Communication Essential in Ensuring Orthotic/Prosthetic Coverage
MICHELLE G. PRETTYMAN, PT:
Prosthetic and orthotic devices have traditionally been provided to patients based on medical necessity and improved function. The initial referral for a device may have been from a physician based on medical assessment, a physical therapist for functional independence, a collaborative team in an orthotic or prosthetic clinic or some combination of these.
The specific fabrication and fitting of a device were likely performed in one to five days by a certified orthotic or prosthetic provider. Prosthetists and orthotists would reassess and adjust devices over several weeks to years.
The payment secured by the provider for the orthotic or prosthetic device would be secondary to medical necessity and functional need.
Today, the cost containment efforts of health care and the developing insurance systems impact access and referral to certified orthotists and prosthetists for devices. The HMOs and PPOs currently developing may or may not include orthotic or prosthetic coverage. If no benefits are available in a plan, physical therapists and occupational therapists, as well as podiatrists, may make equipment decisions for their patients.
Therapists may have orthoses available to noncovered patients for cash, based on educational courses they have attended or by simply ordering from advertisements in professional journals. Other therapists spend time informing physicians, educating patients and/or families, or locating the correct “benefits personnel” of the insurance carrier to negotiate for coverage. If negotiations fail, the patient may not receive equipment or, if able, be required to pay directly to a recommended orthotist or prosthetist. Consumers need to be educated about orthoses and prostheses and assured, if needed, that their insurance plan will provide services.
Insurance plans with orthotic and prosthetic coverage can be complex, require multiple approvals and be contract dependent. As new HMOs and PPOs are formed, physicians, therapists, orthotists and prosthetists are becoming aware of limitations. For example, a benefit plan may contract with a nationally known orthotic manufacturer, but in the case of a complex pediatric case or an above elbow amputation, a skilled specialist may be unavailable and the patient must “make do” with the contracted provider.
To complicate the ordering and referral further, a gatekeeper–either the primary care physician or case manager–must approve the type of device and payment. While primary care physicians have broad knowledge in health care, they have limited knowledge of specific orthotic and prosthetic equipment. Case managers, who are responsible for overseeing the medical care and money expenditure for insurance carriers, are often registered nurses or claims adjusters, neither of whom have knowledge or training in orthoses or prostheses.
Fortunately, there are case managers who participate in professional organizations who are aware of their limited knowledge, and are willing to consult appropriately trained providers to achieve quality patient care. As a physical therapist, I have found case managers accepting of medical necessity information and recommendations for referrals to a specific provider to achieve optimal patient function. Therapists, prosthetists and orthotists need to educate primary care physicians, case managers and consumers to assure appropriate coverage and referrals.
Assuming an insurance plan has provisions for orthotic and prosthetic devices, the next steps are assessment and fabrication of equipment. Orthotic and prosthetic practice integrates medicine, biomechanics, kinematics and material management. This technically advanced and developing knowledge is applied by certified professionals for the optimal fit and function of devices.
Insurers may limit the application of this specialized knowledge by controlling provider choices, denying coverage or “fixing prices.” By setting a specific price for an orthotic or prosthetic device or service, the insurance industry is indirectly influencing the equipment provided. The “fixed price” systems may motivate the orthotist or prosthetist to provide the least service with the least expensive equipment (prefabricated vs. custom). Reassessment, modifications and specific patient problems, such as prior fracture with deformity, the growth of a child or potential for neurologic return, cannot be addressed with “fixed pricing” or prefabricated devices. The specialized technical knowledge of the orthotist and prosthetist must be considered by insurance carriers and balanced with their business goals for the patient’s optimal function and outcome.
Insurance carriers should establish procedures for timely delivery of orthotic and prosthetic equipment. Timely assessment and fitting of equipment can result in earlier hospital discharge, prevent medical complications and improve health, as well as save money over the long term. Delayed authorizations, excessive paperwork requirements, unclear service providers and internal communication holes of today’s insurance plans prevent timely fabrication of equipment.
There are companies that require physician medical necessity and orthotic/prosthetic assessment results prior to authorization, but do not cover the costs of the assessment nor guarantee orthotists/prosthetists that they will be the providers of equipment, if authorized. The processes of gathering needed information may take two weeks or more while care is interrupted, functional improvement halted and hospital discharge delayed.
In physical therapy I have experienced expiration of physical therapy services prior to delivery of equipment leaving the patient or family with incomplete education and training.
These time delays in obtaining devices are problems not only in the newly developing HMO systems, but also in the government funded medical (California Medicaid) programs and need to be addressed in developing insurance plans and health care reform.
As outcome data is collected and clinical or critical pathways are adopted by insurance carriers, the role of orthoses and prostheses over time needs to be considered. There is potential for pathways to identify the “what” and “when” of orthotic and prosthetic devices. Insurers would be wise to consider how patients change over time beyond the established clinical pathways.
As a physical therapist, primarily working with adult neurologic patients, I see very different orthotic needs of a patient who has experienced a cerebral vascular accident during week one vs. three months after onset. If an insurance company pays for an ankle foot orthosis at week one, it may be spending money on a device that is not needed at three months. As health care providers we need to inform insurers of the short-term, as well as long-term orthotic and prosthetic needs of patients so appropriate funds can be located and reserved.
Finally, consumers and employers purchasing insurance coverage must be educated about appropriate orthotic and prosthetic procedures, and encouraged to ask their carriers questions. They should be willing to challenge the insurer if services are not provided by trained professionals in a timely manner or addressing their functional needs. Today, it is believed that ultimately the empowered consumer will determine how insurance companies will provide health care services including orthotic and prosthetic equipment.
WENDY FISCHL BEATTIE, CPO:
Patients should always receive the best orthosis or prosthesis for their needs regardless of their insurance coverage.
This idealistic sounding statement has little basis in the reality of the current climate of cost containment by Medicare, HMOs and other insurance companies and consumer concern
regarding escalating health care costs. Co-pays, deductibles and noncovered items have increased the monetary outlay of the patient in many instances. Orthotists and prosthetists, formerly responsible only for the proper prescription and fitting of devices, are now required to educate the patient, insurance company and physician in costs and value of what we do.
Orthoses and prostheses have been increasingly lumped together with durable medical equipment products. DME items are frequently single purchases for the life of the individual. Orthoses and prostheses are not usually designed for lifetime usage. Custom products may become ineffective with growth, weight change, atrophy, progression of an illness or simply from wear. This type of coverage will undoubtedly change the type or process of fitting the device. Perhaps, the device could be modularized, allowing for less costly repair if a portion of the product fails. For instance, endoskeletal prostheses might permit replacement of a knee mechanism (which traditionally have a one- to two-year warranty) without necessitating the purchase of an entire new prosthesis.
Perhaps the usual timetable for fitting would be altered. If patients can receive only one definitive prosthesis under their insurance coverage, the provisional or prepatory prothesis’ lifespan may be extended for as long as possible. This would allow for more change to the residual limb before starting work on the definitive prosthesis, thereby extending the length of time the finished limb would potentially fit. Of course, this is a compromise for the patient; the temporary prosthesis may not fit optimally for an interim period, in the hope that the next prosthesis will fit better for a longer period of time. It is the prosthetist’s responsibility to help the patient make an informed decision.
Many of the insurance companies follow the lead set by Medicare. Medicare’s policies regarding orthoses and prostheses have changed drastically in the past 18 months. Starting in March of 1995, Medicare has required function levels to be included with any prosthesis ordered. “A functional level is a measurement of the capacity and potential of the patient to accomplish his/her expected, postrehabilitation, daily function. The functional classification is used by the DMERC [regional Medicare] to establish the medical necessity only of prosthetic knees, feet and ankles.”1
People who are considered a level zero do not have the potential to transfer or ambulate and would not be covered for any prosthesis. A level four would include children, active adults or athletes, and Medicare would cover more specialized componentry for knees, feet and ankles. Levels one, two and three cover that in between region into which most of the Medicare population with amputations would fall. These levels might not qualify the patient for such devices as hydraulic knees or energy storing feet, despite a doctor’s prescription.
In orthotics, Medicare now requires a signed statement from the physician indicating the patient’s diabetic condition before approving and paying for diabetic shoes.
More and more of the population is falling under managed care contracts. “In 1995, 56 percent of hospitals had contracts with health maintenance organizations and 69 percent with preferred provider organizations. About 13 percent had direct contracts with their employers to provide care for their employees on a capitated basis.”2 These insurances are often less likely to pay for orthotic and prosthetic services in a carte blanche fashion. Frequently, “high tech” products such as energy storing feet for prostheses, and products deemed “unnecessary” like heavy duty knee joints on an orthosis may be noncovered items. It is important to educate both the patient and the prescribing physician on the options available.
Certainly, these items may still be utilized, but the patient would be responsible for paying for the noncovered products. The patient may decide not to have the item at all. There are also other possibilities. There may be a different product able to serve the patient’s needs which is covered, if the physician agrees to alter the prescription accordingly.
Some insurance companies are now asking for “generic” equivalents, less expensive items not necessarily the top of the line the physician specified on the prescription. Again, patients must be treated as consumers; the practitioner should explain the insurance company’s policy, and allow the patient to choose whether the superior product that might require more out-of-pocket expenses or that which is covered by their insurance will be best for their needs.
Conversely, there are times when an insurance policy will only cover a more expensive device. One national HMO will cover a hinged elastic knee orthosis, but not the less supportive, less expensive patellar stabilizer.
Occasionally, providers will make an exception to their policy or will reconsider an earlier decision when additional information or extenuating circumstances exist. The old adage about the squeaky wheel getting the grease is absolutely applicable here. Not only are certificates of medical necessity from the orthotic and prosthetic provider, the physician and therapists, becoming increasingly mandatory for consideration of coverage, but direct intervention patients can be even more effective.
If patients do not complain or confront the insurance company with the issue, the policy will not be altered. Inform patients of the problem, provide them with the necessary data and any contact people, and allow them to state their case to the insurance company.
Shrinking reimbursement levels coupled with an ever higher cost of doing business place the orthotic and prosthetic practitioner in a corner. “As reimbursements throughout the orthotic and prosthetic fields continue to decrease due to managed care and reduced utilization, it is crucial that orthotic and prosthetic practitioners not relax their attention to ethical billing practices as a way to prop up reimbursements of years past.”3
Competitive billing has lowered fee screens to the point where some products cannot be fit without a loss of revenue. The temptation exists for “up coding,” using a HCFA code or codes with a better reimbursement to make up for the deflated price of the proper code. Not only is this unethical, it may also be fraudulent.
The United States government has recently passed the Federal False Claims Act which prosecutes providers for fraudulent or abusive activity.4 Operation Restore Trust is investigating and prosecuting fraud in five important states: California, Florida, Illinois, New York and Texas. “These states make up 34 percent of the nation’s Medicare beneficiaries. In its first year, Operation Restore Trust has produced $42.3 million in restitution, fines, settlements and recovery of overpayments.”5 While little of these monies was from orthoses and prostheses, the public is increasingly having the perception that we in health care are generally an unscrupulous lot who need careful watching.
Education is the key to overcoming all of the difficulties now facing the orthotic and prosthetic reimbursement issue. It is critical to differentiate between cost and value. “The price-equals value assumption is damaging because it leads payers to believe the lowest-priced product or service saves money.”6 To demonstrate cost effectiveness, it will be necessary to have evidence of improved outcomes. “Unproven treatment plans, procedures and/or technology within the outcomes measures environment will not be selected nor reimbursed by health care payers.”7 We all must educate the patient, the physician and the third party payers in the value of quality health care, at an appropriate cost.
1. (1995, January). Medical Policy, Region Supplier Bulletin 95-01.
2. (1996, July 15). American Hospital Association Figures, O & P Business News.
3. Thomas, P. (1996, Aug. 15). O & P Business News.
4. (1996, July 15). American Hospital Association Figures, O & P Business News.
5. Vladeck, B. (1996, August). The beginning of an end to Medicare fraud and abuse. O & P Almanac.
6. Bostock, F. (1996, September). Outcomes measures: Threat or opportunity? O & P Almanac.
7. Bostock, F. (1996, September). Outcomes measures: Threat or opportunity? O & P Almanac.