The American Orthotic & Prosthetic Association (AOPA) has issued a response to the recent Associated Press (AP) report regarding the 58 percent increase in total Medicare-allowed services for prosthetic feet and additions to prosthetic feet that were paid out in 2010 as compared to 2005.
According to research conducted by for the AP by Avalere Health (Avalere), Washington DC, Medicare paid $94.2 million for prosthetic feet in 2010, which was about $34.5 million more than in 2005, even though in 2010 Medicare covered 1,866 fewer such prostheses. Avalere, an advisory company focused on healthcare business strategy and public policy, looked at Medicare spending on 13 different L-Codes that Medicare covers for prosthetic feet and additions to prosthetic feet. The AP said the data shows a substantial increase in spending due to Medicare beneficiaries receiving more costly and sophisticated prostheses. The L-Codes that had the most significant increases between 2005 and 2010 are L-5981 – all lower extremity prostheses, flex-walk system or equal; and L-5987 – all lower extremity prosthesis, shank foot system with vertical loading pylon. In 2005, L-5981 showed 7,265 total Medicare allowed services, compared to 11,345 in 2010; L-5987 showed 1,636 total Medicare allowed services as compared to 4,626 in 2010.
Thomas Fise, JD, AOPA executive director, and Thomas DiBello, CO, FAAOP, AOPA board president, were contacted by the AP reporter prior to the AP report, and they spoke with him for about an hour, said Fise in the February 16 AOPA Insider newsletter. Despite that conversation and information they provided to the contrary, Fise said the reporter made it appear that all Medicare beneficiaries of prosthetic feet have had diabetes-related amputations. He also said the reporter ignored the 12 percent increase in the O&P collective fee schedule for the cost of identical services during that five-year period.
AOPA has also issued the “talking points” listed below to educate and/or help O&P professionals field questions regarding the AP report.
- Technological advances in prostheses have been fueled by the wounded warriors returning from Iraq and Afghanistan, which in turn has generated improvements in care.
- No prosthesis is delivered to a patient unless there is a physician prescription and a detailed plan, signed by the physician, outlining the patient’s specific needs and the device components to meet those needs.
- K-level is established by the physician.
- There are patients who have potential to improve their mobility significantly, and can become more independent and self-reliant, which is distinct from their athleticism or employment demands.
- Medicare amputee beneficiaries perceive that the Medicare program ought to permit them to have access to the level of technology that gives them the greatest prospect to restore as much mobility, functionality, and independence as possible.
- There is a component of fraud and abuse in prosthetic care, as elsewhere. The industry has responded with proposed legislation, i.e., H.R. 1958, to address these fraud and abuse issues. To date, the Centers for Medicare & Medicaid Services (CMS) has not endorsed these steps, and Congress has not moved to enact the legislation, despite indications of significant potential savings.
Medicare told the AP it was unable to provide information about the ages of beneficiaries who received the different types of prosthetic feet or the states where they live. Those two pieces of information could help address why Medicare beneficiaries are receiving more sophisticated and costly devices. Medicare officials acknowledge widespread deficiencies in documentation of medical necessity for all kinds of equipment, but they are concerned that tightening requirements could restrict access for seniors.
“We are committed to reducing improper payments and fraud, while ensuring that Medicare beneficiaries have access to the care and services that they need,” said Medicare spokesman Brian Cook.
Fise said that the questions raised by the AP report underscore the importance of outcomes data and other evidence-based studies.
