L3000 Anthem Audits
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Lately Anthem has started a nationwide recoupment on all orthotic claims particularly for L3000. These audits do not target the age-old issues of heel cup depth, shell durometer or the date of service not corresponding to the date of dispensing.
Instead a new tactic is targeting the fact that these functional orthotic devices are as with Medicare’s orthotic policy not an “integral part of a brace which is attached to a shoe”.
Providers have cited that they have obtained pre-authorization for such devices and have notified the payers that there is no brace. Despite this, payers have successfully recovered significant sums of $$.
This column has previously stated that third-party payers often have local policies that usurp, taking precedent over National policies. Local policies often do not require a leg brace attached to a shoe for orthotics to qualify for reimbursement. Whether an outside contractor who may be unaware of local coverage policies is conducting these audits and demanding recoupment is unknown. Adding to the confusion is that even local policies may contain conflicting language.
Aside from the age-old wisdom of calling the carrier to obtain written confirmation of patient centric benefit information, what else can one do to fight off these claw backs?
Pre-determination of benefits not prior authorization is the best way to prevent future recoupments. The differences may appear to be subtle; they assuredly are not. Some common differences include:
Pre-Authorization
Of BenefitsPre-Determination
Of BenefitsRequired
Insurance Policy
Dependent on CPT/HCPCSMostly Provider Driven
Guarantees benefits
No
Yes
When are benefits Guaranteed?
When the claim is Processed
Prior to providing the service
Determines procedure Cost/coverage/financial resp.
No
Yes
Determines Medical Necessity
Yes
Most often
Bear in mind that Pre-authorization of benefits may be compulsory or optional dependent on the carrier’s policy. Receiving a “no preauthorization required” does not equate to coverage. A pre-determination of benefits of coverage, after carrier chart review, provides verifiable coverage information.
A more thorough reference may be found at: https://www.outsourcestrategies.com/blog/predetermination-vs-prior-authorization/
For more information on this issue please contact your Kevin Root Client contact representative, who will be happy to assist you with the most current information on this issue.
