I am genuinely trying to understand what is “allowed” and what isn’t when it comes to CTPs/skin subs in the office-based and “mobile”. Everyone has heard about what happened to the owners of a CTP/skin sub company in Arizona.
I am trying to understand the scenario when there is NO published Average Sales Price (ASP):
When there is no published ASP, it is my understanding that the physician must report his/her actual payment for the CTP in block 19 of a paper claim, or in the narrative record of an electronic claim. The Medicare Administrative Contractor (MAC) then reimburses the practitioner based on either the wholesale acquisition cost (WAC) plus 3%, or the invoice price plus other costs (e.g., shipping, handing, or tax). Following the rules, it seems to me that a physician would be reimbursed an amount very close to the actual price they paid for a CTP. In fact, the doctors following the rules on billing CTPs/skin subs tell me that they may actually LOSE money, particularly given the 3% sequester.
However, some practitioners are telling me that they can make huge profits on CTPs. I have been trying to understand exactly how this is achieved. One practitioner showed me that they got two invoices for the same CTP order – one showing the actual price and one the discounted price. It was up to the practitioner to decide which invoice to provide to Medicare. I don’t need to ask whether proving a falsified invoice to Medicare is legal – I know that it isn’t.
Since a practitioner could use a less expensive product for the same outcome, I assume that the only reason to use an expensive product is to make a profit off the discounted price. If there’s another reason, feel free to tell me about it.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
To summarize, products without an ASP can be fee schedule listed if a MAC has a local fee schedule (the local rate MACS). Invoice price is loaded locally and paid from that local fee schedule so inputting the cost in box 19 is not always required, just like ASP products. It is unclear if a price is paid for those products below the local rate is reportable by the physician, manufacturer, or both.
In other MACS which do not have a local fee schedule, the non-ASP products would require an invoice cost in Box 19 and supported by retained documentation that is discoverable in an audit on the actual cost paid for a product “less of all discounts and rebates.” Ultimately for all non-ASP products, the burden of proof for actual net price paid by the provider is on the provider. These discounts are applied at the time the physician pays the invoice, so after a claim has been submitted, which makes it very burdensome because according to the overpayment instructions on each MACs website the claim must be entirely surrendered, then the provider needs to wait between 2-12 weeks for the funds to be recaptured, then resubmit. Providers who go through surrendering the claim after receiving a post date of service discount (rebate) and the reimbursement, then re-bill the claim with the true net cost, the results can be that they will be repaid the local rate entirely (making money) or that they receive the net of the original invoice and the discount (losing money), or many other sequelae within and completely outside that spectrum (additional audits). Confused yet? so is everyone.
I do home health and we continue to see wounds that are not appropriate for a graft being grafted. Horrible infected wounds . Our documentation and photos shows the real damage but the practitioners
Documentation reflects just the opposite. It’s sickening and needs to be stopped.