US Politics
Jim DeWees
Description
Collection
Title:
US Politics
Creator:
Jim DeWees
Date:
7/1/2009
Text:
I am wondering if anyone out here has been following the National Prosthetic Parity issue, and if anyone has read the bill and the language in it.
If not, it is easy to google and find the bill, which is HR 2575, and you will need to add prosthetic along with that to google it. I would highly suggest that everyone read the bill, and think about whether this will actually help those that need these devices or not.
Please let me know if you have read it, and what your thoughts are. I will not repost anything or divulge any information that I recieve.
My thoughts on this bill are mixed.
First off, I am glad that something is being done on a national level, and glad that there is some interest there to address this problem.
Secondly, I am glad that there is at least some mention in the bill on the in-network and out-of-network situation that exists with insurance companies. But, as we all know in this field, the out-of-network benefits are generally written in such a way that there is no realistic way for most amputees to choose an out-of-network facility. The co-pays and deductibles are so high that nobody can afford to go out of their network for the care they need.
But, on the down side, we all know as well that some insurance companies have fee schedules that are so low that there are not very many providers in these networks. I won't mention any names of insurance companies, due to the rules of this listserve (which I totally understand the reasons and appreciate them), but the fee schedules that are written by insurance companies are so bad, that it makes it literally impossible to use any high quality components on these prosthetic devices (a good foot, good liners, good knee joints, etc.) because the prosthetist will lose money on that patient.
As a prosthetist and also an amputee, I can see if from both sides. In fact, when I lost my leg, my insurance was awful. To ME it seemed like a great insurance policy.....on paper it paid for prosthetics, and so I felt like I should just be able to go to the prosthetist that I had chosen, and get the top quality foot, liner, and everything. It was then that I saw what the insurance company was actually paying the prosthetist, and I also learned how much the foot cost, and how much a liner cost, and there was a huge problem there. What the insurance company allowed for the liner was less than the cost of the liner. That problem still exists today with many insurance companies.
After dealing with this frustration for several months, that is when I decided to go to the prosthetics course and get my education, credentials, and certification. That has been nearly 11 years ago now.
Just to inform everyone, in case you are not aware, almost all insurance companies pay doctors, therapists, and hospitals at a rate much higher than medicare allowables. I have spoken with many doctors and practice managers and discussed this with them. They get paid a lot more from private insurance than they do from medicare and medicaid. They will say that they have to rely on the money from the private sector to offset the loss they take on medicare/medicaid work.
I have told them that I rely on my Medicare and medicaid work to offset the loss that I take on most of my private insurance payments. I have actually had to turn a few patients away because I know that I am going to spend thousands of dollars on a knee, foot and everything, plus hours of labor, and get paid less than the cost of the components alone.
They are all shocked when I tell them that some insurance companies pay as much as 43% below medicare for prosthetic devices. I tell them how much a good foot costs (like a Flex Foot Mod III, which is what L5980 is intended for), and the reimbursement from some companies is several hundred dollars below that price. I tell them what a good quality liner costs, and then what the insurance pays, again, a lot less than the cost.
I didn't realize that it seems to be the O&P field that is the one that is getting the bad end of this deal with insurance discounts for whatever reason. I know the reason, but can't say it here.
Another point is now that some private sector insurance companies are now participating in Medicare and Medicaid, they have asked me to sign an addendum to my commercial policies with them. But signing this addendum, it will mean that I will now get paid the insurance company rates, which are MUCH lower then medicaid rates, or the medicare rates. Why in the world would I do that???? I didn't do that, and I WON'T do that. They threatened me that they would cancel my commercial contract with them if I did not sign the adendum, and after speaking with the state Medicaid director, the insurance company had to back down on that threat.
But, the doctors and hospitals were never asked to sign any addendum to their contracts (at least not from any conversations with the doctors I have spoken with), because they get paid more than medicare allowables, so it wouldn't benefit the insurance companies to do that. It is only this field that is targeted.
Today, I deal with this dilema when someone comes to my office with some horrible insurance, and I have to decide if I can afford to give away my service, take a big loss, eat it, OR I could get some cheap junk to throw together, and the compromise my reputation of only using high quality products.....and while I am dealing with this issue, the insurance companies are making record profits, handing out millions in bonus checks, and laughing at us all the way to their banks and to their financial planners and investors.
In the state parity bills, many of them use the medicare allowables as their basis of fee schedules. I realize that this is price fixing perhaps, and maybe can't be included in some national legislation. Or maybe it can....???
But as it is written, all the insurance companies have to do is to reduce their fee schedules to a point where the prosthetists decide that they just cannot afford to do that work, and not sign a contract. Then the insurance companies generally will have at least ONE provider, probably some national provider, who will have a contract with them, but if the patient chooses to go out of network, they can put whatever limitations they basically want to do (which is what they do for ALL their medical services), and limit what the amputees can really get.
I have other thoughts and issues with this bill, but I also realize that it is literally impossible to write anything that could take on the power and influence that these insurance companies have over our elected officials in Washington.
And, if we think that dealing with Medicare and Medicaid (which I have no problems with at the moment) is bad or frustrating, then let's just wait and see what some national healthcare system would do to us all......yikes....heaven help us...oops, that's politically incorrect. How about whatever help us.
Please read the bill, and let me know what you think.
Thanks
Jim DeWees, CP
_________________________________________________________________
Windows Live™: Keep your life in sync.
<URL Redacted>
If not, it is easy to google and find the bill, which is HR 2575, and you will need to add prosthetic along with that to google it. I would highly suggest that everyone read the bill, and think about whether this will actually help those that need these devices or not.
Please let me know if you have read it, and what your thoughts are. I will not repost anything or divulge any information that I recieve.
My thoughts on this bill are mixed.
First off, I am glad that something is being done on a national level, and glad that there is some interest there to address this problem.
Secondly, I am glad that there is at least some mention in the bill on the in-network and out-of-network situation that exists with insurance companies. But, as we all know in this field, the out-of-network benefits are generally written in such a way that there is no realistic way for most amputees to choose an out-of-network facility. The co-pays and deductibles are so high that nobody can afford to go out of their network for the care they need.
But, on the down side, we all know as well that some insurance companies have fee schedules that are so low that there are not very many providers in these networks. I won't mention any names of insurance companies, due to the rules of this listserve (which I totally understand the reasons and appreciate them), but the fee schedules that are written by insurance companies are so bad, that it makes it literally impossible to use any high quality components on these prosthetic devices (a good foot, good liners, good knee joints, etc.) because the prosthetist will lose money on that patient.
As a prosthetist and also an amputee, I can see if from both sides. In fact, when I lost my leg, my insurance was awful. To ME it seemed like a great insurance policy.....on paper it paid for prosthetics, and so I felt like I should just be able to go to the prosthetist that I had chosen, and get the top quality foot, liner, and everything. It was then that I saw what the insurance company was actually paying the prosthetist, and I also learned how much the foot cost, and how much a liner cost, and there was a huge problem there. What the insurance company allowed for the liner was less than the cost of the liner. That problem still exists today with many insurance companies.
After dealing with this frustration for several months, that is when I decided to go to the prosthetics course and get my education, credentials, and certification. That has been nearly 11 years ago now.
Just to inform everyone, in case you are not aware, almost all insurance companies pay doctors, therapists, and hospitals at a rate much higher than medicare allowables. I have spoken with many doctors and practice managers and discussed this with them. They get paid a lot more from private insurance than they do from medicare and medicaid. They will say that they have to rely on the money from the private sector to offset the loss they take on medicare/medicaid work.
I have told them that I rely on my Medicare and medicaid work to offset the loss that I take on most of my private insurance payments. I have actually had to turn a few patients away because I know that I am going to spend thousands of dollars on a knee, foot and everything, plus hours of labor, and get paid less than the cost of the components alone.
They are all shocked when I tell them that some insurance companies pay as much as 43% below medicare for prosthetic devices. I tell them how much a good foot costs (like a Flex Foot Mod III, which is what L5980 is intended for), and the reimbursement from some companies is several hundred dollars below that price. I tell them what a good quality liner costs, and then what the insurance pays, again, a lot less than the cost.
I didn't realize that it seems to be the O&P field that is the one that is getting the bad end of this deal with insurance discounts for whatever reason. I know the reason, but can't say it here.
Another point is now that some private sector insurance companies are now participating in Medicare and Medicaid, they have asked me to sign an addendum to my commercial policies with them. But signing this addendum, it will mean that I will now get paid the insurance company rates, which are MUCH lower then medicaid rates, or the medicare rates. Why in the world would I do that???? I didn't do that, and I WON'T do that. They threatened me that they would cancel my commercial contract with them if I did not sign the adendum, and after speaking with the state Medicaid director, the insurance company had to back down on that threat.
But, the doctors and hospitals were never asked to sign any addendum to their contracts (at least not from any conversations with the doctors I have spoken with), because they get paid more than medicare allowables, so it wouldn't benefit the insurance companies to do that. It is only this field that is targeted.
Today, I deal with this dilema when someone comes to my office with some horrible insurance, and I have to decide if I can afford to give away my service, take a big loss, eat it, OR I could get some cheap junk to throw together, and the compromise my reputation of only using high quality products.....and while I am dealing with this issue, the insurance companies are making record profits, handing out millions in bonus checks, and laughing at us all the way to their banks and to their financial planners and investors.
In the state parity bills, many of them use the medicare allowables as their basis of fee schedules. I realize that this is price fixing perhaps, and maybe can't be included in some national legislation. Or maybe it can....???
But as it is written, all the insurance companies have to do is to reduce their fee schedules to a point where the prosthetists decide that they just cannot afford to do that work, and not sign a contract. Then the insurance companies generally will have at least ONE provider, probably some national provider, who will have a contract with them, but if the patient chooses to go out of network, they can put whatever limitations they basically want to do (which is what they do for ALL their medical services), and limit what the amputees can really get.
I have other thoughts and issues with this bill, but I also realize that it is literally impossible to write anything that could take on the power and influence that these insurance companies have over our elected officials in Washington.
And, if we think that dealing with Medicare and Medicaid (which I have no problems with at the moment) is bad or frustrating, then let's just wait and see what some national healthcare system would do to us all......yikes....heaven help us...oops, that's politically incorrect. How about whatever help us.
Please read the bill, and let me know what you think.
Thanks
Jim DeWees, CP
_________________________________________________________________
Windows Live™: Keep your life in sync.
<URL Redacted>
Citation
Jim DeWees, “US Politics,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/230587.
