This letter is well timed as we just received such a denial for a patient on
top of a denial for a stance control KAFO. However, I feel that ACA’s
request and approach should perhaps be redirected and that an alternative
more “global” strategy may be necessary. It seems that AOPA is also going to
target the individual carriers and its policies specifically as they relate
to Microprocessor controls. My understanding is that these coverage
limitation decisions are determined at the state level, and most state
associations have difficulty battling these fights due to their own limited
We may be better served as a group (amputee, prosthetist, orthotist,
manufacturers, etc) by battling for mandated coverage of
prosthetics/orthotics on parity with Medicare. I believe the ACA and AOPA
has already started into this direction with their legistlative efforts.
This may be a time for the manufacturers, AOPA, AAOP, ABC and BOC in
conjunction with the ACA to highlight/exploit? some of these individual
denials and use them (the patients) in a HIGH profile PR campaign to battle
the insurance carriers. In California we are seeing drastic changes in
benefits for prosthetic and orthotic coverages, ie annual caps of $2000 with
a 50% copay is now commonplace.
It is my belief that insurance is intended to provide financial
assistance/coverage in the event of catastrophic events. If amputation does
not qualify as a catastrophic event, what does? The insurance carriers are
acting to “cherry-pick” cases and items that they will and will not cover.
These item specific coverage limitations allow the insuracne companies to
state that prosthetics and orthotics are “covered benefits” but with some
“minor exceptions in the fine print”. This is misleading and deceptive. My
understanding is that these coverage limitation decisions are determined at
the state level, and most state associations have difficulty battling these
fights due to their own limited resources. I believe some of the insurance
carriers are acting in bad faith in these cases and a legal argument can
perhaps and should, where possible, be made against them.
My suggestions to AOPA, ABC, BOC, AAOP, ACA and ALL the manufacturers, Otto
Bock, Endolite, Utah Arm, Hosmer, Steeper, Becker, Horton, etc. are as
a) approach this issue in a unified fashion to get mandated parity
coverage dictated upon the states from the national level to coincide with
Medicare. Many of these same patients will end up on Medicare at some point
any way. The argument can be made that if these services are provided early
on to the appropriate patients that they may not end up enrolling in
Medicare at a premature – pre-retirement age adding increasing costs to the
Medicare system. These services can allow patients to resume an active,
healthy, LOWER COST lifestyle. Our industry needs the statistics to prove
this, we do not have them. We need the funding to get these numbers to back
b) take advantage of the fact that our service men are receiving and
benefitting from these technologies
– this may sound callous but lets use them to the industry advantage – we
may need to market our strengths – something the industry has not and does
not do very well. Can the veterans experience provide a statistical base of
outcomes informaiton upon which we can build?
c) employ a PR firm that can and will utilize high profile patients to
paint the insurance carriers into a corner. Our argument must be presented
in the right way to the right people otherwise we can and will come across
as just wanting to provide very hi tech – very costly devices at a perceived
high profit. (note: the % profit margins on these “high tech” itmes are not
what the casual observer expects. In many cases it does not even match a
standard retail markup nor does it equal a markup on the lower cost/lower
d) explore the legal issues surrounding these coverage limitations. Is
there discrimination in these coverage limitations, denials and coverge
restrictions? How does this fare with the ADA?
e) everyone needs to pony up and part with some dollars for this effort.
It will take significant resources and time from everyone. The O&P
manufacturers spend an awful lot marketing their items to the field and
increasingly directly to amputees. Won’t do them or patients any good at all
if no one can provide them because they are specifically excluded benefits.
It would serve the manufacturers very well to make some of their resources
and PR staff available in this effort. This would include access to some of
their “professional patients” that are always at trade shows, etc. (Half the
annual budget for the posters we receive from all the manufacturers would
probably cover the cost of this effort.)
f) enlist the efforts of the rehab community(specifically MD, rehab
facilites and physical therapists). If amputees cannot receive appropriate
prosthetic services, THEY will have a difficult time justifying the longer
rehab stays, additional physical therapy and training, etc. This speak to
their economic viability as well.
The issue of specific coverage limitations and the battlegrounds we choose,
will define our industry. Somewhat of a scary thought given the recent
ABC/BOC struggle. The critical issue I feel is to establish parity coverage
for the disabled on par with medicare for both prosthetics AND orthotics.
Ralph W. Nobbe, CPO
Nobbe Orthopedics, Inc.
From: Orthotics and Prosthetics List [mailto:[email protected]] On
Behalf Of Leslie Duncan
Sent: Thursday, June 10, 2004 5:28 AM
To: [email protected]
Subject: [OANDP-L] ACA – representing beneficiaries – is part of workgroup
that also includes manufacturers of myoelectric/computerized devices…
The ACA has announced that it is leading the development of a “National
Action Plan for Access Among Individuals with Limb Loss.” As part of this
initiative, ACA – representing beneficiaries – is part of workgroup that
also includes manufacturers of myoelectric/computerized devices and AOPA.
Together, we are working to reverse “certain imprudent policies regarding
coverage of these devices”, as detailed in a recent letter to practitioners
that included a bibliography to provide “empirical evidence that they can
provide to payors to justify the provision of state-of-the-art devices.”
ACA (http://www.amputee-coalition.org/aca_advocacy.html) and AOPA
(http://www.aopanet.org) have posted this letter on their web sites to
ensure that it is available for all practitioners
It is important for us to educate insurance companies about the scope of
this issue by placing it in context. Not every amputee requires these
devices. A significant number of the 1.2 million amputees living in the US
have trans-tibial or lower amputations, and therefore do not use
microprocessor or myoelectric components.
However, elimination of coverage for these devices by certain insurance
companies is just the tip of the iceberg. Excluding prosthetics from
insurance policies and limiting coverage by imposing unrealistic annual and
lifetime caps are quickly becoming the rule, and not the exception, in the
insurance industry. With these changes, amputees are now facing a national
health crisis as insurers place them at risk for myriad secondary health
conditions resulting from the sedentary lifestyle that naturally arises out
of inadequate prosthetic coverage.
We need to show that the care received from well-trained, professional
individuals, along with the use of appropriate technology, improves outcomes
and prevents secondary conditions. This is an exciting but daunting
long-term project that requires the help and support of every single person
living with the loss or absence of a limb, as well as those who care for
Paddy Rossbach, RN
President & CEO, Amputee Coalition of America
Leslie Duncan, MIS
Manager, Information Services
Amputee Coalition of America
900 East Hill Ave., Suite 285
Knoxville, TN 37915-2568
888-267-5669 ext. 8115
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