Responses: Medicare & new prosthesis
Stephan Manucharian
Description
Collection
Title:
Responses: Medicare & new prosthesis
Creator:
Stephan Manucharian
Date:
11/21/2005
Text:
ORIGINAL QUESTION:
A patient contacted me who was fitted for a prosthesis 3 months ago by
another company. Evaluation revealed unacceptable fit of socket. Patient
does not want to go back to the original provider due to poor service. Does
anybody from Medicare Region A have experience in dealing with such
situation? Questions: I'd rather fit the patient with a new prosthesis vs a
new socket for liability reasons, since I did not make the original
prosthesis. Will Medicare pay? If not, then the only solution might be to
replace the socket. In this situation do you address the liability issue in
any way?
REPLIES:
Have the patient contact medicare and request that the previous company be
required to return payment to Medicare.
Then you will be able to make a new socket.
It is always best if the patient is willing to do everything in writing, it
has more impact.
Although we're in C we had this situation last year. The patient needs to
return the device to the provider. He may even LEAVE it on their doorstep!
Of course having a witness is a good idea, but regardless, he's ok.
Then he will need to call M-Care # on E.O.B. to report the situation. M-C
will investigate and require provider to refund, but will make the client
re-eligible since he/she is without a prosthesis. (This took about 60 days).
We have since fitted and received payment for an entire device.
I think they will pay, but you must be able to prove with documentation
that the patient has made reasonable attempts to get the problem worked out
with the previous provider. I had a similar circumstance earlier this year
and they did pay.
The first step is to tell the patient to go back to the other company and
request another practitioner. If it was your patient in their office, you'd
want them to send the patient back to you to try and resolve the fitting
issues. That being said, the other company has the obligation to make the
patient
feel satisfied with their prosthesis or they must take it back and not
charge for the item. If they cannot satisfy the patient, have the patient
call Medicare and report his problem.
Tell the patient to return the prosthesis and have him request a letter or
receipt that the prosthesis was left at the other company's address. If
they refuse, he needs to get the name of the person that refused to accept
the prosthesis. He can leave it there in the lobby if they like. Have the
patient call Medicare again and report that the leg was returned
back to the company and that Joe Practitioner refused to give him a receipt
or letter of return. Medicare will require them to refund the money already
paid and allow them to file a salvage claim. Once you're certain Medicare is
aware of the situation, start the new prosthesis. Do not let the patient
talk you into returning the leg after yours is finished. Insist they return
the leg and report the return to Medicare.
I do it all the time with Medicare and private payers? Document very
well and send it along with the claim; I've even included a summary
letter from myself, and the patient, letting Medicare know it was a
success and the patient is fully satisfied. I've never had Medicare
deny a claim but remember document well!
I would contact the other provider, explain the situation, and request a
copy of the complete chart on the patient's behalf. Of course you need to
have such request signed by the patient, hippa dictates that such
information be made available to the patient. Compare the original mmts to
existing. Has there been a significant volume change? Are the existing
components inappropriate? If the original components are appropriate, what
liability are you talking about? If a socket change is all that is
indicated..... Don't sell them a new car when a new set of tires will do.
The patient must return the prosthesis to the original
provider due to it being unacceptable and also notify medicare that
this action is being taken. Medicare will then request payment back
from the provider and the patient is then free to go somewhere else.
Check with your carrier to confirm this.
The Medicare carrier needs to receive from your patient a letter stating
that he is dissatisfied with the prosthesis and he is not willing to return
to the original provider. Without the DMERC being notified by the patient
you will not get paid for any new prosthesis or parts. The DMERC may ask the
patient to return the original prosthesis to the original provider because
the procedure requires the funds to be recapped from the original provider
before you can get paid for the new prosthesis. It is up to the patient to
do this with the Medicare carrier not you.
Patient should contact medicare if he is not satisfied with the device and
request that he be allowed to obtain a new device---then i would make a new
device---once you touch someone else's you married it ---it becomes your
baby and yes your liable
Stephan, thiw is Phillipe Cartaya CPO with Advanced OAND p IN MYRTLE BEACH
SWC. aLTHO IM IN REGION C I HAVE HAD THIS HAPEN WITH MEDICARE AND BSBSH.
THERE IS A CRAPPY PRACTIONER INTOWN WHOS MESWS IVE HAD TO CLEAQN UP FOR MANY
YEARS. i ONCE ASKED THE OMBUSMAN ABOUT THIS AND SHE SAID THE PATIENT SHOULD
GO BACK TO THE ORIGINAL PRACTIONER. THEN AQGAIN Ive had them say to taqke a
vedeo and have the doctor write a leter saying the prostheses is poorly made
ands he should be fit with new one or run the risk of injury and pressure
sores , whatever. I had a blue crosws patient who lets say had the worst
peice of shit i have ever seen made for her, AK. when she came in i sent a
copy of the video and my remarks to the precert nurse who approved a new
prosthesews for her with in 24 hourss. this local guy has just had his BOC
revoked and wilol son haqve his ABC which he recieved when they were
offering it to BOC people akso revoked. I would call the ombusman for our
state and explain the situation. You might want to call the Dr to make sure
he will back you up on this, and if the patient is seing a therapist also
get a letter from her <…> You might luck out with the ombusman as the
medicare standers allow this patient to return the prostheses and call
medicare and have them recoup some of the money, but the letters and so
forth siol help you with medicare and the ombusman, best of luck and excuse
my spelling im in a hury P cartaya
I feel for you. Your situation in this case is not a good one. I agree with
your concerns of doing a socket replacement on top of components provided by
another practitioner. Unless I knew the other practitioner and had no
questions about his ethics or clinical judgment I would not do it. If I did
know and trust him or her I would contact and advise him/her of the patients
complaints ( professional courtesy).
That all having been said... perhaps you can try calling medicare and
getting approval for the provision of a new prosthesis. With out some sort
of official exception they are sure to deny the claim.
The only other thought I can suggest is that if you do decide to do the
socket replacement have your attorney draw up a waiver of liability
regarding the existing components and have your prospective client sign it.
Best of luck! Let us know how it goes.
As your insurance agent, I felt I should respond to your original email
to give you as much information as possible. Our opinion is the insured
(you) should limit their liability as much as possible. I am sure this
happens quite frequently, but in your place I do not think I would want
to rely on the workmanship of someone else. The patient is unhappy for a
reason; is the
practitioner sure they are getting the straight answers to all the
questions? Is there something going on that you are not aware of? Is it
ethical for you to call the other facility to find out what might be
going on? Is there truly something wrong with the equipment? These are
questions I cannot answer. I think once our insured (Orthopedic Arts)
makes any adjustment or change to the part, they are now on the hook for
future problems.
That said, if there was a claim on the product, we would do everything
in our power to pull in the original practitioner that fabricated the
prostheses, and their liability insurance company.
Hope this helps. Don Foley Cailor Fleming Insurance
--
The content of this communication is for exclusive use of the addressee and
may contain confidential, privileged and non-disclosable information. If the
recipient of this communication is not the addressee, such recipient is
strictly prohibited from printing, photocopying, saving on any media,
distributing or otherwise using the information contained herein. If you
received this communication in error, please contact the sender by e-mail,
fax or telephone and destroy this document.
Stephan Manucharian, CP
Orthopedic Arts
Brooklyn, NY 11201
718-858-2400; Fax: 718-858-9258;
<Email Address Redacted>
A patient contacted me who was fitted for a prosthesis 3 months ago by
another company. Evaluation revealed unacceptable fit of socket. Patient
does not want to go back to the original provider due to poor service. Does
anybody from Medicare Region A have experience in dealing with such
situation? Questions: I'd rather fit the patient with a new prosthesis vs a
new socket for liability reasons, since I did not make the original
prosthesis. Will Medicare pay? If not, then the only solution might be to
replace the socket. In this situation do you address the liability issue in
any way?
REPLIES:
Have the patient contact medicare and request that the previous company be
required to return payment to Medicare.
Then you will be able to make a new socket.
It is always best if the patient is willing to do everything in writing, it
has more impact.
Although we're in C we had this situation last year. The patient needs to
return the device to the provider. He may even LEAVE it on their doorstep!
Of course having a witness is a good idea, but regardless, he's ok.
Then he will need to call M-Care # on E.O.B. to report the situation. M-C
will investigate and require provider to refund, but will make the client
re-eligible since he/she is without a prosthesis. (This took about 60 days).
We have since fitted and received payment for an entire device.
I think they will pay, but you must be able to prove with documentation
that the patient has made reasonable attempts to get the problem worked out
with the previous provider. I had a similar circumstance earlier this year
and they did pay.
The first step is to tell the patient to go back to the other company and
request another practitioner. If it was your patient in their office, you'd
want them to send the patient back to you to try and resolve the fitting
issues. That being said, the other company has the obligation to make the
patient
feel satisfied with their prosthesis or they must take it back and not
charge for the item. If they cannot satisfy the patient, have the patient
call Medicare and report his problem.
Tell the patient to return the prosthesis and have him request a letter or
receipt that the prosthesis was left at the other company's address. If
they refuse, he needs to get the name of the person that refused to accept
the prosthesis. He can leave it there in the lobby if they like. Have the
patient call Medicare again and report that the leg was returned
back to the company and that Joe Practitioner refused to give him a receipt
or letter of return. Medicare will require them to refund the money already
paid and allow them to file a salvage claim. Once you're certain Medicare is
aware of the situation, start the new prosthesis. Do not let the patient
talk you into returning the leg after yours is finished. Insist they return
the leg and report the return to Medicare.
I do it all the time with Medicare and private payers? Document very
well and send it along with the claim; I've even included a summary
letter from myself, and the patient, letting Medicare know it was a
success and the patient is fully satisfied. I've never had Medicare
deny a claim but remember document well!
I would contact the other provider, explain the situation, and request a
copy of the complete chart on the patient's behalf. Of course you need to
have such request signed by the patient, hippa dictates that such
information be made available to the patient. Compare the original mmts to
existing. Has there been a significant volume change? Are the existing
components inappropriate? If the original components are appropriate, what
liability are you talking about? If a socket change is all that is
indicated..... Don't sell them a new car when a new set of tires will do.
The patient must return the prosthesis to the original
provider due to it being unacceptable and also notify medicare that
this action is being taken. Medicare will then request payment back
from the provider and the patient is then free to go somewhere else.
Check with your carrier to confirm this.
The Medicare carrier needs to receive from your patient a letter stating
that he is dissatisfied with the prosthesis and he is not willing to return
to the original provider. Without the DMERC being notified by the patient
you will not get paid for any new prosthesis or parts. The DMERC may ask the
patient to return the original prosthesis to the original provider because
the procedure requires the funds to be recapped from the original provider
before you can get paid for the new prosthesis. It is up to the patient to
do this with the Medicare carrier not you.
Patient should contact medicare if he is not satisfied with the device and
request that he be allowed to obtain a new device---then i would make a new
device---once you touch someone else's you married it ---it becomes your
baby and yes your liable
Stephan, thiw is Phillipe Cartaya CPO with Advanced OAND p IN MYRTLE BEACH
SWC. aLTHO IM IN REGION C I HAVE HAD THIS HAPEN WITH MEDICARE AND BSBSH.
THERE IS A CRAPPY PRACTIONER INTOWN WHOS MESWS IVE HAD TO CLEAQN UP FOR MANY
YEARS. i ONCE ASKED THE OMBUSMAN ABOUT THIS AND SHE SAID THE PATIENT SHOULD
GO BACK TO THE ORIGINAL PRACTIONER. THEN AQGAIN Ive had them say to taqke a
vedeo and have the doctor write a leter saying the prostheses is poorly made
ands he should be fit with new one or run the risk of injury and pressure
sores , whatever. I had a blue crosws patient who lets say had the worst
peice of shit i have ever seen made for her, AK. when she came in i sent a
copy of the video and my remarks to the precert nurse who approved a new
prosthesews for her with in 24 hourss. this local guy has just had his BOC
revoked and wilol son haqve his ABC which he recieved when they were
offering it to BOC people akso revoked. I would call the ombusman for our
state and explain the situation. You might want to call the Dr to make sure
he will back you up on this, and if the patient is seing a therapist also
get a letter from her <…> You might luck out with the ombusman as the
medicare standers allow this patient to return the prostheses and call
medicare and have them recoup some of the money, but the letters and so
forth siol help you with medicare and the ombusman, best of luck and excuse
my spelling im in a hury P cartaya
I feel for you. Your situation in this case is not a good one. I agree with
your concerns of doing a socket replacement on top of components provided by
another practitioner. Unless I knew the other practitioner and had no
questions about his ethics or clinical judgment I would not do it. If I did
know and trust him or her I would contact and advise him/her of the patients
complaints ( professional courtesy).
That all having been said... perhaps you can try calling medicare and
getting approval for the provision of a new prosthesis. With out some sort
of official exception they are sure to deny the claim.
The only other thought I can suggest is that if you do decide to do the
socket replacement have your attorney draw up a waiver of liability
regarding the existing components and have your prospective client sign it.
Best of luck! Let us know how it goes.
As your insurance agent, I felt I should respond to your original email
to give you as much information as possible. Our opinion is the insured
(you) should limit their liability as much as possible. I am sure this
happens quite frequently, but in your place I do not think I would want
to rely on the workmanship of someone else. The patient is unhappy for a
reason; is the
practitioner sure they are getting the straight answers to all the
questions? Is there something going on that you are not aware of? Is it
ethical for you to call the other facility to find out what might be
going on? Is there truly something wrong with the equipment? These are
questions I cannot answer. I think once our insured (Orthopedic Arts)
makes any adjustment or change to the part, they are now on the hook for
future problems.
That said, if there was a claim on the product, we would do everything
in our power to pull in the original practitioner that fabricated the
prostheses, and their liability insurance company.
Hope this helps. Don Foley Cailor Fleming Insurance
--
The content of this communication is for exclusive use of the addressee and
may contain confidential, privileged and non-disclosable information. If the
recipient of this communication is not the addressee, such recipient is
strictly prohibited from printing, photocopying, saving on any media,
distributing or otherwise using the information contained herein. If you
received this communication in error, please contact the sender by e-mail,
fax or telephone and destroy this document.
Stephan Manucharian, CP
Orthopedic Arts
Brooklyn, NY 11201
718-858-2400; Fax: 718-858-9258;
<Email Address Redacted>
Citation
Stephan Manucharian, “Responses: Medicare & new prosthesis,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/225759.
