Documentation, Coding & Reimbursement Flashcards

What is 'prior authorization' in the context of O&P reimbursement?

Answer: Insurance carrier approval obtained before providing a service to confirm coverage

Prior authorization is formal approval from the insurance carrier obtained before delivering O&P services, confirming that the planned device will be covered and reimbursed.

Under which Medicare benefit category are most prosthetic and orthotic devices covered?

Answer: Part B (Medical Insurance)

Most prosthetic and orthotic devices are covered under Medicare Part B (Medical Insurance) when prescribed by a physician and deemed medically necessary.

Which fee schedule does Medicare use to determine reimbursement rates for prosthetic and orthotic devices?

Answer: DMEPOS (Durable Medical Equipment Prosthetics Orthotics and Supplies) Fee Schedule

The DMEPOS Fee Schedule establishes Medicare's allowed payment amounts for prosthetic and orthotic devices based on HCPCS L-codes.

How does Medicaid O&P coverage typically differ from Medicare coverage?

Answer: Medicaid coverage for O&P varies by state because each state administers its own program

Medicaid is a joint federal-state program administered individually by each state, resulting in significant variation in O&P coverage, limits, and reimbursement rates across states.

What is the standard Medicare Part B co-insurance percentage that patients are responsible for on covered O&P devices?

Answer: 20% of the Medicare-approved amount

Medicare Part B pays 80% of the approved amount for covered O&P services after the deductible, leaving the beneficiary responsible for 20% co-insurance.

What is 'balance billing' in the context of O&P reimbursement, and how does it apply to Medicare-participating providers?

Answer: Billing the patient for the difference between the provider's charge and the insurance payment, which is restricted for Medicare participants

Balance billing is charging a patient the difference between a provider's fee and the insurer's allowed amount; Medicare-participating providers agree not to exceed the Medicare-approved amount.

How does Medicare's Competitive Bidding Acquisition Program (CBIC) affect O&P suppliers in covered geographic areas?

Answer: Selected suppliers win contracts through a bidding process and set payment amounts, limiting which suppliers can serve Medicare beneficiaries in those areas

Under CBIC, only suppliers awarded contracts through competitive bidding can furnish covered items to Medicare beneficiaries in designated areas, establishing bid-based payment rates that replace the fee schedule.