When I lost my leg in 1996, everything old became new again. Getting out of bed in the middle of the night presented new challenges. Getting dressed in the morning suddenly required thought and planning. And walking, one of the most basic and simplest human activities, now demanded intense attention.
Every prosthetist in the United States should be able to relate to that experience. Because in the last 18 months, everything old and reliable has become new and undependable.
color by numbers
When I owned my own prosthetic facility, the process of providing a patient a prosthesis presented few challenges. I could file a claim with Medicare and other payors and predict the likely outcome with 90% certainty. I knew which claims would get paid and which would get denied. I could even predict the likely basis for denial in most instances.
I left the patient care side of prosthetics in late 2006 to work for a prosthetic component manufacturer, but the basic model for filing claims remained the same. The prosthetist examined the patient and recorded his findings. Those findings got incorporated into a letter of medical necessity that the prosthetist sent to the patient’s doctor. That letter detailed the patient’s condition and her need for a new socket, knee, foot, liner, or a new prosthesis entirely. The doctor would write the requested prescription and the prosthetist would then file the claim.
So long as you established the medical necessity of the prescribed device, Medicare would pay you. Private payors were nearly as predictable.
Medicare rarely audited claims. Private payers did so even less. Until everything changed.
In August 2011, the Office of the Inspector General issued a report on lower limb prosthetics. OIG’s concluded that Medicare erroneously paid $97M in prosthetic claims, or roughly 16% of the total annual Medicare spend on these devices. (Many in the O&P industry dispute OIG’s conclusions. However, what no one can contest is that this report shaped the federal government’s perception of prosthetic claims.)
Almost simultaneously, each of the four contractors hired by Medicare to process claims in different regions of the United States issued “Dear Physician” letters. These letters required doctors to record specific patient information in their medical records. They included a list of desired clinical findings stretching across 14 bullet points. The contractors noted that these clinical criteria were by no means exhaustive.
Next, Medicare’s auditing contractors swung into action. These Recovery Auditors started reviewing old claims, sometimes looking back as far as three years while applying the standards set forth in the Dear Physician letters retroactively. Since the vast majority of claims filed before the Dear Physician letters lacked that level of documentation – especially in the prescribing physician’s medical records – the RA’s ruled that they didn’t comply with Medicare’s requirements and demanded immediate repayment from prosthetists.
On top of retroactive audits, the same contractors that had issued the Dear Physician letters began launching “widespread prepayment claim reviews.” Focusing on the documentation supporting particular types of claims – generally those that involved the delivery of higher-cost prosthetics – these reviews occur after the prosthetist delivers the prosthesis but before Medicare pays the claim.
By the end of 2012, the limited evidence available suggested that audits had become the rule, not the exception for O&P businesses. An American Orthotic and Prosthetic Association survey of its membership last fall revealed that more than 75% of the prosthetic facilities in the United States were fighting at least one audit.
In a little more than 12 months, filing a Medicare claim had gone from color by numbers to the equivalent of trying to replicate a Salvador Dali painting, stroke for stroke … for every claim.
what’s old is new again
In my current role, I get to speak to prosthetists around the United States about the state of the prosthetics profession. I present my vision of how to navigate the claims process successfully. It’s one of my favorite parts of the job. I’ve delivered countless talks at national conferences, at local events, and at seminars over the past 24 months.
The tenor and content (and title) of these talks have changed dramatically since I began delivering them in February 2011. The ideas I presented that seemed like overkill then receive a very different reception now.
Prosthetists express dismay, anger, sadness and frustration in equal parts when talking about how a process they understood and depended on changed so quickly. As I watch and listen to them describe these sudden and profound shifts, I can’t help but think about the hundreds of new amputee consultations I participated in when I still owned my facility.
I would shake my head sympathetically as people described how their life had taken this inexplicable turn, how everything they knew and understood had become alien. I would reassure them. I told them, based upon my own personal experience and conviction, that someday – I couldn’t tell them when, but someday – they would wake up and the act of putting on a prosthesis and walking with it would be a natural part of their lives.
It’s hard to overstate how much the claims process has changed in just over a year. I can shake my head sympathetically as I talk with these small business owners. I can offer my thoughts about how to successfully operate a company in this environment. And I can tell them that as they improve their internal systems and shore up their claim processes, what they see as inefficient and mechanical today will become second nature tomorrow.
It used to be that patients and prosthetists shared an experience that revolved around the patients’ rehabilitation. Now they also share the experience of having to relearn everything they took for granted.
The prosthetists who figure out how to rehabilitate their businesses quickest will have a decided advantage over those who can’t. The difference is that you can measure a patients’ success by how many steps they take or how dextrous they are with their prosthetic hands and fingers. We’ll be measuring a prosthetist’s success by how many are still operating in 2014.