- Human Interest
- O&P Practitioner
- Physical Therapist
- Other Healthcare Professional
Case file for Medicare
Posted By: Wil on October 17, 2012
Hello Colleagues and Guests,
I've been told by at least one practitioner that letters have been sent
to the SBA Ombudsman office and the only response was a typical
government form letter stating that Medicare does have the right to
audit. I have asked for this information to be sent to me with all of
the appropriate HIPPA information deleted so we can include this
information in a case file. When we go back to our congressional
representatives and take written proof that the SBA or any other federal
agency is not playing by their own rules, information that supports this
claim simply enhances our position and our cause.
Following is an excerpt from the OIG report that I recently posted a
Section 427(a) of the Medicare, Medicaid, and SCHIP Benefits Improvement
and Protection Act of 2000 (BIPA) prohibits Medicare payments for
prosthetics and custom fabricated orthotics unless the items are (1)
furnished by a qualified practitioner and (2) fabricated by either a
qualified practitioner or a qualified supplier. Section 427(b) of the
BIPA required the Secretary to promulgate regulations to implement the
requirements at section 427(a) of the BIPA. As required by 42 CFR i??
424.57(c)(12), Medicare suppliers must also maintain documentation
supporting that prosthetics and custom fabricated orthotics were
delivered to beneficiaries. In 2010, CMS allowed $276 million in
Medicare payments for 257,797 prosthetic and custom fabricated orthotic
claims (excluding accessories, additions, and other supplemental
prosthetic and orthotic items).
This was a federal mandate and was never implemented as required by law.
The definition of qualified provider is spelled out in the legislation.
Once again, this information becomes part of our case file and is
important information when we present additional information to our
congressional representatives. It appears from this OIG report that
Medicare must take some blame for paying claims that should not have
been paid under the umbrella of this federal mandate.
We are waiting on a legal opinion about the authority that the SBA has
in matters regarding unfairness for small businesses. Unfortunately, we
still don't have the reply. As soon as we get an opinion, that
information will be passed along to you.
If you have HIPPA compliant correspondence that you are willing to share
for our case file, please send it along. Or, if you want it posted on
the oandpsolutions.org website instead, that can be arranged as well.
The more written information we compile, the better our chances will be
in helping to resolve these serious Medicare (and soon to be Medicaid)
On another note, we were informed yesterday by one of the insurance
companies that handle a self insured federal group that L 4631 (CRO
Walker) was not a covered medical expense because it is considered a
foot "supporting" orthosis. This is the kind of stuff that we have to
fight, otherwise it will not be long before other comprehensive O&P
devices are excluded from insurance coverage as not being medically
necessary. In a case like this, the only thing we can do is let the
client go back to their employer and explain the problem. Hopefully,
this client will not suffer an amputation before this issue is resolved.
Rather sad isn't it? I'll let you know how this turns out.
Wil Haines, CPO
Avon, IN 46123
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