Private payers ‘exploit’ O&P changes

Friday, April 22, 2016

WASHINGTON – It’s no surprise to O&P stakeholders that private payers are picking up on a widely criticized proposed rule by Medicare to deny coverage for prosthetic devices that were previously covered.

“We predicted that the rule would, ultimately, be exploited by private health insurers,” said Michael Oros, president-elect of the American Orthotics and Prosthetics Association during a press call last week.

The four DME MACs in July released draft local coverage determinations for lower limb prosthetics that include a number of proposed changes, including requiring a face-to-face visit and requiring patients to complete a rehab program. UnitedHealthcare and Cigna have made coverage changes in the wake of the proposed rule, AOPA says.

Mark Martin, who lost his leg to an aneurysm in 2014, has experienced firsthand this cookie-cutter approach to providing prosthetic care.

“I experienced denials even on my initial preparatory prosthetic,” said the 40-year-old from Portland, Ore. “Then, when I advanced to the being ready for a definitive prosthetic, I was met with wave after wave of denials. Many, many months passed that I could have been advancing my recovery.”

After a public uproar, CMS said it would hold off on implementing the LCDs until further study, but the simple fact that the agency didn’t withdraw them made the proposed changes fair game for other payers, says AOPA.

Adding to stakeholder frustration: everything from the lack of transparency from the very start of the LCD process, to CMS’s refusal to name the individuals who comprise a workgroup it has formed to study the changes.

“There is no assurance that any stakeholders or patients would be involved in this,” said Tom Fise, executive director of AOPA.

CMS has also denied a Freedom of Information Act request filed by AOPA asking to view the several thousand public comments made on the proposed rule.

There are currently about 2 million amputees in America, and that number is growing by nearly 200,000 a year. Appropriate prosthetic devices enable most of them to return to their previous activity level and lifestyle, they say.

“Under United’s coverage, I would not be able to have the same device as I currently use to keep my lifestyle as active,” said Rob Rieckenberg, 37, of Minneapolis, who lost a leg after he was mugged and left on train tracks and was hit by a train. “It’s hard enough to recover from losing a limb, but to be told by your insurance company that it’s not a medical necessity is another devastating blow.”