month prior to installing the cover to assure
proper alignment. We bill without the cover code and then bill the cover
separately a month later when it's provided.
I would hope that no practitioner would provide a test socket for trial
fitting and advise the amputee to use it outside of the home. We
occasionally do a week long home trial with the test socket for difficult to
fit amputees. We have them sign an actual contract stating they will not
wear it outside of the home. It would be very dangerous for them to
ambulate outside of the home with an incomplete device. How do you know
that what you're seeing is a test socket? Perhaps what you are seeing is a
completed prosthesis without the cover?
No confusion, you are right, they are wrong.
I believe with private insurance you can bill anytime after prior approval.
You can bill for what has been provided but you still need to have signed
validation of receipt for what you are billing. A good instance is say your
patient leaves on a check socket with an MPK knee and a foot and everything.
You can have them sign and you bill for everything that has been done at
that point. Obviously not acrylic or flexible socket/ rigid frame but if
you have built in the ischial containment and total contact and suction blah
blah blah, all of that can be billed. Then you bill the acrylic and
flexible socket/rigid frame when it is transferred to definitive.
Thank you all, for the responses..I will keep posting as they come in.
Michele Hattingh
Administrator
Prosthetic Care Facility of VA
15738 Foleys Way
Haymarket VA 20169
571-445-3390
571-4453392
www.prostheticcarefacility.com
Treat others as you want to be treated.
out there that are interpreting the very long standing rule incorrectly, my
advise is to get with your
Jurisdiction representative on the phone and get clarity.
_____________________________________________________________________________
_____
Michelle,
I agree with your final assessment and it is very well written. As someone
who sees a great deal of finished bills and then see the patient with the
prosthesis that should match and I see them for other than Prosthetic
Treatment, I have found a large number of fraudulent billings. The most
frequent one I have found are the cosmetic cover and skin. Some billings
have been for two test sockets, when the client has told me that there was
only one and there is only one in the patient file. If there is a second
test socket, it should have justification in the patient file, but this has
never been found by me.
I say all of this only to protect our Profession from being caught in a lie
and bringing down the 85% that do all of this honestly and properly. I have
found this in even the larger companies that have internal check systems
that are supposed to catch these mistakes.
_____________________________________________________________________________
_________________________________________________________________________
Your understanding is correct.
The work around that I've seen in the Portland, OR area is facilities
delivering what I would consider to be a check socket. They are not making a
laminated socket. The patient is provided a plastic socket and that is the
final delivery. I have even seen facilities that make a plastic socket, use
it as the check socket, and if fit is good then wrap that check socket in
fiberglass tape and tell the patient it is the final product. As long as
they don't bill for carbon fiber and acrylic resin it seems to be a loophole
that some companies are willing to exploit.
_____________________________________________________________________________
___________________________________________________________________________
If the pt leaves your facility with prosthetic components in varying states
of completion, then you should have them sign a delivery ticket. If they
never return you will have standing to take whatever action required, such
as billing, prosecution for grand theft, or whatever. You can only control
what you can control, CYA!
To avoid be accused of unbundling one should not bill haphazardly, and be
accurate and true to the products and professional services rendered, and
ask yourself is it justifiable and supported in the medical record.
Thank you for the insight...
-------Original Message-------
From: <Email Address Redacted>
Date: 4/21/2015 1:54:29 PM
To: <Email Address Redacted>
Subject: Fw: Billing before final - responses.
A couple more responses.
Your process that you've been following is the same process we follow. I
Have heard of other facilities billing out everything except the acrylic
Or ultra-lite, however, since those codes are considered to be add-on
Codes, they have to be added on to something that includes a base code.
Therefore, we do not bill out walking test sockets and then bill the
Acrylic and/or ultra-lite at a later date. It is billed all at one time.
If the patient receives socks and/or liners prior to the delivery date of
The finalized prosthesis, we will bill those out independently just as we
Would if we provided them regardless if the patient was receiving a
Prosthesis or replacement socket, etc.
-----------------------------------------------------------------------------
---------------------------
Following...
We understand, interpret and follow the billing rules as you indicated your
clinic does/has. I am regularly surprised about other billing methods I am
told about.
Especially the scenario you described :Full billing with test socket trial.
I will be anxious to hear the results of your post.
-------Original Message-------
From: <Email Address Redacted>
Date: 4/21/2015 10:31:41 AM
To: <Email Address Redacted>
Subject: Billing before final - responses.
Good morning List,
It seems, there are many of us that interpret the OLD rule just like it was
written. No billing till the treatment is complete. Then there are some
that have interpreted it in a slightly different way. As a facility that
DOES use the Test Socket protocol and I believe John was one of the founders
of this protocol back in the early 90's. We NEVER go to a final until the
patient has reduced to Zero ply sock. We have patients out there that are
going past a year+ and they are in their 2nd or even third TS. That means No
billing during this time, That's why our very small one man clinic has
Loaner components. For those that are skeptical about the TS protocol, in
22 years and 100's maybe 1000's of patients neither of our clinics has ever
had a Catastrophic fail or claim. Its about education and safety..the
products that we use could likely keep a wing on a boeing...expensive but
worth it for the patient. But I degress..Here is the synopsis of the
responses.
No, it has not changed. At the AOPA conference in October, this was
discussed in great detail. It is not appropriate at any time to bill for a
patient sent out in a test socket. This was followed by a discussion of the
liability of sending a patient out in TS in the first place.
Your understanding is correct. The only time that you should waiver is for
death or cancellation of an order which needs to be clearly documented.Some
practices have decided that they can provide a patient with a walking check
socket and bill it. A walking check socket is not a final product.
Unfortunately, they get by with it because most patients don't have a clue
We had a patient that was billed (by another practice that was later shut
down by Medicare) fir a complete prosthesis when they were measured. They
did not actually receive anything until a year later.It's disgusting for
those trying to survive in this ugly system.
Smells like rotten fish
I've been advised by AOPA that I am able to bill work done with appropriate
documentation of occurrence. What we as practitioners refuse to
understand, is Medicare views all payees as fraudulent. I have my
practitioners document everything. I have billed and been reimbursed via
Medicare in your very circumstance, having proved our work and expense to
date' we were compensated. If you'd like to talk further please feel free
to call me at my office.
You are supposed to bill test sockets with the date that the final
prosthesis is delivered. That does not mean that every practice does so and
that they do not sometimes get paid when they shouldn't. I see practices
bill test sockets all the time prior to delivery. But, just because you get
paid for something doesn't mean that you are doing it correctly. I could
give multiple reasons why you should not, from a billing and liability
perspective, do a dynamic/walking check socket that leaves your office
before the final delivery. Most practices are getting away from this
practice because of the liability. There are still some practitioners who
insist upon it and they do it knowing the liabilities involved and the
potential loss. There really is not any protection of your financial
interest if the patient chooses not to return with your check socket. You
can however bill salvage value for custom componentry when a patient passes
away before delivery and you have already fabricated custom components. All
returnable components must be returned. The problem with this philosophy
with a walking check socket is... Good luck returning a knee or a foot once
it has been worn by the patient outside of your office.
You are correct. A facility can deliver a device, but cannot legally bill
Medicare until the detailed written order is received and all delivery
paperwork is signed. And you can only bill for what you actually delivered.
In our facility, for example, those amputees desiring a cover are usually
provided the prosthesis for a month prior to installing the cover to assure
proper alignment. We bill without the cover code and then bill the cover
separately a month later when it's provided.
I would hope that no practitioner would provide a test socket for trial
fitting and advise the amputee to use it outside of the home. We
occasionally do a week long home trial with the test socket for difficult to
fit amputees. We have them sign an actual contract stating they will not
wear it outside of the home. It would be very dangerous for them to
ambulate outside of the home with an incomplete device. How do you know
that what you're seeing is a test socket? Perhaps what you are seeing is a
completed prosthesis without the cover?
No confusion, you are right, they are wrong.
I believe with private insurance you can bill anytime after prior approval.
You can bill for what has been provided but you still need to have signed
validation of receipt for what you are billing. A good instance is say your
patient leaves on a check socket with an MPK knee and a foot and everything.
You can have them sign and you bill for everything that has been done at
that point. Obviously not acrylic or flexible socket/ rigid frame but if
you have built in the ischial containment and total contact and suction blah
blah blah, all of that can be billed. Then you bill the acrylic and
flexible socket/rigid frame when it is transferred to definitive.
Thank you all, for the responses..I will keep posting as they come in.
Michele Hattingh
Administrator
Prosthetic Care Facility of VA
15738 Foleys Way
Haymarket VA 20169
571-445-3390
571-4453392
www.prostheticcarefacility.com
Treat others as you want to be treated.
Citation
“Fw: Billing before final - responses.,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/237176.
