Part B costs overall: $256,164 million
Physician costs: $71,079 million
Outpatient hospital: $40,204 million
Home health: $11,420 million
DME: $6,427 million
You really gotta watch CEOs of hospitals who have political ambitions. I’m looking at Florida Governor Rick Scott, who oversaw the bilking of BILLIONS of dollars from Medicare while he was CEO of HCA hospitals.
But I also hate DME. They prey ***directly ***on the sick and miserable.
Generally, yes. At least in the DME fraud cases I saw. I doubt anything much has changed, though.
Generally the braces are some combination of elastic, velcro, and maybe some hinges for the knee, or some metal strips for support (knee or back). They aren’t rocket science.
Mhendo, the article you linked was a great one and should be read by everyone to understand one of the indirect cost drivers of healthcare. Each payor has its own rules, and coders have to understand those rules. And they are completely Byzantine. (I’m also a CPC or Certified Professional Coder; coding rules have expanded hugely in the past 20 years…)
(Multiple posts because I missed the edit window. Sorry.)
i have the CPAP and (thanks to the PCP who damned near killed me)a bare-bones walker.
No charge.
And - the CPAP debacle has me getting 'Copy for your records" letters from both the provider and Medicare.
The Medicare letters always state that the patient cannot be billed - even if Medicare declines the claim - the cost is all on the provider.
Very few patients actually need a brace. Physicians will typically only order custom braces for post-surgical patients or people wandering around without an ACL, and so on. If you would get the same benefit from a $10 drugstore brace, they’ll say so. Though they might just dispense one and charge $50 for it.
Didn’t mean to abandon this thread and wanted to clarify.
Yes-I have hospital privileges.
I do all my own coding.
When I worked for other people, we occasionally had a company come in to check that we were coding correctly. I consistently was cited for undercoding. This was partially secondary to undervaluation of the worth of my services and partially secondary to fear of audits.
Part of it doesn’t make logical sense to me. For example:
As part of a follow-up visit with a Medicare patient, I routinely review things like whether they can care for themselves and their fall risk. I’ve always just billed it as part of a regular visit (for which I get about $75). However, Medicare pays for a yearly Annual Wellness Visit that doesn’t involve any exam except checking weight and blood pressure and basically consists of evaluating all of the things that I routinely do anyway. For this, they pay about $115. It seems wrong to me to bill this extra money once a year for something that I do at every visit anyway. I have to get it into my mind that I deserve to be compensated for this work, even though I have been doing it all along.
Another reason to be wary of overcoding is that the government contracts out fraud recovery. These companies are paid based on collections. The more fraud they find, the more they get paid. In addition, they are allowed to extrapolate. If they review 10 charts and find one improper code, they can assume that 10% of your billing is improper. Fines, IIRC are triple damage plus $10,000 per incident, which can quickly add up if you have several thousand patients. You may say that it is rare to be audited, but I know of at least one local doctor who was audited and charged with criminal Medicare fraud. After several years, huge damage to his reputation and probably several million dollars in legal fees, he was cleared of all charges and left to pick up the pieces. Of course, malpractice insurance won’t touch billing fraud.
While I am also sure that many hospitals do try to overbill, when I was admitting, the cases I that got sent back to me to correct the coding were usually along the lines of one where a patient was admitted with pneumonia, which is paid as a 3 or 4 day stay. On the day prior to being discharged, he developed an abnormal heart rhythm which required a couple of days to address before he could safely go home. Since Medicare pays for a set number of days based on the original diagnosis (not going to link to a description of diagnostic related groups or DRGs), they denied the extra days, and the hospital billers had to figure out a way to code the visit to convince Medicare that it was not just a routine pneumonia admission.
Overall, Medicare has been cracking down on fraud and abuse, which is good, but which puts extra burden on the physicians to document everything, which is where the frustration with the DME providers (I left out a word in the title) comes in. They make the patients the promise that everything will be paid for then dump the paperwork on the doctors. For example. here are the requirements to justify a knee brace.
Also, I have tried, as the doctor above does, to just throw them away, but these stupid companies keep sending them every single day unless I respond, and there are always the patients who get upset that I haven’t just ordered their brace when they are told that all they have to do is agree and it will be shipped to them. My staff has to take the time to explain that I need to actually see them and to document a visit before they get their free brace, or else explain to them why they really don’t need a brace and why I am depriving them of a free benefit that they are entitled to.
And son of a bitch! This same company just sent me a request for bilateral wrist braces and a knee brace for ANOTHER patient and I now wasted time reviewing her chart to find that she has never complained of any wrist or knee pain so I now have to have my staff call her to tell her she will need to be evaluated before she can get any braces and also call the company to tell them to stop sending the forms until I can evaluate the patient!
I don’t think this problem is confined to just medical devices … watch one of the networks’ news casts some night and you’ll have a list of drugs to ask your doctor about … leaving the poor doctor with having to say “we won’t know for sure until after the autopsy” …