Making the Reimbursement Case for Advanced Lower-limb Technology

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By Maria St. Louis-Sanchez

With a smart approach, getting third-party reimbursement for advanced lower-limb technology in this challenging healthcare landscape is possible, although practitioners may need to fight for their patients, according to the experts The O&P EDGE interviewed.

The strategy begins with the recognition that the game has changed and that the effort of making the case for fitting advanced technology is essential. "Some 15-20 years ago, it was so easy for prosthetists and orthotists to do business with insurance companies," says Andreas Kannenberg, MD, PhD, executive medical director for Ottobock North America, Austin, Texas. "No one really asked for documentation and justification, and many of the business owners are at an age where they well remember the good old days when everything was so easy."

With Medicare audits and crackdowns on spending, prosthetists have a tougher time now getting even standard devices reimbursed. Making the case for advanced lower-limb technology—and the growing price tag that comes with it—is going to be a challenge. However, it's a challenge that O&P practitioners need to accept for the patients who would benefit most, the experts say. "

If people can't access the most medically appropriate technology, then you will have patients who are inherently limited," says David McGill, JD, vice president of reimbursement and compliance for Össur Americas, Foothill Ranch, California. "The long-term effects to society and the individual are hard to calculate, but I can tell you that they are profound."

BE PREPARED FOR A FIGHT 

O&P practitioners know from experience or research studies that advanced technological components can improve the safety and functional outcomes for many of their patients. 

"A lot of the newer technologies like the microprocessor knees and feet, they open the door to quality of life," says Sam Brouillette CP, CFo, a member of the clinical services team at SPS, Alpharetta, Georgia. "They help anywhere from security and stability to improved socket comfort."

But knowing this information and getting third-party reimbursement for these devices are two different things. 

"If you focus on just providing the best quality care to every patient— and you do that in a vacuum without considering the insurance side—you will have really happy patients and, unfortunately, be out of business in six months," McGill says. "There has to be a balance. You have to design your business so that you consider not just the clinical side, but the effects of different payer coverage policies on the claim side as well."

 Getting claims reimbursed, especially for advanced technological componentry, is harder than ever, the experts say. First, as devices become more advanced, they also become much more expensive, which may make a payer wary. Second, as Medicare audits became more commonplace, insurers also became more likely to scrutinize claims on the front end, making the overall reimbursement process take much longer. The result of this healthcare landscape is that some patients are fitted with devices that may be less than ideal because they are the fastest—but not the best—solution, McGill says.

Instead, McGill says, when prosthetists know their patients could benefit from more complex devices that insurers are more inclined to deny, they need to take a different approach from the start. 

"They need to say, ‘I'm not going to do the thing that gets my claim approved the fastest; I'm going to document everything to get my patient approved for this device and fight like heck for it,'" McGill says. "Thinking about the problem that way and working from the ideal claims outcome backward is better than starting with concessions and working forward."

Of course, high-tech solutions are not suitable for all patients. The highest likelihood of successful claim reimbursement is when prosthetists choose the patients who would benefit the most from the technology and who are willing to be patient and work alongside the practitioners, says Brian Kaluf, BES, CP, clinical outcome and research director for Ability Prosthetics & Orthotics, headquartered in Exton, Pennsylvania.

"If the patient is not willing to participate and be involved in the appeals process, they might not be invested in their own care enough to see it through," he says. "They may be dejected by the long wait time and be frustrated and ultimately become dissatisfied with their care." For those willing to take on the fight, the experts say, O&P practitioners need to be prepared.

WRITE A BULLETPROOF CLAIM FOCUSED ON THE PATIENT

It sounds easy: Prosthetists need to write claims that focus on their patients and explain why the technology would be best for them. Unfortunately, many prosthetists do not do this, the experts say. Some cut corners at the beginning of the fitting process and do not document as much as they should. Then, when the claim is rejected, they don't have the information they need for a good appeal.

"Do I want to try to shortcut at the beginning and hope the claim goes through and then have to backfill, or do I want to spend much more time up front to make sure the claim is bulletproof?" asks McGill. "The chance of success is ultimately higher if I just do it right the first time."

Ironically, the most successful claims with the quickest reimbursement turnaround for high-tech devices do not focus on the devices. Instead, they focus on the patient's needs, says Kannenberg. Too many times, he says, he has seen prosthetists get so excited about high-tech prostheses that they forget to include the information payers need to know to make decisions— the conditions and needs that the patient has and why he or she would benefit from the requested device.

"What I often see in their statements of medical necessity is that they spend a great deal of time and text explaining how the fancy technology works, while sometimes the patient is just mentioned by name and social security number," he says. "It's all centered around technology."

He likens it to a person shopping for a truck that could tow a boat but instead of answering the essential question for the customer, the dealer explains how a combustion engine works. "

That is not the information I need to make a buying decision," he says. "That is the biggest challenge for prosthetists and orthotists—to provide the information the insurance companies really need to make their decisions."

By focusing on the novel technology, prosthetists are making their claims more likely to get rejected because it might still be considered experimental, says Kaluf. Many times, marketing language from manufacturers makes devices sound as innovative and distinct as possible, when insurance companies want proven devices.

"You'd think that you want something to sound as flashy and novel as possible," Kaluf says. "But when they are submitting a claim and describe the device as whiz-bang and make it sound like it solves everything for every patient, it's not believable. It's marketing fluff.

" Instead, he says, it's better for the claim to be as direct as possible. "Focus on the specific functional need of the patient, highlight how the advanced technology fulfills that specific functional need, and how no other technology can provide that," Kaluf says. "It's more boring and tedious to do that, but it's also more likely to succeed."

The experts say the practitioners should be documenting everything and backing up their documentation with research. From the beginning, they should be testing gait and how a patient handles slopes so they can use that information later if need be. If possible, test the patient with similar devices on loan to help prove that he or she can benefit from the specific componentry. If, for example, a patient with a transtibial amputation has a history of falling, the practitioner should reference studies in the documentation and justification that show how microprocessor componentry in the knees and ankles can help decrease fall risk. This makes the claim stronger and builds documentation in case the claim must be appealed in the future.

"When you file an appeal, you cannot provide information that is completely different than what you provided the first time," says Kannenberg. "It all starts with your first entry in your own record."

USE RESEARCH TO STRENGTHEN CLAIMS

Practitioners can prepare for claims that insurance companies will initially reject and why they will reject them. Payer policies spell out exactly what they pay for and, buried deep inside, they cite justification for their decisions to label technology experimental or investigational by using research that backs up their arguments. O&P practitioners can submit stronger claims by providing newer research than that which payers are using for their decisions and that backs up practitioners' positions about how the technology can help specific patients.

In many cases, the experts say, payers are using outdated research that is easy to challenge.

"We know what the insurance companies think," McGill says. "They are giving us the blueprint to beat them."

Trying to figure out what research every payer relies on for their decisions sounds more daunting than it is, McGill says. Most payers adopt different versions of the same policies, and many of those are built on Medicare's Local Coverage Determination (LCD) for Lower Limb Prostheses. Practitioners just need to know a few arguments that come up repeatedly, he says.

"You don't have to learn arguments for 200 different payers. You will see variations on the same four to five themes across the board," he says. To help practitioners find the research they need, he's created a large index of clinical research and articles—it currently stands at more than 400 items—that is publicly available for free download at www.ampdpod.com, a website for the limb loss/difference community that he and his podcasting cohost, Peggy Chenoweth, created.

Brouillette says the LCD is a big help for understanding the research insurers are looking for. "Read the LCD," he says. "It…gives us a huge portion of our documentation requirements. It says what is covered, and when, and everything else that follows."

Solid research that proves the technology works does not have to come from outside sources, Kaluf says. Ability Prosthetics & Orthotics has a database of outcome measures for all its patients. "We have a database to show the ultimate outcome for that particular technology, and that is a huge advantage," he says. "We can show, after the fact, how that patient is doing, and we can use the performance of one patient to help make the case for another."

Kaluf says keeping track of patients and their outcomes should be standard practice. "Some people think that having a database and performance measures is research, but if you look at healthcare today, having data is commonplace," he says. "You really can't say you are providing a high level of care unless you are tracing patient outcomes and are able to report on those."

DEVELOP EXPERTISE IN DOCUMENTATION OR HIRE AN EXPERT

Employees who know how to document claims well and write effective appeal letters are invaluable to modern O&P practices. These employees are especially important to getting highcost claims approved.

McGill says practices should have employees who specialize in highend claims and appeals. "If you can dedicate one person to write all of the appeals, and they take that job seriously, then over time they will do it much faster than other employees and will develop a process and will become an expert," he says.

McGill says employees don't have to be lawyers to write effective appeals. "They don't have to have specific training other than their fervent belief that patients should have the best access to technology," he says. "All you need is someone who wants to advocate for your patients in a focused way and be able to express thoughts clearly. Anyone can learn to do that."

Claims experts should also be focused on details and getting everything perfect. If, for example, a claim has information that contradicts information in the physician's record, the insurance company will always side with the physician, Kannenberg says.

"They will always consider the physician's record more reliable because they consider the physician not to have a financial stake in the game," he says. Kannenberg once saw a claim where an orthotist was trying to get reimbursed for high-end componentry when the neurologist had prescribed devices that were simpler and less expensive. "That could have been easily resolved, and upon discussion, the neurologist could have changed the prescription," he says. But the claim writer did not notice the discrepancy and it was ultimately rejected.

If you do not have the expertise on staff, there are still options.

"Some companies use third-party billing experts who amass a lot of expertise," McGill says. There are even contractors who specialize in writing claims and appeals, he says. "There are a lot of different ways to get there, and there's no perfect solution," McGill says. "It's a matter of what's right for your business."

BE PREPARED FOR REJECTION

If the initial claim is rejected, don't despair, the experts say. It should be expected in some cases.

"With private insurance companies, we are looking for a reasonable outcome from an unreasonable source," Brouillette says.

Prosthetists should be planning for an appeal on more complex devices when they first start treating the patient, says McGill. They should be building the case for an external review in all their documentation.

"You should always assume the worst-case scenario when filing a claim on higher technology devices and be prepared to receive a denial and go to an external review. If you get approved earlier than that, great, but recognize that an external review is likely the only place where you will get a fair shake on your claims," he says.

McGill believes insurance companies plan for practitioners to give up. "They are applying a medical policy that is designed to act as a barrier and are assuming that the vast majority of people won't appeal, and they are right," he says. Instead practitioners should view the initial rejection as one of the first steps to final approval. If the practitioner has a solid claim that focuses on the patient and is backed by research, he or she has a fighting chance of getting the technology reimbursed.

"When you get information together properly, when you are able to get someone not connected to the payer to review [the claim], and you fight like heck for it, you're successful more often than not," McGill says.

Maria St. Louis-Sanchez can be contacted at msantray@yahoo.com.