Following are the replies that I received and I must admit it makes for
interesting reading…..however, there are very few suggestions as to how we
may remedy this issue.
There are plenty of suggestions as to the reason how we got here:-
Lack of research funding because only solid publications can support what we
are doing – that may have merit but how will that change the ignorance
associated with insurance personal. It may give us more credibility….? Not
Insurance companies are running out of money and therefore the hesitation to
honour an obligation to pay post pre-authorization……So then I ask – how
come the CEO’s of all the major insurance companies earn between $8M and
$42M in bonus which they earned by denying their members critical care
There are comments about the standard of prosthetic treatment dropping and
therefore so does the respect…..although I don’t agree as to the broad
statement, but I can see why some clinics may have to do that to survive in
There were some positive replies that mentioned how far our profession has
come over time and I ponder that statement – In Germany I was a
Orthopedische Mechaniker Meisster – ‘orthopaedic technician’…..I was given
the task to treat the patient with a prosthesis and got paid for exactly
that. In South Africa I was a Orthopaedic technician and worked at a major
hospital and then private practice. I got paid for treating patients and
there was no denial post an authorization. I immigrated to the USA in 1990
and was amazed at my title of Orthotist and Prosthetist. I had access to the
most advanced components and had no problem getting authorizations and had
no problem getting paid. Denials were normally associated with admin staff
errors……what a wonderful profession. So how did my profession advance
with regards gaining more respect and recognition I wonder……
I have been in clinical, research and adjunct staff in the prosthetic
industry for 39 years this year. I am asking for opinions as well as
suggestions as to how we may all come together as a profession to overcome
this overwhelming lack of respect and acknowledgement of who we are and what
we do to help our patients.
I am sure I am not alone when I state that our profession, from the
insurance industry right through to congress carries very little support nor
respect. When we can jump through all the hoops to get a prosthetic
treatment pre-authorized, just to get a denial after we billed for the
treatment with no logical explanation as to the reason for the denial. When
a procedure L-Code did not require pre-authorization but then gets denied
because it is considered experimental after being in use for 20 years? A
treatment gets denied for the ‘lack of K-level activity and its clearly
stated on all relevant documentation. How about the favourate, we did not
receive the supporting documents and we have a fax receipt indicating
otherwise. I can go on and on, but you all know that the denials normally
have no grounds – but the insurance companies do it because they can…..
and there is nothing we can do about it, but appeal, upon appeal, upon
appeal it and hope for the best.
Insurance companies pay us, not for the treatment as prescribed or as
executed, but for what they decide to pay for whether it has grounds or not.
It is then up to the clinician and the doctor to appeal that decision by
spending hours on administrative documentation as opposed to treating
When a prosthetic company can offer a 30-40% discount to the big insurance
companies because they have negotiated a 25-30% discount structure with the
big manufacturers and because they have coverage throughout the continental
USA, we the small clinics have to accept these terms to gain in-network
status…….but we do not get the same discount from the manufacturers
because we don’t have the same volume.
Our associations fought like hell to get our clinical notes accepted as part
of the grounds for ‘medical necessity’ and everyone is so excited, just to
find that it really does not matter because with or without our clinical
notes, the pre-authorized treatments still get denied.
Nothing that has been done – from upgrading our schooling to a post grad
education, to incorporating a residency program, to getting our notes
accepted as support documentation, to having our clinics and ourselves
accredited has separated us from Durable Medical Equipment. What are we not
We have Licensure in some states – not all? However, licensure has not
stopped anyone from doing what we do as it’s so watered down by the time it
gets approved, that’s it’s really just revenue for the state. It also is not
reciprocal from one state to another?
We have 2 associations that cannot agree on much and are so de vided that we
can never show a united front.
Ladies and gentleman, we have to do something to regain the respect from the
Insurance industry, the medical community and the associated government
departments because what we are doing right now is not improving matters, it
is making it worse. How do we go about doing that? Do we all pay into a fund
and get a lobbyist to fight for our rights….or perhaps an ombudsman – they
are suppose to listen and solve issues?
I have no idea how to remedy this issue, but we the clinicians have to take
matters into our own hands and fix this.
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