Aetna Health Care

Recently Aetna Health Care released an update to their National Policy  https://www.aetna.com/cpb/medical/data/400_499/0451.html#dummyLink2 covering custom fabricated orthotics (L3000-L3030). There are several conflicting statements regarding their coverage of these devices. Aetna has also relied on the revised policy as their source document for audits retroactive to the effective dates of the new policy.

In order to facilitate space requirements for this forum, this letter will be broken down into several sections. As a priority, in order to reduce the risk of recoupment and improve your chances of successful challenges on foot orthotic audits,  what you need to document when billing custom foot in orthotics to payes will be provided first. A more detailed story on this will be provided in future segments.

The Top Ten DME billing tips when billing custom foot orthotics to a third-party carrier are:

        1) Subscribe to your third party carrier’s list serves and download all policies effecting your practice.

        2)Mark the carrier’s policy dates of effectiveness and termination.

3) Highlight any significant requirements or changes that may significantly impact coverage criteria and their effective dates.

4) If policy language is confusing or contradictory contact your provider representative or carrier in writing.

5) Obtain prior authorizations when required and retain the employee’s name and ID number as well as the log number of the call in the patient’s EMR.

6)If you must bill on the date of delivery, be sure that your biller does not bill on the date of impression.

7)If the patient fails to show up, have a template explaining custom item cancelled by patient (you can reference the Medicare Internet Only Manual clause (more on this in a future segment)

8) Be sure your date of delivery coincides with the chart note.

9) The written proof of delivery should include a lay person description of the dispensed item(s) or use the UPC code sticker from the lab and the proper HCPCS code. Be sure to use words like one pair of LT and RT in this document. Scan one into the EMR as well.

10)  Be sure you provide a follow-up return visit documented in the chart. As with surgery you are responsible for responsibly following the patient for 90 days at no charge for any adjustments.

As for your initial question: Please go back to your Middle or High School history courses where you were taught about Ex Post Facto. That is one cannot retroactively apply present law to something that occurred prior to the present law effective date.

This defense was succesfully used in an audit that UHC attempted many decades ago when they tried to retroactively enforce a new regulation requiring the use of the KX modifier. Siimply invoking Ex Post Facto to their auditing manager, and voila several days later the audit when up in smoke!

Depending on the number of claims in any audit you may need legal assistance.

All the big insurance companies will try to get away with murder. You must stand your ground and don't be intimidated. Adhere to the ten rules and you should be fine.