Inadequate contract reimbursement for expensive items- RESPONSES

Inadequate contract reimbursement for expensive items- RESPONSES

Randy McFarland

8/26/2005

ORIGINAL POST
Hi List members,
   What do you do when a physician specifies a particular brand/model of
a more expensive off the shelf device that costs you about the same as
what the contracted reimbursement will be? (The manufacturer even
recommends the L code with the inadequate fee.) I'm finding this is
happening more often, and with a contract, we can't ask the patients to
pay.
     The options I can think of are:
1. Try to talk the doc into another model that will do the same
thing and costs less.
2. Create carve outs in your future contracts or negotiate better
reimbursements for such procedures.
Randy McFarland,CPO
Fullerton, CA


         Thanks to those who sent the following
RESPONSES
Good luck on the carve out - they can send them to the O&P facility down
the street who would be more than happy to absorb the costs. We have
this issue.

My understanding is brand/manufacturer substitutions are acceptable as
long as physician HAS NOT indicated brand name necessary or similar on
Rx. We show patient example/picture of product we offer, state our case
regarding functional difference (i.e. there are none) and allow them to
decide.

The following was copied directly from my personal coverages page
(United HealthCare). I personally don't care that the doctor prescribes
Proprietary, I tell the patient that their insurance will pay for
generic. If they prefer the proprietary brand that the doc ha ordered,
it's on them, as in a cash transaction.

Both In / Out of Network


--
Durable medical equipment is covered if it meets the following criteria:



--
  Ordered or provided by a physician for outpatient use.
  Used for medical purposes.
  Not consumable or disposable.
  Not of use to a person in the absence of a disease or disability.


--
 If more than one piece of Durable Medical Equipment can meet functional
needs, benefits are available only for the most cost-effective piece of
equipment.

I have looked and looked and have not found the clause that says that I
am contractually bound to subsidize the insurance company or their
insured.
The insurance companies look at this the same as they do with Rx drugs.
The only difference is they make provisions for those people who want
proprietary drugs. My plan calls for $10.00 co-payment for generic and
$35.00 co-payment for proprietary drugs. They have made no inquiries
about the practice since I instituted it and when I show the patients
the printout, no one has complained. It is the insurance plan's policy,
not mine. I'm just following the rules that they set.


Respectfully - and for what it's worth - - you made the
bed...........you know the rest I have NO CONTRACTS

We have taken the approach that our contracts are for generic not
name brand devices. If you look at your procedure code definitions
none specify a brand name - the only one I can recall is the CTI and
the Lennox Hill that were specifically identified. If in approaching the
MD - he continues to insist on the brand name we provide it off
contract. Has solved the problem for the most part - most MD's can
understand this concept as do the UR/UM staff.

Try discussing the economics of this with the physician. Most of them
will understand the business side of this issue, especially in light of
having to operate in the managed care arena. If you can also present
some of the comparable features of an alternative orthotic, I would bet
they would be agreeable to any recommended changes.

I too have had problems with getting the physicians to understand that
the insurance companies do not always pay enough to cover the cost of
the item. Some of the strategies I've used have included generic
demonstrations of the
same product. In most cases I've seen able to convince my physicians
that what I'm providing is the same or performs the same task. The
greatest difficulty comes with Doctors who don't want anything else
Brand name only in those cases I sometimes will call the doctor and tell
him that due to the cost I can't provide it. The interesting thing is
how often the doctor calls back to find out what options there are to
fit the patient, its usually after he can't get what he wants but
sometimes we have to stand our ground. If more of us would stand our
ground instead of capitulating to
these ridiculous unilateral reduction in fees we might actually save our
profession. If more practitioners would be colleagues instead of
competition we might be able to at least get the insurance companies to
realize that we won't work for pennies and maybe our patients will get
the prosthetic and orthotic devices they need without the constant
arguing with people who have
know idea how a custom prosthetic or orthotic device is made. But
forgive me I'm preaching to a member of the same choir. Just thought I'd
add my two cents.

Many Rx forms have written statement at bottom such as In order for
brand name to be necessary, physician must check/initial this box_____
or simply Brand name necessary____. I've never seen a physician check
these boxes or write brand name necessary on Rx's. Most manufacturers,
including Bakersfield, offer multiple designs/models for single
pathology (i.e. patella sublimation). When Doc writes for Don joy
K.O. or Bakersfield knee sleeve we still must engage our expertise in
selecting specific design/model. We routinely ignore brand name
specification. Our guess is, as long as patient is satisfied with their
overall experience (Orthotist briefly reviews pathology, orthotic goals,
how any orthotic may accomplish these goals, similarity of functional
mechanisms/limited differences between manufacturer designs, common
complications, etc.) physician will not take issue and will continue to
send referrals. As with medications, I believe the impetuous is on
physician to state/indicate on Rx, in some way, brand name is
required/necessary. Look forward to seeing responses.

If you haven't already, modify your Rx pads to read something like a
drug prescription pad. Try something like, A suitable alternative
device may be substituted unless the prescribing physician indicates
'Brand Specific' in the field above. The opposite wording would not
help. If you put, Brand Specific unless checked here ___, you'll be
locked into providing that brand. A simple call or meeting with the
physician may reveal he was writing Don Joy or Jobs because he
thought it was the same as saying Band-Aid or Kleenex. Carve-outs
are an alternative, but if the payer thinks your cherry-picking, you may
be dropped because of inadequate diversity in products and services. OR,
the patient's may say you denied them services, and even if you didn't,
you may be dropped.

Refuse service due to inadequate reimbursement. I know it sounds like a
simple ( or impractical) idea. That's the only way to change it in the
long run.

I have run across this before - I have called the ordering physician and
simply asked if I can substitute brands. I have yet to get a negative
response. I make sure that I have documented that the doctor approved.
If a physician ever says no or is reluctant, I am willing to explain
costs and reimbursement.