Where Ethics and Economics Meet

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By Miki Fairley

Balancing Patient Needs with Reimbursement
Challenges and Other Ethical Dilemmas

gears and compass

In the course of daily patient care and running businesses, O&P practitioners and business owners confront myriad ethical dilemmas and decisions, some of which are easily navigated, and some with more obscure paths. Most people have a moral compass, or conscience, that guides them in making ethical decisions, but how can you be sure your moral compass is pointing north as you travel down the path of modern O&P care, fraught with reimbursement challenges, patient requests for specific products, and referral pressures? The O&P EDGE asked several O&P professionals for their perspective on this issue.

Reimbursement Challenges

The O&P profession is recognized as a caring profession, but reimbursement issues can present dilemmas as the realities of business finance meet a sense of ethical obligation to help patients. If a patient comes to you for an O&P service but has insufficient resources to obtain the device, is it ethical to turn the patient away? If your business is not financially able to absorb the cost of helping, is that decision unethical? If the business is in a position to help, but doesn't, is it unethical? If you decide to help in those scenarios, how do you decide which patients to help and how much you will do? Is it ethical to help one patient if you cannot help others? What factors should you take into account if you provide a device at cost (labor and materials), less than cost, or even pro bono?

Gary M. Berke, MS, CP, FAAOP, owner of Berke Prosthetics, Redwood City, California, and adjunct clinical assistant professor at Stanford University, California, summed up factors to consider, such as "the patient and family situation, cost of the components, the business and marketing situation, as well as the time needed and difficulty of the case."

"In hardship cases, we consider patients' needs on a caseby- case basis because there are so many variables involved," says Drew Buffat, CP, director of prosthetics, De La Torre Orthotics and Prosthetics, Pittsburgh, Pennsylvania. "This is more of an issue in prosthetics, since prostheses are so much more expensive than orthoses. [The patient's] co-pay is going to be so much higher. We consider their financial situation and consider payment plans or taking off a percentage of the cost. We figure what the component will cost us and try to at least cover our cost."

It's up to every business owner to make those decisions, says Andreas Kannenberg, PhD, MD, executive medical director North America, Ottobock, Minneapolis, Minnesota. He recommends that business owners set limits that reflect their ability and willingness as to how much at-cost, discounted, or pro bono work they do. "There is no one ethical answer; everyone has to decide for himself or herself."

Sometimes what's best for the patient and what's best for the business happily coincide. "Particularly in prosthetics, many of our patient relationships can become very long term," Phil Stevens, MEd, CPO, FAAOP, Hanger Clinic, Salt Lake City, Utah, points out. A patient might be between insurance coverages or waiting for Medicare eligibility. "Providing free or discounted services to this patient in the short term may help create a relationship that allows you to provide covered care for that patient in the long term," he says. "In situations like this, the discounted care can be seen as a longer-term investment. However, if a patient is uninsured and remains uninsured, you can create the expectation that you'll help him again."

What would you do if...

  • You disagree with the physician's prescription and believe a higher- or lower-level or simply different device would better meet the patient's functional needs?
  • A patient has no apparent medical or functional need for an orthotic device, although he or she feels a need for it, has a physician's prescription for it, and is willing to pay out of pocket for it? (Editor's note: This situation confronted Matt Wegmann, a board-eligible orthotist who recently completed his residency at Metropolitan Orthotic Laboratory, Minneapolis, Minnesota. Wegmann discusses this case in the accompanying article, "Orthotic Intervention for Those without Physical Limitations-An Ethical Perspective.")
  • The patient's functional level clearly indicates a high-tech prosthesis is optimal, and the physician trusts your judgment, yet you're fairly certain the insurance company will deny the claim and you don't really want to go through the time and hassle of fighting the denial?
  • A patient doesn't need a particular high-tech device, but he or she demands it, is willing to pay the difference between the device cost and what insurance will pay, and has a prescription for that level of device?
  • A large hospital or medical group pressures you to change the date of service for an orthosis or prosthesis in violation of Medicare rules or insurance contract provisions so that Medicare or the private insurer pays you directly even though the healthcare entity's reimbursement already includes the device cost? Although the ethical and legal answer is obvious, what if the hospital or medical group threatens to stop sending you referrals if you don't succumb? What if its referrals constitute the majority of your patients and losing its business may mean laying off employees who depend on their paychecks?

Stevens adds, "If you're not the owner or manager of the facility, you need to go to your supervisor and explain what you'd like to do for that patient and why, and let them make that decision. The cost of your actions is not coming out of your salary, so it's really not your decision to make."

"Our first concern shouldn't be about if we're going to get paid, but rather what is right for the patient," says D. Scott Williamson, MBA, CAE, president, Quality Outcomes, Fredericksburg, Virginia. "Ask yourself, 'How can I make this work for the patient?' Then consider your options regarding providing components and labor at cost, no charge, or discounted." The patient can be directed to charitable organizations and community resources that may help. The value of favorable media publicity when a company provides O&P care at low or no cost to a patient should not be overlooked either. Not only may this bring in new patients, but the company's reputation is enhanced as a caring, giving part of the community, elevating the O&P profession as a whole.

Doing Well, Doing Good

Ethics and economics converge for independent O&P practitioners when they run their businesses efficiently and profitably. "One of the great things about being independent is that you have the flexibility to make the right decision for the patient, even if it's not in your financial best interest," Williamson says. "I like the saying, 'You have to do well in order to do good.' Doing well in your business enables you to do good [for] the people who you feel really deserve it."

ethics compass

Laying an Ethical Foundation

The codes of professional conduct or canons of ethics for O&P professional organizations provide a foundation for making ethical judgments. The American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) Code of Professional Responsibility is also the standard for the American Academy of Orthotists and Prosthetists (the Academy) and the National Commission on Orthotic and Prosthetic Education (NCOPE). To view the document, visit www.abcop.org/about/Pages/ProfessionalDiscipline.aspx. The Board of Certification/Accreditation (BOC) has a Code of Ethics, which can be accessed at www.bocusa.org/downloads, and the U.S. National Member Society of the International Society for Prosthetics and Orthotics (US ISPO) has a Code of Conduct for Humanitarian Organizations, which can be accessed at www.usispo.org/code.asp. The American Orthotic & Prosthetic Association (AOPA) Code of Interactions with Healthcare Professionals encompasses ethics O&P companies should abide by in their interactions with healthcare professionals and entities. To view this document, visit www.aopanet.org, click on "Resources" in the toolbar, and then click on "Resources" in the drop-down menu that opens.

The patient's right to choose or refuse a treatment option also impacts ethical decision making. "Patient-centered care is driven in part by the ethical principle of autonomy and considers patients' cultural traditions, personal preferences, values, family situations, and lifestyles," points out an article in the Journal of Healthcare Risk Management  titled, "Ethics, Risk, and Patient-Centered Care: How Collaboration between Clinical Ethicists and Risk Management Leads to Respectful Patient Care" (Vol. 31 (1):32-7, 2011).

Other Ethical Issues Arise

Helping patients who have insufficient insurance or other financial resources is only one of many ethical dilemmas confronting O&P professionals and practice owners. To gain insight into factors to consider in ethical decision making, The O&P EDGE  discussed various scenarios with the interviewees, covering areas such as those that follow.

Prescription Dilemmas

When the O&P clinician disagrees with the physician's prescription, good communication usually resolves the issue, according to the interviewees.

"When the physiatrist, physical therapist, and prosthetist or orthotist are together in a clinical setting, it's easier to discuss the best solution for the patient," says Joyce Perrone, a consultant with Promise Consulting and director of business development for De La Torre Orthotics and Prosthetics. "If a prescription comes to our office and we disagree with it, we make our case to the medical practice. If they agree and issue a new, changed prescription, and put reasons for the change in their notes, then we are covered."

"Most referring physicians expect you to be the subject matter expert and appreciate it when you fill that role," says Stevens. Prosthetic prescriptions tend to fall into two categories, generic and detailed, he notes. The generic prescription is the most frequent; the physician relies mainly on the prosthetist's judgment. Detailed prescriptions often come from physicians with a strong interest in prosthetics. "As a result, they are very interested and open to a conversation about the patient. Communication is obviously the key."

Berke recommends arranging a brief meeting or phone call with the physician to gain a better understanding of his or her reasoning for the prescription. "Often I find that the physician or surgeon was not aware of the nuances of the case and is willing to work with us on the appropriate prescription recommendation."

Prescription Doesn't Fit K-Level

Buffat recalls a case in which the prosthetist felt the patient presented with a K2 level based on his functional ability, but the physician had prescribed a K3-level foot since the patient was a hunter and outdoorsman. The prosthetic team didn't think it could justify a K3 foot to the insurance company; however, the patient wanted a particular high-end foot and the physician was hard-pressed to say no. "We had to discuss some of the tests, such as the AMPPRO/AMPnoPRO [Amputee Mobility Predictor, with and without prosthesis] and other factors we rely on to justify a particular K-level," Buffat says. The healthcare team and patient agreed to use a K2 foot and then reevaluate the patient in six months to see if he was achieving the potential to use a K3 energy-storing multiaxial foot, a goal the patient accomplished.

De La Torre also has had experience with a K-level and prescription mismatch, such as a K3-level ambulator with a prescription for a SACH or other basic foot. The prosthetist approached the situation by talking with the physician about why a higher-end foot would be the better solution. "The relationship with the physician is really the key," Buffat says.

"The fact that a patient or referring physician saw the component in a magazine article doesn't mean it's the most appropriate thing for that individual," Stevens points out. "However, folks who come in requesting a certain component often want to be educated on what's out there." Explaining that a patient needs to reach a certain functional level before a particular component is indicated gives them a goal to work toward, he says, adding, "I've found there's a big difference between saying, 'This is not right for you' and 'This is not right for you yet.'"

Device Necessity Not Justified

Rarely, a patient may present with no discernible functional challenge but feels a need for an orthotic intervention and has a physician's prescription. More common is the patient who demands a higher-tech device than his or her functional level warrants, is willing to pay additional costs out of pocket, and has a prescription. Do you provide the desired device? The professionals we interviewed generally agreed that providing the device isn't unethical as long as it won't harm the patient and the patient is fully informed about why the O&P practitioner feels the device is unnecessary or inappropriate. "We want to engage the patient in their treatment and give them confidence in their daily activities," Williamson says. "If [the device] makes the patient feel better and more functional, aren't we helping the patient?"

Cosmetic and specialized prostheses present another challenge since they often are not, strictly speaking, medically necessary, and therefore not reimbursable. Buffat explains that for insurance to pay for these types of components or devices, he has had to build a case around function. Perrone adds, however, that claims based on cosmetic and psychosocial benefits may, on occasion, be paid in workers compensation cases. Buffat cites the case of a patient with a transmetatarsal amputation using a traditional toe filler and footplate that was causing problems. Buffat says they focused on function to justify reimbursement. "The patient was requesting a higher-end device to solve not only comfort and cosmetic issues but also to provide the function he needed for push-off through toe-off through the metatarsal joint."

Payer Pressures Can Test Ethics

"We're under pressure constantly to bill Medicare or the insurance company directly rather than the hospital or nursing home when Medicare rules and some insurance contracts specify that the hospital or nursing home is indeed responsible for paying us," Perrone says. "These systems push back; nobody wants to pay for the item," she adds, noting that an O&P practice lost referrals from a large physician group over this very issue. Some other providers of durable medical equipment (DME) or O&P may supply O&P devices to the hospital or nursing home, saying that they will bill Medicare or the private insurer when actually the hospital or nursing home is legally or contractually obligated to pay the O&P provider instead, Perrone explains. "Then, when we bill them directly and appropriately, they think we made an error."

Medicare reimburses hospitals, rehabilitation facilities, and Medicare Part A-covered skilled nursing facilities under a prospective payment system (PPS) that includes medically necessary O&P devices, whether or not the facility provides them through its own resources or through an outside supplier; thus the O&P provider doesn't bill the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) since the device cost has already been reimbursed.

An exception is the "two-day rule," under which the O&P provider can bill the DME MAC directly when the device is delivered within the 48-hour period before the patient's anticipated discharge home and is being delivered only for training in use and care of the device.

solutions compass

However, the online Jurisdiction D DME MAC Supplier Manual warns, "A facility may not, through a stratagem of relying upon a supplier to furnish such items, improperly shift its costs for furnishing medically necessary items to a beneficiary who is a resident in the facility to Medicare Part B. Nevertheless, beginning two days before the beneficiary's discharge, a facility may take reasonable actions to permit a supplier to fit or train the beneficiary with the medically necessary item that is for subsequent use in the beneficiary's home." (www.noridianmedicare.com/dme/news/manual/chapter5.html)

There are strict guidelines that people will play fast and loose with, and a company may lose referrals if another company says it will go with a different date of service to have the insurance carrier pay for the device, Perrone says. "I'm in the hot seat frequently to handle audits; I'd rather lose a doctor than pay a lot of damages. So you find yourself fighting these battles, and when it comes to ethics, it's not always black and white. But you have to pass the "sniff test" [accuracy, reasonableness, or moral rightness of something], and if you feel it's going to be wrong, you can't do it."

Again, ethics and economics can meet on this issue. "We need to position our businesses strategically so that our market basket is not concentrated on one source," Williamson says. "With multiple referral sources, it's harder for a referral source to twist your arm."

EMRs-Watch That Code!

Electronic medical records (EMRs) pose another potential pitfall. In generating prescriptions, the records often include a Healthcare Common Procedure Coding System (HCPCS) code that must match the device provided. However, the prescribing physician may use a different code than the one the O&P provider would use. Perrone warns, "If someone thinks, 'Well, this code pays a lot more' and so they use the printed code, the device won't match and is not going to pass an audit." The O&P provider can't simply change the electronic medical record (EMR) code; he or she must contact the physician to change the code and amend the prescription, she explains. "It's been a lot of work for us lately; the electronic world has added a whole new level of complexity."

Strong Ethics, Good Business

Ethical practice is sound business, as various business writers and researchers have noted. Although the ethically wrong choice can produce a short-term gain, it can be a long-term loss. For example, the Institute of Business Ethics research has found that companies that train their staff in ethical standards financially outperform those that do not (Does Business Ethics Pay? 2004 and Does Business Ethics Pay?-Revisited 2007). Ethical companies prosper more in the long run by earning respect and trust of consumers and other business entities, thus gaining more business. Based on practitioner perspectives and organizations' codes, the "north" of the O&P moral compass is "Do what is best for the patient as fully as you can under whatever circumstances you encounter."

Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at

Editor's note: The views expressed in this article are those of the individuals interviewed only and do not represent the position of The O&P EDGE. This article is not intended to be prescriptive in nature but to spark dialog about the topic of ethics in O&P.