Re: New Medicare Prosthetic Coverage Requirements? - Response Summary
Brett R. Saunders, CPO, FAAOP
Description
Collection
Title:
Re: New Medicare Prosthetic Coverage Requirements? - Response Summary
Creator:
Brett R. Saunders, CPO, FAAOP
Date:
1/22/2013
Text:
Thank you everyone for responding.
Most people pointed out the existing rules for providing care at a SNF..you can find them in the Medicare Supplier Manual Chapter 6 #13 DMEPOS and an Inpatient Stay. It is IMPORTANT reading and we should all be familiar with these rules.
One person pointed out the disclaimer at the end of the document that reads CGSMedicare is not responsible if the information they provide is not correct. - If you attempt to access the LCDs (Local Coverage Determinations) you have to agree that the information they provide might not be accurate before you can access them.
MY issue with this document is ….
1) An auditor will take this document and use it, with all the inaccuracies, as THE checklist they will use for documentation review, or
2) An authorization department for one of the Advantage programs will use it as a requirement for authorizations. - I have had many cases of Advantage plans misreading an LCD and denying coverage already. This will only increase the problem, or
3) That this is an end-run around regulations of coverage by determining 'not medically necessary'. It seems that the Medicare regions have started this use of determination of 'medical necessity' or 'not medically necessary' to deny coverage for items that have PDAC review and approval, as they have with AFOs such as Arizona AFOs and Ritchie Braces. I see this as a power grab by the DMACS to circumvent regulatory/statutory rules and the PDAC. It leaves confusion for practitioners as there is much subjectivity in determining necessity of a particular service or device in relation to other treatment options and financially punishes the provider for the physician's treatment choices.
4) That the DMACs are forcing changes to the traditional provision of P&O care without understanding the history of how O&P care evolved and the typical way physicians and orthotists/prosthetists interact, without consulting with the O&P industry to find 'best practices', or providing clear guidance and education for the physicians, therapists, and O&P practitioners.
Brett Saunders, CPO, FAAOP
> -----Original Message-----
> From: Orthotics and Prosthetics List [mailto:<Email Address Redacted>] On
> Behalf Of Brett R. Saunders, CPO, FAAOP
> Sent: Monday, January 21, 2013 3:06 PM
> To: <Email Address Redacted>
> Subject: [OANDP-L] New Medicare Prosthetic Coverage Requirements?
>
> CGS Medicare has published a new Prosthetic Documentation Checklist and if I
> read this correctly,
>
> Prosthetic devices can only be delivered to patients in SNF units if:
>
> 1 It will be medically necessary after discharge, AND
> 2 Is fit and delivered within 2 days of discharge from the SNF, AND
> 3 Is NOT needed for inpatient treatment or rehabilitation.
>
> Is this a new change in policy on coverage for prosthetics??
>
> The document I am referencing is found at
> cgsmedicare.com/jc/coverage/mr/PDF/MR_checklist_LLP.pdf
>
> How could a prosthesis NOT be considered as needed for inpatient treatment
> and rehabilitation?
>
>
> Brett R. Saunders, CPO, FAAOP
Brett R. Saunders, CPO, FAAOP
<Email Address Redacted>
761 County Road 466
Lady Lake, FL 32159
(352) 259-9749 Phone
(352) 259-8209 Fax
Most people pointed out the existing rules for providing care at a SNF..you can find them in the Medicare Supplier Manual Chapter 6 #13 DMEPOS and an Inpatient Stay. It is IMPORTANT reading and we should all be familiar with these rules.
One person pointed out the disclaimer at the end of the document that reads CGSMedicare is not responsible if the information they provide is not correct. - If you attempt to access the LCDs (Local Coverage Determinations) you have to agree that the information they provide might not be accurate before you can access them.
MY issue with this document is ….
1) An auditor will take this document and use it, with all the inaccuracies, as THE checklist they will use for documentation review, or
2) An authorization department for one of the Advantage programs will use it as a requirement for authorizations. - I have had many cases of Advantage plans misreading an LCD and denying coverage already. This will only increase the problem, or
3) That this is an end-run around regulations of coverage by determining 'not medically necessary'. It seems that the Medicare regions have started this use of determination of 'medical necessity' or 'not medically necessary' to deny coverage for items that have PDAC review and approval, as they have with AFOs such as Arizona AFOs and Ritchie Braces. I see this as a power grab by the DMACS to circumvent regulatory/statutory rules and the PDAC. It leaves confusion for practitioners as there is much subjectivity in determining necessity of a particular service or device in relation to other treatment options and financially punishes the provider for the physician's treatment choices.
4) That the DMACs are forcing changes to the traditional provision of P&O care without understanding the history of how O&P care evolved and the typical way physicians and orthotists/prosthetists interact, without consulting with the O&P industry to find 'best practices', or providing clear guidance and education for the physicians, therapists, and O&P practitioners.
Brett Saunders, CPO, FAAOP
> -----Original Message-----
> From: Orthotics and Prosthetics List [mailto:<Email Address Redacted>] On
> Behalf Of Brett R. Saunders, CPO, FAAOP
> Sent: Monday, January 21, 2013 3:06 PM
> To: <Email Address Redacted>
> Subject: [OANDP-L] New Medicare Prosthetic Coverage Requirements?
>
> CGS Medicare has published a new Prosthetic Documentation Checklist and if I
> read this correctly,
>
> Prosthetic devices can only be delivered to patients in SNF units if:
>
> 1 It will be medically necessary after discharge, AND
> 2 Is fit and delivered within 2 days of discharge from the SNF, AND
> 3 Is NOT needed for inpatient treatment or rehabilitation.
>
> Is this a new change in policy on coverage for prosthetics??
>
> The document I am referencing is found at
> cgsmedicare.com/jc/coverage/mr/PDF/MR_checklist_LLP.pdf
>
> How could a prosthesis NOT be considered as needed for inpatient treatment
> and rehabilitation?
>
>
> Brett R. Saunders, CPO, FAAOP
Brett R. Saunders, CPO, FAAOP
<Email Address Redacted>
761 County Road 466
Lady Lake, FL 32159
(352) 259-9749 Phone
(352) 259-8209 Fax
Citation
Brett R. Saunders, CPO, FAAOP, “Re: New Medicare Prosthetic Coverage Requirements? - Response Summary,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/234529.
