Provision of Services and Reimbursement

Provision of Services and Reimbursement

Lance Hoxie

4/11/2002

Within the last several days, a number of emails have been posted concerning
the provision of a sophisticated transfemoral prosthesis and denial of its
coverage by Medicaid. The commentary about this matter also referred to
whether it was unethical to deny providing such a device when payment for it
was unavailable.
As established by the ABC Canons, it is the sole responsibility of the
physician or other appropriately licensed health care provider to determine
the medical appropriateness of the orthosis or prosthesis. Yet, the Canons
also address the responsibility of the orthotist or prosthetist in
determining the wants and needs of the patient.
                C2.2 Orthosis and Prosthesis Evaluation and Recommendation
                It is the responsibility of the orthotist or prosthetist to
recommend specific orthotics and/or prosthetics design. The orthotist
and/or prosthetist shall recognize that each individual patient is different
and deserves specific and responsive guidance from the orthotist or
prosthetist. After evaluating a patient, the orthotist or prosthetist shall
recommend to the physician or other prescribing healthcare provider specific
orthotic or prosthetic designs along with the reasoning for such
recommendations. The orthotist and/or prosthetist shall be guided at all
times by concern for the physical, emotional, social and economic welfare of
the patient. All decisions by the orthotist and/or prosthetist must be made
with the understanding and intent that the patient's best interests are the
primary concern.
                C2.4 Provision of Services
                The orthotist and/or prosthetist shall recognize the
patient's freedom of choice in selection of the orthotic or prosthetic
design and treatment . . . Provision of services for personal financial gain
of the orthotist or prosthetist, rather than for the need of the individual
receiving the services is unethical.
Thus, it is the duty of the orthotist or prosthetist as noted by Canon C2.2
and C2.4, to provide the patient with the specific orthotic or prosthetic
design that will meet the patient's needs. However, the Canons do not
intend to create a financial responsibility in which the practitioner must
pay out of pocket to provide an orthotic or prosthetic design for the
patient. Nor do the Canons establish the right of the patient to receive an
orthosis or prosthesis for which he or she is unable to pay, either by
insurance, self-pay or a combination of both. Rather, the Canons suggest
that in determining the patient's needs, and to the extent possible, it is
the practitioner's responsibility to explain what the patient's insurance
coverage will provide, what other options are available to the patient, and
what the patient's financial responsibilities will be. As a practical
matter, it is often to the benefit of the patient and the practitioner to
determine, prior to the provision of service, what benefits are available
for what types of devices. In doing so, many practitioners will also
attempt to locate other financing sources such as charitable organizations.

The bottom line is - for the referring provider, the patient, and the
practitioner, it becomes a delicate balance between cost and solution that
still attempts to meet the patient's orthotic or prosthetic needs.

Lance Hoxie
Executive Director
American Board for Certification in Orthotics and Prosthetics, Inc.