Billing and Collections Q&A

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Running an O&P facility in today’s landscape of enhanced scrutiny and changing billing requirements can leave even the most seasoned billing professional feeling frustrated. If you have a billing question, Got FAQs? can help you sift through the confusion and get you the answers you need. This month’s column addresses durable medical equipment (DME) fee schedules for workers’ compensation and no-fault claims, and billing claims for which the referring physician is not certified through the Provider Enrollment and Chain/Ownership System (PECOS).


Q: We are an O&P provider in New York, and want to know if the rule that you cited in a September 2012 article is still applicable to physicians submitting worker’s compensation and no-fault claims. We would appreciate you clarifying this so we can report the correct information to the physicians we work with on a regular basis.

The previous question was: “We are durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers located in the state of New York. A group of physicians in our area recently started providing orthoses to patients directly, and referrals from this physicians’ group have decreased. One of the physicians contacted us and requested that we provide devices to the physician’s patients who are covered by workers’ compensation or no-fault insurance since the practice will only be reimbursed for the cost of these devices. Does the DME fee schedule apply to physicians or only to DME and O&P providers?”

A: The rule, stating that the DME fee schedule applies only to DME suppliers and not to medical providers supplying DME directly to patients, for purposes of reimbursing the cost of DME under the no-fault law, is still applicable. The Office of General Counsel issued the following opinion on April 6, 2009, representing the position of the New York State Insurance Department on the applicability of the workers’ compensation board (WCB) directive to the DME fee schedule in no-fault claims:

“Under…Article 51 of the New York Insurance Law, a provider of health services is limited in what he can charge to an insurer by the amounts specified in the workers’ compensation fee schedules. The existing fee schedules prepared and established by the chairman of the Workers’ Compensation Board for industrial accidents are hereby adopted by the Superintendent of Insurance with appropriate modification so as to adapt such schedules for use pursuant to the provisions of section 5108 of the Insurance Law….

“Since 11 NYCRR [New York Codes, Rules, and Regulations] 68.1(b)(1) (Regulation 83) adopts the WCB’s fee schedules and ground rules for no-fault billing and reimbursement, and because physicians are excluded from the DME fee schedule, the WCB’s directive interpreting the DME fee schedule applies to charges arising from no-fault claims, in accordance with the clear intent of Insurance Law § 5108(a) to ensure that no-fault health services are reimbursed in accordance with the WCB fee schedule.” For more information, visit

Q: I am a Medicare-certified and -accredited provider in Oklahoma. For several years, my office has worked with a physician who is not PECOS certified. We have billed UnitedHealthcare in the past and never had any issues. Lately we are receiving denials stating “physician not PECOS certified.” Why would our claims suddenly be denied for this reason? The odd thing is, some claims are paid and others are denied. Please advise what I am missing so we may avoid getting these denials in the future.

A: The denied claims were for patients who have Medicare Advantage plans. According to UnitedHealthcare’s Doc#: PCA14398_20141015, the insurer follows Medicare guidelines and the referring physician must be PECOS certified. The paid claims were for patients who have commercial plans, and PECOS certification is not required in those cases. To read the article, visit

Lisa Lake-Salmon is the president of Acc-Q-Data, which provides billing, collections, and practice management software. She has been serving the O&P profession for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact or visit

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