Implants typically require a significant investment on the part of an ASC,
which makes it critical to capture reimbursement for these FDA-approved
devices. Missing an implant payment can instantly turn a profitable procedure
into a money loser.
Follow these five tips to improve your chances of getting paid for implants.
1. Use a cover letter and include the implant log. If the claim is denied because it requires the invoice, do not resubmit
the claim with the invoice alone. Send a cover letter explaining that
the requested information (i.e., invoice and log) is attached for the
payor to reprocess for additional payment.
It's also a good practice to note on the cover letter that "this
is not a duplicate submission.". Make sure to submit the manufacturer's
invoice and implant log, not the purchase order.
When submitting a case with the invoice, include a copy of the implant
log. Confirm that the lot or reference number matches the stickers on
the log. Highlight the lot number on the invoice so it's easier for
the processor to identify the item on the invoice.
2. Craft a detailed appeal. If an implant is covered under your contract, and is denied as non-covered
due to the invoice not being available from the manufacturer, an appeal
will be required. Send a custom appeal with a copy of the contract showing
the coverage. Include a copy of the manufacturer's invoice and implant
log. Make sure to lay out the contract terms in the appeal with the exact
amount of the expected reimbursement.
3. Review codes. Prior to submitting a claim/appeal, confirm the correct use of the HCPCS
code. If a generic code was used (e.g., L8699), check if a more specific
code is appropriate.
When updating the HCPCS code to a more specific code, submit a corrected
claim. A best practice is to include a cover letter explaining the corrected
claim, what was corrected, what additional payment is expected and what
supporting documentation is attached.
4. Check contracts. Review contracts for implant reimbursement eligibility and any implant
reimbursement thresholds. Some carriers will not reimburse for implants
Also, verify the carrier's coding preference: L codes versus C codes.
5. Factor in invoice delay. One of the biggest challenges for contracted centers is when a payor requires
a copy of the invoice for implant reimbursement. Device manufacturers
typically do not send out invoices for 2-4 weeks post service date.
There are a few ways to handle these payors, and it depends on the specific
payor and how they processes claims. The optimal approach would be to
submit the claim without the invoice. If this approach is taken, make
sure the charge amount complies with the contract by using the cost in
the purchase order. Follow up by faxing a cover letter, invoice, implant
log, and a copy of the claim when the invoice becomes available.
As a last resort, hold the claim until the invoice is available from the
manufacturer. Some payors will process a claim without the invoice and
do quarterly audits of the implants. Another option is to contact the
manufacturer and request a better process to receive the invoice earlier.
Getting paid for implants is often no easy task. Even in the best of circumstances,
it's not unusual to see payments missed or underpayments made. That's
why ASCs must develop processes to effectively monitor implant payments
and address when payments are missed or underpaid. Failure to do so could
result in leaving thousands of dollars on the table every time a payment
is not completed correctly.