La. Admin. Code tit. 50 § XVII-501

Current through Register Vol. 50, No. 11, November 20, 2024

Section XVII-501 - Reimbursement Methodology

A. Effective for dates of service on or after September 6, 2007, the reimbursement for prosthetic and orthotic devices is 90 percent of the 2007 Medicare Fee Schedule amount or billed charges, whichever is the lesser amount, unless otherwise stipulated. If an item is not available at 90 percent of the 2007 Medicare fee schedule amount, the flat fee that will be utilized is the lowest cost at which the item has been determined to be widely available by analyzing usual and customary fees charged in the community.

1. This rate does not apply to prosthetics and orthotics that are:

a. already reimbursed at a higher amount than 90 percent of the 2007 Medicare Fee Schedule; or

b. not included on the 2007 Medicare Fee Schedule, such as customized items for which there is no established fee. These items must be individually priced.

B. Items not listed on the Medicare Fee Schedule will continue to be reimbursed at the lowest cost at which the item has been determined to be widely available by analyzing usual and customary fees charged in the community for the HCPC procedure code.

C. Effective for dates of service on or after January 1, 2009, reimbursements for prosthetic or orthotic services or devices shall only be paid to an accredited provider.

D. Effective for dates of service on or after March 7, 2009, the reimbursement for prosthetic and orthotic devices shall be reduced by 3.5 percent of the fee amounts on file as of March 6, 2009.

1. The rate reduction shall not apply to items that do not appear on the fee schedule and are individually priced.

E. Effective for dates of service on or after August 4, 2009, the reimbursement for prosthetic and orthotic devices for recipients 21 years of age and older shall be reduced by four percent of the fee amounts on file as of August 3, 2009.

1. The rate reduction shall not apply to items that do not appear on the fee schedule and are individually priced.

F. Effective for dates of service on or after January 22, 2010, the reimbursement for prosthetic and orthotic devices shall be reduced by 5 percent of the fee amounts on file as of January 21, 2010.

1. The rate reduction shall not apply to items that do not appear on the fee schedule and are individually priced.

G. Effective for dates of service on or after July 1, 2012, the reimbursement for prosthetic and orthotic devices shall be reduced by 3.7 percent of the fee amounts on file as of June 30, 2012.

1. The rate reduction shall not apply to items that do not appear on the fee schedule and are individually priced.

La. Admin. Code tit. 50, § XVII-501

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:1597 (July 2005), amended LR 34:881 (May 2008), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:1903 (September 2009), repromulgated LR 36:521 (March 2010), amended LR 36:1253 (June 2010), LR 36:2567 (November 2010), LR 39:2770 (October 2013).

AUTHORITY NOTE: Promulgated in accordance with R. S. 36:254 and Title XIX of the Social Security Act.