The Dark Side of Parity

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By Jim DeWees, CP

Three years ago in Indiana, a group of amputees and prosthetists got together to battle for parity. Differing views and ideas were tossed around, along with some concerns. I had two concerns at the time. I felt the bill should specify that amputees would have the freedom to choose their prosthetist, as long as the prosthetist had a valid Medicare Provider ID number. This would prevent networks from dictating where the amputee must go for treatment. My other concern was about the bill's ramifications. Forcing insurance companies to do something always opens a way for them to dodge the demand.

The Indiana group developed the bill using the Amputee Coalition of America (ACA) template, then presented it to the state congress and senate. It passed in 2008 and went into law shortly thereafter. The new law specifies that O&P has to be covered on par with other benefits: maximum lifetime benefits equal to normal benefits, provision of the same benefits specified by Medicare guidelines, and reimbursement at least at Medicare's rates. But the bill also includes protection for the insurance companies: medical necessity is determined by the insurance company, which is already a battle, and they only have to pay contractual rates if the provider is "in network" (providers must be in network to get paid for the work).

Today, I am faced personally with the consequences of this parity law.

My individual insurance recently switched networks, and the new network has no medical providers in my area—no primary-care doctors, surgeons, pediatricians, therapists, prosthetists, or anyone else. I was forced to change insurance companies and thought that would be simple. However, since the insurance companies have been forced to pay for prosthetics on par with Medicare, they have changed their policies. I went to a local agent, we looked at one application, and among the questions about diabetes, pregnancy, and cancer, was the question, "Are you an amputee or use a prosthetic limb?" A "yes" answer meant rejection. We looked into five more companies, and they were all similar. The agent hadn't been aware of this new policy, but he finally found one company that would take my application but wants a "voluntary waiver" for prosthetic benefits. For me, that's okay because I make my own legs and never bill for them, but what about amputees who cannot make their own? I cannot support an insurance company that does this.

In eight years, I have had policies with three different companies and they never asked anything about amputation, and I never had a problem getting a good policy. But now that this parity law is in place, it seems that all insurance companies are doing this. I have patients with similar problems. One patient who had prosthetics benefits for several years no longer does—she received a letter stating that parity had passed, and for her to maintain her policy she had to voluntarily waive her O&P benefits. Of course, she had to do that or be faced with trying to find another policy.

If you think this must be illegal, you're wrong—I met with the Indiana Department of Insurance, and a representative told me it's both legal and commonly practiced.

I know this was not the intent of the parity bills, but this is the consequence. I fear that this will be similar to what is going on now at a national level, where the government thinks it can force insurance companies to do something, but the insurance companies change their policies and make matters worse. Forcing insurance to accept all pre-existing conditions sounds good on paper, but the insurance companies will charge prices that nobody could realistically afford, or they will offer coverage only if the patient voluntarily waives treatments for the pre-existing condition. In my situation, I will be forced to buy a policy or pay a fine ($2,250 for my adopted son is also an amputee and not insurable even though he is perfectly healthy). But what if I cannot find a policy to buy? There is nothing in the reform that addresses the behavior or practices that insurance companies are notorious for.

After this battle, I felt forced to keep my current policy and hope that they get some providers in my area.

The only reason I am not able to get insurance is parity. Anyone working on parity in their state today should think again about what they are really getting into.

Jim DeWees, CP, is the owner and president of the Prosthetic Center of Indiana, Bloomington, and founder and president of Prosthetic Limbs for the Dominican Republic, a 501(c) 3 organization.