Advocating for Ambulation

Encouraging patient involvement may be a key strategy for subverting a coverage crisis. It's natural. When economic times are tough, consumers hold on to their wallets a little more tightly, and business owners focus more on receiving payments for services rendered. But when the services rendered involve prosthetic care and patients have difficulty getting coverage for their devices, claims for payment are denied, or previously paid claims are lost through audits, it's a no-win situation for patient and prosthetist alike. Subverting these scenarios will involve extending the patient/prosthetist partnership beyond the walls of the prosthetics facility and the physician/ prosthetist relationship beyond the prosthetic prescription. The Amputee Coalition has found that an increasing number of aging baby boomers are less likely than previous generations to accept minimal levels of health insurance coverage or medical care, which bodes well for practitioners who are looking to get their patients more involved in the reimbursement process. Indeed, says Sue Stout , chief policy and programs officer at the Amputee Coalition, "I'm seeing consumers getting more engaged in the...reimbursement discussion-not just Medicare/Medicaid, but private insurance." While the group's active constituency leans more in the direction of private insurance than Medicare coverage, she notes that many of their more active consumer members report unsatisfactory experiences with private health insurance plans, which may limit coverage to one prosthesis per lifetime or put an unreasonably low monetary cap on prosthetic coverage. Tools for Patients "We have been spending quite a bit of time working on the issue of how best to assist consumers as they advocate for themselves with insurance companies as well as government programs for coverage of prosthetic devices," Stout says. "We are working to arm consumers with... information that empowers them to have a conversation with their doctor about making sure that they properly document the need for prosthetic devices in the medical record." To that end, the Amputee Coalition has created a "Dear Physician" letter, which is available for download on its website ( www.amputee-coalition.org/medicare doc/dr-medicare-letter-v2.pdf ). The letter describes the need for detailed notes and findings that must be included in the patient's medical records before the prosthetist provides the necessary prosthetic solution and submits a reimbursement claim to Medicare. The letter also notes the need for identifying the patient's functional or K-level and provides a list of the five K-levels and their descriptions. Stout says that the Dear Physician letter has been made available to the Amputee Coalition's network of more than 260 support groups and 1,000-plus peer visitors and lead advocates across the country. More than 500 people have accessed the letter on the Coalition's website since January 1, 2013, and she reports instances where it was successfully used to facilitate a positive outcome for the patient with his or her physician and prosthetist. "I think that's an excellent tool," notes Bruce "Mac" McClellan, CPO, LPO, FISPO, FAAOP , 2012-2013 president of the American Academy of Orthotists and Prosthetists (the Academy). "I firmly believe that patients are going to have to become much more aware and much more proactive about their prosthetic care and about the situation that our profession is being put in by these new enforcements by CMS [Centers for Medicare & Medicaid Services]." Bypassing the Medical Model Perhaps the level of patient involvement has contributed to the current industry audit crisis-and perhaps prosthetists are partially to blame for that, suggests Jeffrey Brandt, CPO , CEO and founder of Ability Prosthetics & Orthotics, headquartered in Gettysburg, Pennsylvania. "The problem is that we have established a pipeline of clientele in our industry, many of whom don't go to the physician regularly once they're an existing user. They develop a relationship with the orthotist or prosthetist, and over the years they are allowed to bypass the medical model, which requires the doctor to examine a patient who is having trouble with his aging prosthesis and...write the patient a prescription for a new prosthesis." Instead, many patients prefer to go directly to their prosthetists when they need replacement devices, and they have been allowed to do so, Brandt says. To address this issue, just over a year ago Ability began asking each incoming patient, "Have you recently been to your doctor? If not, you need to see him or her first." The patient is then given a data sheet with K-level reference information for his or her physician and is encouraged to act as a liaison between the prosthetist and physician by asking the physician to contact the prosthetist during or after the appointment, for example. "The sheet helps physicians to formulate a better note, Brandt explains, "so the case meets all required medical and payer standards." "The patient is an extremely important part of this," McClellan stresses. "They, for the most part, don't have any idea if a RAC [Recovery Audit Contractor] audit is being performed regarding their particular device. The interaction is between the prosthetic practice and the CMS contract auditor, and any money recouped comes from the prosthetic practice and not the patient, who maintains possession of their prosthesis. "Some practices are literally in danger of closing because of audit demands for [the] return of the entire amount billed for prostheses that patients are successfully using," McClellan continues. "Patients need to be educated about this crisis so they can be aware of the ramifications it could have upon them in the future. Otherwise, by the time they feel the pinch, it may be too late." He advises patients to learn more about orthotic and prosthetic parity legislation and also to look into the healthcare exchanges some states are setting up in response to the Affordable Care Act. "[Patients] need to be sure that prosthetics and orthotics are included in their state healthcare exchange. They can do this by contacting their state legislators." Roger Marzano, CPO, CPed, vice president of clinical services, marketing, and sales at Yanke Bionics, headquartered in Akron, Ohio, notes that patient coverage issues aren't limited to Medicare. "Private insurance that carries a Medicare buyout policy is also increasing scrutiny of claims," he says. "Humana, Medical Mutual, and others have also subjected us to various audits. Oftentimes, it's a post-payment audit; they paid us for it, but then we have to backtrack and jump through hoops-even for claims that aren't heavy, high-dollar prosthetic claims." The K-Level Conundrum The jury is still out about whether patient involvement can help to resolve these issues, but there are several benefits to educating patients about their K-levels-the chief of which involves optimizing patient progress. "Some patients like to have a goal for themselves. If we tell them what we can provide for them based on their function today, explaining their potential to become a K-3 level ambulator, it gives them a goal to strive for, not only physiologically, in their healthcare recuperation, but psychologically as well," Marzano says. The Coverage Crisis: Would Pre-authorization Help? The O&P EDGE asked industry leaders if pre-authorizations were a potential solution to the current frenzy of claims audits: Bruce "Mac" McClellan, CPO, LPO, FISPO, FAAOP: "On the surface, this might appear to be a good idea. In practice, what would happen if this turns out to be a really lengthy, drawn-out process? What would happen to new amputees who were waiting for their initial prosthesis or the long-term user who has either lost the fit of their prosthesis or had it broken beyond repair? Where would that leave these people? They could potentially be waiting for weeks or even months for authorization." Brian Kaluf, CP: "I think pre-authorizations would make things better for two reasons. Number one is because most of the time the clinical case can tolerate a time delay on the front end, and it puts everybody on the same page as far as making the clinical decision on which technology is appropriate for this patient. It also allows verification that it will be a reimbursed intervention, allowing the clinician to proceed with providing the highest level of care, and it relieves a lot of apprehension and financial risk to the individual clinic." Chris Lake, CPO, LPO, FAAOP: "Implementing a pre-authorization procedure would be pretty smart from a Medicare standpoint. I can't find a reason that it would be bad. We already go through a similar process with other third-party payers. Even though private insurers will often have a disclaimer that a favorable pre-authorization or pre-determination is not a guarantee of payment, at least the medical necessity is taken care of. At the end of the day, that's what the audits are or at least should be all about-the medical justification for a particular item." Roger Marzano, CPO, CPed: "I don't know that CMS [the Centers for Medicare & Medicaid Services] will do that because it's going to be a costly step...ultimately. Then they're going to be the deciding factor instead of the physician. So it would be no different than trying to get a knee brace or a stance control KAFO pre-certed through the insurance company now. Insurers barely do it; I can't imagine that you're going to get the granddaddy of all insurers-CMS-to do that." Yanke clinicians rely on a physical medicine and rehabilitation (PM&R) physician associated with its amputee clinic to assist them in evaluating function and assigning K-levels, which is becoming a tricky business and seems to be directly tied to prosthetic RAC audits. Coverage questions often hinge on K-level questions, so understanding the levels holds added significance for patients who are invested in their own care. "The industry is giving us more tools to better define our K-level classifications, which is a good thing, since it takes an hour to administer the amputee mobility predictor (AMP) test properly, and that's a lot for some amputees to undergo," Marzano says. "Since we began using that tool, we've...had to scale down some of our expectations or interpretations of the amputee's K-level." Brian Kaluf, CP, who works at the Ability patient care facility in Greenville, South Carolina, points out a large gray area, "especially between the K-2 and K-3 border, where a lot of patients are either being overprescribed or under-prescribed prosthetic technology," he says. "Both of those situations have adverse effects- either higher, unnecessary healthcare costs, or patient functional limitation because the K-level system can only view them in black and white." K-level misinterpretation can lead third-party payers to over-scrutinize clinical decisions made for individual patients who may fall into an overlapping gray area on the scale. "That makes it difficult to provide care as a clinician to patients with very unique...needs," Kaluf says. It also "makes it difficult for a third-party payer whose only measuring stick is a K-level system based on technology in the late 1970s or early '80s," he says. Brandt recalls that when the K-level system was developed, the word "potential" was added to each K-level descriptor. "The minute the word 'potential' appeared, it gave everybody a pathway to provide a K-3 level leg, although the patient might actually, at the time of that delivery, be a K-2," he says. "The sooner we get rid of the word 'potential' in these K-levels, the better off everybody is going to be. Medicare pays for two legs-a temporary limb and a definitive limb. So after running a new or existing amputee through a battery of baseline tests and outcomes measures that are all documented, we provide a temp to a new amputee, and then at incremental stages, we run them through the same tests. When we see a change in the K-level score, then we can justify going to the definitive leg." Brandt's outcomes-based practice collects research-grade clinical data on every patient encounter. Ability's clinicians administer the PEQ-MS (Prosthesis Evaluation Questionnaire-Mobility Section) to each prosthetics patient, along with other objective functional outcomes measures, to arrive at an assessment of the patient's K-level. "We give them a really nice printout of a report of where they stand functionally," Brandt notes. "It's motivational, and they are encouraged to share it with their physician, who often appreciates receiving four pages of outcomes data that he or she can slip into the [patient] chart-and that elevates us as providers." "We've got to be a lot more scientific and more concrete about our justifications for these K-levels," he adds. Marzano says it's helpful when a patient shares his or her prosthetist's K-level assessment with the physician. "You want to basically make a lobbyist of your patient because I think the overall power lies with the amputee themselves to change this situation. If enough amputees say, 'Doggone it, I'm not getting what I should be getting, and I'm not able to return to my fullest potential because the medical community doesn't understand how to classify my functional level. That alone shouldn't be enough to deny me coverage of a prosthesis!'" Tips for Upper-limb Prosthetics Coverage Since Lake Prosthetics & Research, Euless, Texas, focuses primarily on upper-limb prosthetics, Clinical Director Chris Lake, CPO, LPO, FAAOP , doesn't deal in K-levels, and there is no equivalent system to serve as a guideline, so getting coverage confirmed for a patient's prosthesis can be doubly challenging. But after nearly 20 years of practicing, he has developed a plan that he's used so often-and that works so well-his success rate in gaining approvals is close to 100 percent. Lake's plan consists of four steps: State clearly and immediately in all documents that the objective is to empower the individual to approximate as closely as possible and feasible the pre-amputation functional level. Create a prototype fitting and let the patient wear a temporary prosthesis at home, on the job, and in physical and occupational therapy. Each patient thus becomes a single-patient case study—a representative of evidence-based practice. Demonstrate why the patient needs a particular device. Lake fits a patient with a socket and adaptations that allow him or her to use a passive hand, a body-powered hook, and a myoelectric hand, then videotapes the patient going through his or her day. Through this process, it becomes clear, Lake says, how the patient is able to use better body mechanics with one prosthesis over the others. Network with your physicians whenever possible. "Talk to them and work with them at clinics or screenings of patients," he advises. "We're all learning what physicians need to document in their notes," he continues. "When it comes down to it, it's the practitioner's responsibility to work intimately with their core doctors so that they understand why the patient needs a particular device. This in turn helps the physician document in a manner that meets the expectation of the third-party payer." The Power of Patient Involvement In addition to following these four steps, Lake says that patient involvement contributes materially to his high success rate in gaining coverage for appropriate devices. "All the patients are involved to some level, whether advising their employer's HR [human resource] department that they need a particular prosthesis, writing a letter confirming what the device has accomplished for them, or providing an in-person demonstration in front of an ALJ [administrative law judge] or review board, testifying to the necessity and effectiveness of the prosthesis in their life." John Tyo, CP, BOCP , director of Syracuse Prosthetic Center, New York, can personally attest to the value of high-level patient involvement. At the American Orthotic & Prosthetic Association (AOPA) mid-March Policy Forum in Washington DC, Tyo seized the opportunity to make a powerful case against a RAC audit focused on a prosthesis Tyo provided to Jim, a 70-year-old patient who has a transfemoral amputation as the result of a traumatic accident 38 years ago. An active outdoorsman and respected community leader, Jim is a K-4 level patient whom Tyo successfully fit with a microprocessor knee three years ago. Documentation provided by the physician was deemed unconvincing, even after four levels of appeal. Because returning the payment for this and several other audited items would have amounted to more than $200,000, Tyo took his case, and Jim, to the offices of several lawmakers so that the quality of his work could speak for itself-both literally and figuratively. To reach the congressional offices, Jim navigated the subway system, pedestrian traffic, multiple stairways, and miles of hallways. "If he had any other type of prosthesis," Tyo informed congressional staffers, "he would not have been able to get here. He either would have fallen and hurt himself or he would have had to stop long before he got here. This device is what he absolutely has to have to function." "It was clear and evident," Tyo says, "and they listened." Resolution of his case is pending, and Tyo is hopeful that congressional intervention inspired by Jim's presence will make a difference. Don DeBolt , chief operating officer at AOPA, agrees that direct public policy advocacy in collaboration with practitioners is where patients can have real impact. While he says that patients should always try to get the physician to provide the needed documentation to the O&P practitioner, he adds, "Patient involvement directed at the physician has had mixed results as physicians tend to resent the need to fill out more forms, regardless. They do not get paid to fill out forms or provide additional documentation for a third party's payment. One physician's office sent an AOPA member a fax saying, 'Don't bother sending these requests for more documentation. We just trash them.'" Instead, he suggests that involved patients reach out directly to their legislators by writing letters and sharing their stories. "Encourage patients to visit the district or Washington offices of their representatives and senators, come to AOPA's Policy Forum, and talk to local media when they are being denied proper care because of a RAC audit or other government interference delaying their care." Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.

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