Where can I find information on how often a new AFO is covered by Medicare and other insurances. Can a patient get a new i.e. solid ankle AFO ( L-1960) every new calender year?

Thanks,

Heinz

We had very specific job responsibilities, like most of us.  I took my responsibilities and broke them down into categories, and outlined them something like this...ABCDE.  The RN in charge was furious with me for being so thorough and detailed oriented.  I remember her stating "We don't need to go thru A to E, we need to focus on A and E.  There's no need for the BC&D. Just get to E fast and forget the other stuff!"  Needless to say, that RN wasn't working for that practice much longer.

Today, I still stand firm on being so detailed oriented, which has led me to where I am this day.  With the CMS, Recovery Audit Contractors (RAC's) and the OIG looking closer at claims that were submitted and paid, we should all adopt policies and procedures to ensure that our claims stay paid!  I've been in many O&P practices over the years and I've seen a multitude of errors from lack of patient signatures & dates, lack of clinical & supporting documentation, lack of details on delivery receipts and claims submitted that were submitted without medical justification, to name a few.

Who's the Boss running the show anyway?  Ignorance is not acceptable, just ask any auditor or investigator.  Are employers watching what their employees are doing in the name of the business?  If so, perhaps there wouldn't be so many inefficiencies. 

If employers are like me, I don't like to "Micro Manage" employees.  However, I will take extreme measures to ensure that employees are properly trained and have an open door policy to answer questions.  But, I can't help wondering if employers have the right training, skills and knowledge to train their employees affectively, or if they take the time to invest in their staff.

Someone has got to "Train the Trainer" to keep abreast of all these ongoing changes.  Even though I'm a long time, experienced medical biller, I too have to continue my research, training and education to stay on top of my game!  Do I like to be pulled away from other tasks to do this?  That's debatable, but necessary and mandatory!  What about you?  Do you have mandatory training requirements set in place to ensure you and/or your employees are up-to-date on all these rapid changes taking place in our healthcare industry?  Set aside the professional staff requirements for a moment and think about your administrative & billing staff.  When was the last time you invested in their training?  Just a thought...Happy Friday!

If a physician, or non-physician practitioner refers a patient to another provider for services and/or items, but failed to update their Medicare Enrollment Record by April 5th, the Supplier/Providers claim(s) are supposed to be denied.

My opinion is the PECOS is just another way of "linking" pieces together to help combat Fraud & Abuse, and enforcing stronger accountability. 

I personally agree 100% with stengthening Fraud & Abuse efforts; however, I believe we need a better system set in place on the front end, and more manpower to accomodate the changes they continue to make.  Although the CMS and the NSC have taken great strides with tackling revisions to the DMEPOS Supplier Enrollment Application, and mandating Facility Accreditation for some, it has caused a huge backlog in the Supplier/Provider Enrollment process. With the delay in the PECOS implementation date of April 5, 2010, I can't help but chuckle, because I can only forecast another delay because of the backlog already established.

Without writing a book, I will close in saying, we need better infrastructure! I'm not confident with the way the system operates today, nor am I confident in those in charge of operations.  In addition, I doubt very seriously that "Healthcare Reform" would bring positive changes to our healthcare system, especially with the mess that has already been created.  Who created this big mess anyway??? 

I have been teaching Claims &  Billing Symposiums for over five (5) years now, and have had numerous people attend.  The problem is that employers do not send their employees to a Claims & Billing Class annually.  BIG MISTAKE...because there are so many changes that affect billing each and every year; therefore, your billers  need to stay up to date on the latest developments to avoid claim delay, denials and/or appeals. 

I wonder why they don't send their employees for annual training.  Perhaps employers believe it is too costly.  Sad thing is...it is more costly to have denied claims because the claims were not initially prepared correctly, and/or lack of medical justification documentation. In the long run it cost employers more time and money to correct and/or appeal a claim. 

Words of Wisdom...Invest in Your Staff!!!

If you are one of these mentioned, you are in for a rude awakening if you get audited, which there are many audits going on, especially with the RAC's and Medicare.  Words to the wise...conduct a medical record audit, especially for the past five (5) years, and make sure that you have sufficient medical record documentation to back up and justify your claims.  It is also important to KNOW YOUR ACTIVE MEDICAL POLICIES as it relates to medical record documentation, and DO NOT "THINK" that you know them, as that can come back to haunt you later.   

I am astounded at the number of suppliers that simply overlook this critical area, and even more so that "think" they are documenting and retrieving supporting medical documentation, when in fact many are really clueless. 

I have to ask myself...WHY??? It is my firm belief that this happens for several reasons.  In my humble opinion, they are, but not limited to, the following:

1.  O&P Schools do not "clearly" teach Practitioners about the "do's and don'ts" regarding medical record documentation, and supporting documentation.

2.  O&P Facilities/Suppliers fail to hire "qualified" employees with medical background experience.

3.  Failure to review and keep current with the LCD's...Medical Policies.

4.  Lack of understanding of what Supporting Documentation is, and what documentation to request from referring physicians, and other healthcare providers.

Lastly, you should never assume that  you are in the clear if your claim(s) have been paid...there are always the "post audits" that can take place, and can go back at least five (5) years.  AUDIT, AUDIT, AUDIT...Protect your Practice and"Stay Connected"...you're business depends on it. 

I am a firm believer in "Accountability", especially when billers are submitting claims on behalf of another.  If one files a fraudulent claim, they are not only coming after the owner(s) and practitioner(s), they are coming after the one(s) who completed and submitted the claim for payment.  Sympathy for ignorance??? Don't think so, nor do I think the OIG takes this lightly!

During my Claims & Billing Symposiums, for the past five (5) years now,  I repeatedly discuss this scenario in greater detail.  As I always say...you can lead a horse to water, but you cannot force em' to drink. 

TRAIN, EDUCATE & DEVELOP your staff...it makes good business $ense and mandated by Compliance.  "Stay Connected"....

The writer gave the LCode and Modifier for what they were billing, and the first thing I noticed was the incorrect Modifier.  Repair and Replacement Modifiers changed at the beginning of 2009. BILLERS ALERT...PAY CLOSE ATTENTION TO ONGOING CHANGES, as they seem to happen frequently.  If you don't, you risk potential denied claims!

Below is the information posted on one of the Jurisdications website, they all follow the same suit...

"New Repair and Replacement Modifiers

Effective for claims with dates of service on/after January 1, 2009, the RP modifier will no longer be accepted for the use of repair and replacement.

The following modifiers will be required:

RA Replacement of beneficiary-owned DMEPOS due to the expiration of the equipment's reasonable useful lifetime or to loss, irreparable damage, or when the item has been stolen.

RB Replacement parts furnished in order to repair beneficiary-owned DMEPOS.

Please report the appropriate modifier on claims in 2009.

Electronic claims submitted with an RP modifier for dates of service on/after January 1, 2009, will be rejected via an error on the GenResponse report.

Paper claims submitted with an RP modifier for dates of service on/after January 1, 2009 will be denied as an unprocessable with the following reason code: CO-4 The procedure code is inconsistent with the modifier used or a required modifier is missing.

Claims will need to be resubmitted with the correct modifier.

It's a "Good Day" when you verify insurance and actually get a human being on the phone to speak with.  The Bonus...when they know what they are doing and what they are talking about.

A "Bad Day"...when you get a New Employee from the Insurance Company on the phone and they are totally clueless about the questions you are asking relating to Orthotics and Prosthetics, and the call takes nearly one (1) hours as the CSR places you on hold to, repeatedly, go speak with her supervisor to find out the answers to your questions.

A "Not so Bad Day"...mixed with a little of both :-)

Next week, perhaps I will blog about claims, payments and denials. 

If you have something you would like me to blog about, send me a comment and I will most certainly consider it.  Have a great weekend!

Today, a friend of mine called and was telling me the same thing, and that one rep advised her to ALWAYS pre-authorize Custom Devices, even when the CSR tells you that NO AUTH is required, which led my mind to wander back when I teach Claims & Billing Courses when I would always tell folks...just ask for the pre-auth number anyway and thank them.  Hang up and call the pre-auth dept.

As a matter of fact, I verified insurance for a prosthetic patient recently, was told all of the LCodes required prior authorization, I submitted for prior auth and just received a letter from the insurance company indicating that NONE of those LCodes needed prior authorization!

Makes one wonder if the insurance companies, and/or their employees know what they are talking about?  Furthermore, they expect providers to verify and authorize...when we follow these procedures, at times it is still a risk.

Ugh...insurance companies!

I have to admit that it can be a challenge to interpret some of these policies, and applaud those professionals that challenge the medical policies when necessary.  Because of those challenges, some of the medical policies have been revised accordingly.

Most Insurance Companies have lagged way behind in adopting Medicare Medical Policies for DMEPOS, but over the past 2 years they have jumped on board that ship, and follow most of these policies to a tee!

Insurance, Claims & Billing Staff MUST stay on top of your game to avoid claim denials and/or delays!  This is not an option, but a mandatory requirement to remain successful.

Have a great day!