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Medicare Orthotics & Prosthetics Billing


I have just taken on the billing for an O&P group who has had very bad luck with their billing.  They outsourced billing 4/1/16 and they are now bringing back in-house and I have a lot to clean up.  I have come across SEVERAL Medicare claims that there appears to have not been touched.  It shows the claims were sent to Medicare in late 2015 and early 2016 but nothing beyond that.  There are also several that the billing company followed up on and just noted no claim on file but failed to file, despite the fact there was still time to do so.  I am no longer to obtain proof of timely filing through Emdeon so I just have the date notated in Futura showing when it was billed, rebilled, etc.  Some of the claims I may have a written log in the chart.  I am unable to rebill these claims in the old system. 

Does anyone know if I am able to get these claims paid if I have proof of timely?  If so, am I able to send paper claims with proof of timely?  ANY help would be much appreciated.   :'(

Medicare has a very strict 365 day rule.  I have actually had a claim or two over the years that went past timely filing and we had a legitimate reason with proof, but were unable to get Medicare to pay.  (We had a patient that presented to the office with a commercial insurance.  The claim was submitted and paid.  Over a year later the insurance retracted and said "patient had Medicare primary at the time of service".  The patient never informed the office that they even had Medicare.  We submitted to Medicare with the letter from the commercial carrier within two weeks of getting the letter but they still denied.)  I truly feel for the provider.  We have gone into offices that outsourced to a bad billing service.  It makes our job very tough.  However, from the insurance carrier standpoint it's still the provider's responsibility to make sure the claims are paid and they don't really have a leg to stand on.  We have had some commercial carriers that have made one time exceptions for providers in this situation, but Medicare...... personally I have not had Medicare pay a claim over the timely filing limit even when we had a good reason and proof.

Sorry.  :(

So, so sad!  I knew that was going to be the response.  I thought maybe someone out there in billing land would know some trick that I was unaware of.  So irritating that people perform their jobs in this manner and the providers lose money in products and reimbursement.  Now onto monies that can be collected.  Thank you so much for the response.

It is sad.  Many providers use this as a reason not to outsource.  Truth is I have seen a lot of loss both ways.  The important thing is for the provider to know that they have a competent person or service handling their billing.  They should also request regular reports so that they are overseeing what is happening.  Too many providers simply close their eyes to that part of their practice and they end up paying dearly!

I agree with Michele, I've cleaned up many messes from other billing companies and the number one complaint was just letting claims sit, or not following up on appeals, not getting authorizations, etc. It can give us good billing companies a bad name. I just try to find a way to capitalize on the faults of the previous billing company and assure them a different outcome.  For those I usually will give them a break as a trial with short term contract.


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