THANKS to one and all for the support and response received from my last
posting regarding Medicare and evidently, many of our collective problems.
I am continuing to follow steps that have been provided to us by CMS
following communications CMS received from our Oklahoma US Senator. I wish
I could proclaim good news on the Medicare reimbursement front,
unfortunately I cannot! In conjunction with continuing consideration for a
class action suit (no lack of plaintiffs, from what I have seen), I am
constructing a letter requesting legislative and policy changes within
CMS. This letter will be sent to our (Oklahoma) US legislators and
hopefully many professionals and Medicare recipients will actively
participate. I am including the proposed document for opinion and
colleague scrutiny. Please provide input and feedback. Further, feel free
to copy part and/or all for dissemination and personal use. We must speak
together to be heard! Evidently we must do so informally as I really don’t
see much “action” in the way of our professional associations and
organizations. Thank You!
First, we would like to Thank You for your timely response and assistance
regarding our problems with Medicare. We recognize that you are attempting
resolution under the confinements of the law. However, we are in dire
straits! And it appears that we are not alone.
Keith Crownover, BS, CPO, BOC(po), LPO
____________________________________
Senator and/or Congressman,
We continue to muddle through the quagmire that has become the attempt of
obtaining Medicare reimbursement. I am diligently following the steps
provided, at your request, by CMS. In doing so, we are getting absolutely
NO WHERE! However, we have been told to expect increasing difficulty by
our Ombudsman! Evidently, CMS is requiring the referring physician’s
patient notes and that these notes demonstrate necessity for the particular
items billed. This would seem reasonable if Physicians had the education
and experience of Prosthetics and Orthotics, but they do not and have no
idea as to the necessity of ordering a specific type of suspension system
to hold on a prosthesis and that this type of system demands a total
contact “L” code, amoung numerous others. This is but one example of the
terrible problems that continue to snowball and become increasingly
critical. If these problems continue, many Orthotic and Prosthetic
providors will be unable to accept Medicare as payment is delayed and in
many cases refused.
We respectfully request the introduction of policies/procedures and
necessary legislation to abate these escellating problems that are choking
our field and punishing Medicare recipients:
* Orthotics and Prosthetics are NOT Durable Medical Equiptment and should
not be lumped in and treated as such. Due to
physiologic/neurologic/pathiologic changes within a human being, an
orthosis and/or prosthesis will not always fit and fuction appropriately
for five or more years.
* Institute evaluations/audits to curb fraud and abuse by employing and/or
utilizing Nationally Certified Orthotists and/or Prosthetists to review
claims and conduct “on-sight” examination of patients randomly, within the
field, in order to ascertain whether or not that which was perscribed by
the licensed Physician is indeed that which the patient received from the
Medicare provider and that which CMS was billed. On-sight patient and
documentation reviews would curb fraud and abuse without harming and
bancrupting legitament certified Prosthetists and Orthotists. Also,
Physician notes that do not demonstrate the necessity or request for
certain designs and components would not be necessary. Furthermore, CMS
costs would be reduced as required documentation, reviews and denials
pending appeals would see a long term reduction. The greatest benefit
would be in relief of fraud and abuse perpitrators and timely payment to
legitamet providers.
* Institute and ENFORCE meaningful sanctions upon perpitrators of fraud
and abuse, consistantly.
* Enpanel a National coalition of Certified Orthotists and Prosthetists
(volunteers) to innerface with CMS as new technology is developed and
current L-codes are evaluated and/or re-assigned. Currently, new and
revolutionary technology cannot be provided to Medicare recipients and
actually be reimbursed by CMS. For example: There is an Knee-Ankle-Foot-
Orthosis (KAFO; AKA: leg brace) that uses a knee joint that locks with a
persons weight bearing and then unlocks and helps with the step a person is
taking completely safely. This joint has helped many victums of stroke and
those with multiple types of neurologic and neuromuscular assaults function
safely and more naturally than ever before. CMS refuses to acknowledge the
uniqueness and value of this joint and pays far less than the value of the
metal used to construct the joint itself. Thereby making it impossible for
providers to absorb these costs themselves much less think of an
appropriate profit margin. Thereby,
It does not take a lot of intellect to understand that we are in a crisis.
I realize that as far as Healthcare, this is not close to the tip of the
ice berg. Nevertheless, CMS’ actions regarding proper reimbursement for
items rendered to their recipients is wrong! Rather than embarking on a
lengthy legal battle, I would prefer to see those whom we elected
acknowledge and effect legislation OR proper rules and procedures to
rectify these issues. Afterall, we are not really talking about one small
medical practice in one state. This is a regional and dare I say, National
issue. Not only for providers, but for the tens of thousands of Medicare
recipients receiving sub standard or no care at all due to the lack of
providers (as numbers dwindle into bancruptcy at the hands of CMS OR refuse
to remain Medicare providers). Receipients may also go without proper care
due to the refusal of providers to utilize the best available designs and
resources because he/she knows CMS will never pay or at best leave them
waiting six months or so for any reimbursement for the provision of certain
items. Senator, I am circulating requests for these types of
coorespondences to be submitted to every legislator in Washington.
Medicare recipients cannot be left waiting while other citizens get better
care than they are afforded. Medicare providers cannot wait while banks
and creditors close the doors on their businesses because CMS refuses to
pay that which it owes and do so in a timely fashion. Thank you for your
time and attention to this very urgent matter.
Sincerely,
